Grove Of Elmhurst, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Elmhurst, Illinois.
- Location
- 127 West Diversey, Elmhurst, Illinois 60126
- CMS Provider Number
- 145339
- Inspections on file
- 47
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Grove Of Elmhurst, The during CMS and state inspections, most recent first.
Staff failed to maintain resident dignity by using personal cell phones while providing care. A resident’s daughter reported CNAs frequently on their phones, including one CNA who paused a personal call, with earbuds in, only after being approached. A resident stated she sees staff on their phones during care “all the time,” and another resident also reported observing staff phone use during care. The mother of a nonverbal, non-alert, and non-oriented resident stated she often sees staff on their phones, including while they provide care, and described this as disrespectful. The DON acknowledged that staff should not use cell phones during care and that doing so is disrespectful, even though facility policy already strongly discourages personal calls or texting during work time except under extraordinary circumstances or during breaks.
A resident with functional quadriplegia, ventilator dependence, and heart failure had an order and facility policy requiring daily cleansing and dry gauze dressing changes to the enteral tube site on the night shift. During observation, surveyors noted a foul odor and found the feeding tube dressing dated nine days earlier, with dried black drainage and a pronounced odor. When the nurse removed the dressing, the underlying skin was reddened, inflamed, and appeared raw. Review of treatment records showed night shift staff had documented daily dressing changes during this period, despite the unchanged, dated dressing, and the DON confirmed that dressings are to be changed daily and not documented unless actually performed.
A resident with functional quadriplegia, ventilator dependence, and heart failure received incontinence care during which a CNA wiped stool from the buttocks toward the vagina twice, contrary to clean technique and facility policy. The resident’s perineal area had to be cleaned a second time, and the shift coordinator/CNA later stated he had instructed the CNA to wipe away from the vagina, noting that wiping stool toward the vagina could lead to a UTI. The DON confirmed that perineal care should be performed by wiping away from the vagina to prevent contamination and infection, as required by the facility’s incontinence and perineal care policy.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These deficiencies were observed during the survey and were linked to failures in following established protocols.
A resident sustained a significant laceration on her right lower leg after her skin caught on the uncapped right front wheel connector of her wheelchair during a transfer. The injury required hospital treatment and sutures. Staff interviews and observations confirmed the wheelchair was not in safe repair, and the facility's maintenance policy requires equipment to be properly maintained.
Surveyors found that multiple insulin pens and vials were not labeled with resident names, open dates, or expiration dates, and expired medications were not removed from storage. Staff confirmed that labeling and timely disposal were required, but these procedures were not followed according to facility policy.
Three residents with cognitive impairments and documented needs for assistance with personal hygiene were observed with long, dirty, or broken nails, indicating that required nail care was not provided. Nursing staff confirmed that nail care should be performed on shower days, but observations and care plans showed this was not consistently done.
A resident who returned from the hospital with a stitched leg laceration was not assessed by staff, and the wound dressing was not changed for several days. No wound care orders were transcribed into the POS, and staff relied on hospital records for treatment guidance. Facility policy requiring prompt wound assessment and treatment was not followed.
Two residents with pressure injuries did not receive wound care as prescribed by their providers. In one case, a stage 4 sacral wound was not treated with the ordered collagen and calcium alginate dressings, and in another, a right heel wound did not receive the specified medihoney with calcium alginate dressing. Nursing staff did not implement the documented treatment orders, and the required protocols for wound care were not followed.
Two residents with indwelling urinary catheters did not receive care in accordance with infection control protocols, including improper cleaning of catheter tubing, drainage bags resting on the floor or placed on beds, and drainage bags positioned above the bladder causing urine backflow. Staff failed to document catheter care as ordered, and both residents reported that catheter care was not performed regularly.
Three residents with significant weight loss or malnutrition were not provided their prescribed nutritional supplements as ordered. In one case, a dietician's recommendation to increase a supplement was not implemented, and in two other cases, residents were not served their required supplements with meals despite clear orders. Staff confirmed the omissions, and no facility policy on nutritional supplements was in place.
Several residents experienced missed or canceled outside medical appointments due to the facility's failure to coordinate transportation, communicate appointment details to nursing staff, and document cancellations or refusals in the medical record. Issues included lack of notification to nurses, incomplete documentation, and failure to arrange required escorts, despite facility policy requiring such coordination.
Surveyors found that staff failed to administer medications as ordered, resulting in a 12% medication error rate. One resident received an incorrect dose of Zinc due to stock issues and lack of documentation, while another received a lower dose of Duloxetine and was not instructed to rinse their mouth after a steroid inhaler, contrary to policy. Errors were linked to improper medication storage and failure to follow physician orders.
The facility did not promptly implement contact precautions or cohorting for a resident with confirmed C. difficile infection, resulting in a roommate at risk for infection remaining in the same room for several days. Additionally, an LPN failed to wear a gown while providing high-contact care to a resident on enhanced barrier precautions for a gastrostomy tube and MDRO colonization, contrary to facility policy.
The facility did not properly implement its antibiotic stewardship program, resulting in incomplete monitoring and documentation of antibiotic use for two residents. One resident's assessment form for a UTI was not completed, and a required sensitivity analysis was not performed. Another resident received two antibiotics, but only one was reviewed, and the assessment form was incomplete and unclear about the indication. The facility's policy requiring documentation and reassessment of antibiotic use was not followed.
A resident with Alzheimer's and other conditions had a scrotal wound that was not assessed or treated when first identified. Despite a CNA claiming it was reported and documented, there was no record of the wound in the resident's EHR. The wound was later assessed by the Wound Care Director and Nurse Practitioner, who were unaware of it, and identified as moisture-associated skin damage. The facility's policy requires documentation of skin alterations, which was not followed.
A facility failed to prevent cross-contamination by improperly handling soiled items during incontinence care. A CNA placed soiled bedding on the floor and a stool-covered washcloth on a nightstand. A resident's name band was also smeared with feces, which was confirmed by an LPN. The DON stated that soiled items should be placed in a plastic bag, as per policy.
A resident with severe cognitive impairment engaged in a physical altercation with two other residents, using a decorative flagstick and headphones to hit them on the head. One resident sustained a small skin tear and bleeding, while the other did not have any injuries. Staff members intervened by separating the residents and calling for assistance. The facility's policy emphasizes providing care in an environment free from abuse, but this incident highlights a failure to protect residents from physical abuse.
A resident was physically abused by an agency CNA, resulting in bruising on her face and arm. The abuse occurred after the resident expressed discomfort with the CNA's care. Despite the resident's pleas, the CNA continued the abuse, causing significant physical and psychological harm. The facility's care guidelines and abuse policy were not followed.
The facility failed to provide a resident with hand splints as recommended by the Therapy Department, leading to a lack of contracture prevention. The resident, in a persistent vegetative state, was observed multiple times without the prescribed orthotics, and a glitch in the EMR system prevented staff from seeing the task for applying the hand braces.
A facility failed to administer scheduled pain medication to a resident with multiple diagnoses, including traumatic subdural hemorrhage and respiratory failure, on several occasions. The resident's MAR showed multiple unsigned entries, and there were no nursing progress notes explaining the omissions. The resident's daughter expressed concerns about the resident experiencing pain, and the NP confirmed the need for the medication due to the resident's inability to communicate pain levels.
The facility failed to identify, report, assess, and obtain physician orders for new skin breakdowns, and did not ensure that treatment dressings were in place or that soiled dressings were changed for residents with stage 3 and stage 4 pressure ulcers. This resulted in several residents having untreated wounds, some of which contained necrotic tissue, and the deterioration of their conditions.
The facility failed to obtain physician orders and complete self-administration assessments for four residents who were found with medications at their bedside. These residents, who were cognitively intact, reported self-administering their medications without instruction or supervision. The facility did not follow its policy requiring evaluations and physician orders for bedside medication storage.
The facility failed to ensure that intravenous medications were administered by qualified staff, specifically LPNs who were not authorized to perform this task. This deficiency affected five residents who received IV therapy from LPNs, contrary to the facility's policies and the Illinois Nurses Act.
The facility failed to provide timely incontinence care and respond to call lights, affecting eight residents. Observations revealed residents in saturated briefs and unsanitary conditions. Interviews and Resident Council Meeting minutes indicated slow response times from agency CNAs, particularly during the 3 PM - 11 PM shift, with reports of residents waiting hours for assistance.
The facility failed to maintain proper hand hygiene and infection control practices for four residents. A respiratory therapist and a CNA were observed handling soiled items and providing care without changing gloves or performing hand hygiene, violating the facility's infection control policies.
The facility failed to use McGeer's criteria to determine the necessity of antibiotics for four residents. The Infection Preventionist confirmed that the forms were not completed due to the presence of many agency nurses and the absence of a facility policy on McGeer's criteria.
The facility failed to ensure that call lights were within reach for three residents, leading to potential delays in care. Observations revealed that call lights were either on the floor or placed on a dresser, making them inaccessible. The residents, who had no upper extremity impairments, expressed frustration about the inaccessibility of call lights, which is against the facility's policy.
The facility failed to document required details for residents with pacemakers, including orders for checking the pacemaker and specific information about the device. This deficiency was identified in two residents, leading to incomplete care planning and potential gaps in pacemaker management.
The facility failed to change a resident's midline catheter dressing, measure, and document the external length of the catheter and arm circumference as per policy. The resident had a midline catheter with a dressing dated 3/24/2024, which was not changed by 4/04/2024. The Infection Preventionist acknowledged the oversight, attributing it to the resident's hospital visit.
A resident with multiple diagnoses, including severe intellectual disabilities and schizoaffective disorder, was left in pain for over an hour due to a transfer sling left under her. Despite continuous screaming, staff did not promptly address her pain, and the resident only received pain relief after the surveyor's intervention. The DON confirmed that staff should check on residents immediately if they hear screaming and that transfer slings should not be left under residents.
The facility failed to dispose of controlled medications per its policy, as observed in three residents. Medications were found inappropriately returned to punch cards with tape or band-aids over the slots. The Director of Nursing confirmed that controlled medications should be discarded properly and witnessed by two nurses.
Staff Cell Phone Use During Resident Care Undermining Resident Dignity
Penalty
Summary
The facility failed to respect residents’ dignity and right to a dignified existence and self-determination by allowing staff to use personal cell phones while providing resident care. A resident’s daughter reported that CNAs were on their phones “all the time,” including an incident where a CNA, wearing earbuds and engaged in a personal call, told the person on the phone to “hold on,” reached into her pocket to pause the call, and only then addressed the daughter. The same daughter stated she had recently observed CNAs on their phones while providing care to her mother. One resident stated she sees staff on their phones during resident care “all the time,” and another resident stated she does see staff on their phones while providing care. A nonverbal, non-alert, and non-oriented resident’s mother also reported seeing staff on their phones frequently, including during care, and described it as disrespectful and something that should not happen. The DON confirmed that cell phones should not be used while providing care and acknowledged that it is disrespectful for staff to be on their phones while caring for residents, despite the facility’s written policy that strongly discourages personal calls or texting during work time except under extraordinary circumstances or during scheduled breaks.
Failure to Perform and Accurately Document Daily Feeding Tube Dressing Changes
Penalty
Summary
A resident with functional quadriplegia, ventilator dependence, and heart failure had an active physician order, dated 12/4/24, for cleansing the enteral tube feeding site with normal saline and applying a dry dressing every night shift. During surveyor observation, the resident was noted in bed with a foul odor that was not consistent with stool. Later that morning, during incontinence care, staff exposed the resident’s abdominal tube feeding site and observed a split 4x4 gauze dressing with dried black drainage near the tube and a pronounced odor. The dressing was dated 12/29, indicating it had not been changed for approximately nine days despite the daily dressing change order and the facility’s policy requiring daily cleansing and dry gauze coverage of the enteral tube site. The resident’s nurse confirmed that the date on the dressing reflected the last time it was changed and acknowledged that the dressing should have been changed before the day of the survey, stating that tube feeding dressings are typically changed daily on the night shift. When the dressing was removed, the skin underneath was described as reddened, inflamed, and appearing raw. Review of the December and January Treatment Administration Records showed that night shift staff had documented completion of the tube feeding dressing changes on multiple days after 12/29, even though the physical condition and date of the dressing indicated those changes had not been performed. The DON stated that feeding tube dressings should be changed daily on the night shift to prevent infections and that staff should not document dressing changes unless they are actually completed.
Improper Perineal Care Technique During Incontinence Care
Penalty
Summary
The facility failed to provide incontinence care in a manner that prevented potential urinary tract infections for one resident. The resident was admitted with diagnoses including functional quadriplegia, ventilator dependence, and heart failure. During observed incontinence care, a CNA began by cleaning the resident’s vaginal area while the resident was on her back, then, after the resident was rolled onto her side, the CNA wiped stool from the top of the buttocks toward the vagina twice, despite the presence of a moderate, tar-like bowel movement. As a result, the resident’s vaginal area required a second cleaning after she was rolled back onto her back. The shift coordinator/CNA later stated he had quietly instructed the CNA to wipe away from the vagina, acknowledging that wiping stool toward the vagina could lead to a urinary tract infection, and the DON confirmed that stool should be wiped away from the vagina to prevent contamination or infection. The facility’s incontinence and perineal care policy required maintaining clean technique to ensure cleanliness, comfort, and prevention of infection and skin irritation. These observations, interviews, and record review showed that staff did not consistently follow the facility’s incontinence and perineal care policy or accepted clean technique during perineal care for this resident.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the facility's failure to follow established protocols for continence care, catheter management, and infection prevention.
Failure to Maintain Wheelchair in Safe Repair Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's wheelchair was maintained in safe repair, resulting in an accident. The resident sustained a 7 cm L-shaped laceration on her right lower leg after her skin caught on the uncapped right front wheel connector of her wheelchair while transferring from the wheelchair to the toilet. The injury was severe enough to require the resident to be sent to the hospital, where she received 11 sutures. Observations on subsequent days confirmed that the right front wheel connector of the wheelchair remained uncapped. Interviews with facility staff revealed that the LPN who responded to the incident did not notice the uncapped connector at the time, but the Rehab Director and Nurse Practitioner later confirmed that the connector should have been capped and that its condition likely contributed to the injury. The Director of Nursing stated that staff are expected to report any medical equipment in disrepair, including wheelchairs, and that all equipment should be kept in good, safe repair to prevent injuries. The facility's maintenance policy requires the maintenance of equipment and the building environment.
Failure to Properly Label and Remove Expired Medications
Penalty
Summary
Surveyors observed that the facility failed to properly label and store medications, specifically insulin pens and vials, for multiple residents. Insulin pens and vials for seven residents were found without required labeling, such as the resident's name, the date the medication was opened, and the expiration date. Additionally, some medications, including a Humalog Kwik pen and a vial of Humulin R insulin, were found without any resident identification. Staff interviews confirmed that all insulin pens should be labeled with the resident's name and the open and expiration dates, as some insulins are only viable for a specific number of days after opening. Further, expired medications were not removed from storage as required. Two vials of Ativan, which had expired, were found in the medication room refrigerator, and there were no current orders for Ativan for the resident in question. The facility's own policy requires that all opened medication vials be labeled with the date opened and discarded within the specified timeframe, yet this was not followed. These findings were based on direct observation, staff interviews, and review of physician orders and facility policy.
Failure to Provide Required Nail Care to Dependent Residents
Penalty
Summary
The facility failed to provide necessary nail care to three residents who required assistance with activities of daily living (ADLs). One male resident with severe cognitive impairment and contracted hands was observed with long nails and a brownish substance underneath, despite being care planned for total staff participation in personal hygiene. A female resident with mild cognitive impairment, who required partial assistance, was found with a broken nail and long, dirty nails on all fingers. Another male resident with moderate cognitive impairment and a documented need for partial assistance was observed with long nails and a broken, jagged nail. Interviews with nursing staff confirmed that nail care, including trimming and grooming, should be provided on shower days, as outlined in the facility's policy. However, observations and record reviews indicated that these residents did not receive the required nail care, despite their documented deficits and care plans specifying the need for staff assistance with personal hygiene.
Failure to Assess and Obtain Wound Care Orders After Hospital Return
Penalty
Summary
A resident returned from the hospital with a laceration on the right lower leg that required eleven stitches. Upon observation, the resident's wound was covered with a gauze dressing that was brown with dried blood stains and was unraveling. The resident reported that no staff had assessed the wound or changed the dressing since returning from the hospital. Three days after the resident's return, the wound dressing remained unchanged, and the same dried blood stains and unraveling gauze were observed. Review of the resident's Physician Order Sheet (POS) by both an LPN and the Wound Care Director revealed that there were no wound care orders documented for the resident's leg wound. The Wound Care Director confirmed that she had not assessed the wound since the resident's return and stated that prompt assessment and obtaining wound care orders should have occurred. The Treatment Nurse later changed the dressing and stated that she used orders from the hospital records, as no orders had been transcribed into the POS. The facility's policy requires prompt identification, documentation, and treatment for residents with skin breakdown, which was not followed in this case.
Failure to Follow Prescribed Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to follow prescribed treatment orders for pressure wounds in two residents. In one case, a wound care nurse and aide changed a resident's sacral wound dressing and did not apply the ordered collagen and calcium alginate dressings, instead using only a white bordered gauze dressing. The nurse was unsure why the prescribed treatment was not followed, despite clear orders and care plans specifying the use of collagen and calcium alginate with a bordered gauze dressing. The resident's wound was present on admission, classified as stage 4, and exhibited slough tissue and undermining. In another case, a resident developed a facility-acquired unstageable pressure injury to the right heel. The wound care nurse applied a dressing that included medihoney ointment and adaptic, but did not follow the specific order to use medihoney with calcium alginate, ABD pad, and rolled gauze. The treatment administration record did not show that the nurse practitioner's order was implemented. The wound care nurse stated she believed she was following the correct order, and indicated that the wound care team was responsible for reviewing and transcribing treatment orders. Facility policy required prompt identification and appropriate treatment for skin breakdown, but the prescribed wound care protocols were not followed in these cases.
Failure to Provide Proper Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate care to residents with indwelling urinary catheters, resulting in multiple infection control breaches. For one resident with a neurogenic bladder and a history of urinary tract infections (UTIs), staff were observed emptying the drainage bag but not cleaning the catheter tubing as required. During catheter care, the drainage bag was seen resting on the floor and later placed on the resident's bed, both actions contrary to infection control protocols. Staff also used a soiled towel to drape the resident and placed dirty linens on a clean area of the bed. Additionally, the staff did not clean the top inch of the catheter tubing near the insertion site and touched clean surfaces with soiled gloves after providing perineal and catheter care. Another resident with an indwelling urinary catheter due to obstructive and reflux uropathy was observed with the drainage bag positioned above the bladder, causing urine to backflow into the bladder. The drainage bag was also seen resting on the floor and later placed on the bed during care. After catheter care, the drainage bag was again raised above the resident's body, resulting in visible backflow of urine. Both residents reported that staff did not regularly clean their catheter tubing, and one noted frequent hospitalizations for UTIs and regular antibiotic use. Review of care plans and physician orders confirmed that catheter care was to be performed every shift, and the drainage bag was to be kept below the level of the bladder. However, there was no documentation in the electronic medical records for either resident indicating that catheter care was performed as ordered. Facility policy required cleaning the catheter from the insertion site outward and maintaining the drainage bag off the floor and below the bladder, but these procedures were not followed during the observed care.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to process and implement dietary recommendations for nutritional supplements for three residents identified as at risk for or experiencing significant weight loss and malnutrition. For one resident, despite a registered dietician's recommendation to increase the frequency of a nutritional supplement due to ongoing weight loss, the order was not updated in the electronic medical record, and the resident continued to receive the supplement at the previous, lower frequency. This resident's weight continued to decline over several months, and staff interviews confirmed the dietary recommendation was not implemented. Two additional residents, both with documented needs for nutritional supplements due to malnutrition or increased nutritional requirements, were not served their prescribed supplements with their meals on multiple observed occasions. Meal tickets indicated the supplements were ordered, but the items were missing from their trays. Staff interviews confirmed that the kitchen was responsible for including these supplements, but they were not provided as required. The facility did not have a policy regarding nutrition or nutritional supplements at the time of the survey.
Failure to Coordinate Transportation and Appointment Procedures Resulting in Missed Medical Appointments
Penalty
Summary
The facility failed to properly coordinate and document transportation and appointment procedures for residents requiring outside medical appointments, resulting in multiple missed or canceled appointments. One resident, who was cognitively intact, was unable to see her orthopedic physician because the necessary paperwork was not prepared, as the nurse was not notified of the appointment. This resident reported that this was not the first time appointments were missed due to lack of communication between the transportation coordinator and nursing staff. Review of the electronic medical record confirmed that appointment details were not entered, and the transportation coordinator admitted to not notifying the nurses or updating the resident's calendar in the EMR. Another resident reported missed doctor's appointments in the past due to the transportation coordinator's failure to arrange transportation. The transportation coordinator kept records of scheduled and canceled appointments on paper but did not document canceled appointments or resident refusals in the medical record. The resident's care plan and progress notes did not reflect any refusals or reasons for missed appointments, and the transportation coordinator was unable to provide clear reasons for the cancellations. A third resident, also cognitively intact, expressed concern about a canceled doctor's appointment, stating it was due to transportation issues and lack of an escort, which was the responsibility of the transportation coordinator. The transportation service had no record of the appointment being scheduled, and there was no documentation in the progress notes explaining the cancellation. Nursing staff confirmed that the resident was prepared for the appointment, but the absence of an escort and poor communication led to the cancellation. The facility's policy required timely scheduling and coordination of transportation and escorts, but these procedures were not consistently followed.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
Surveyors identified that the facility failed to administer medications as ordered, resulting in a medication error rate of 12% (3 errors out of 25 opportunities) during observation of medication passes. In one instance, a registered nurse administered only 50 mg of Zinc to a resident, despite the physician's order specifying 110 mg twice daily. The nurse acknowledged the error, noting that the available stock was insufficient and that she sometimes attempted to compensate by giving an additional 50 mg later, but this was not documented and still did not meet the prescribed dose. In another case, an LPN administered three 20 mg capsules of Duloxetine (totaling 60 mg) to a resident instead of the ordered three 30 mg capsules (90 mg). The LPN also failed to provide water and encourage the resident to rinse their mouth after administering a steroid inhaler, contrary to both facility policy and manufacturer guidelines. The medication cart was found to contain both 20 mg and 30 mg Duloxetine capsules, which contributed to the error. The facility's policies require strict adherence to physician orders and proper administration techniques, including mouth rinsing after certain inhalers.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to properly implement infection prevention and control measures for residents with acute gastrointestinal infections and those requiring enhanced barrier precautions. One resident began experiencing acute diarrhea and was later confirmed to have a C. difficile infection. Despite this, the resident was not immediately placed on contact precautions, and their roommate, who was at risk for infections due to multiple comorbidities, was not moved to another room until three days after the onset of symptoms and one day after the positive test result. Facility policy and CDC guidelines require immediate implementation of contact precautions and cohorting only with other residents with the same infection, but these were not followed. Additionally, a nurse failed to adhere to enhanced barrier precautions for another resident with a gastrostomy tube and colonization with a multidrug-resistant organism. The nurse entered the resident's room and performed high-contact care activities, including medication administration through the feeding tube, without wearing a gown as required by facility policy. The resident's care plan and facility policy both specified the need for gown and glove use during such activities to prevent the transmission of infectious agents.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required, resulting in incomplete monitoring and documentation of antibiotic use for two residents. For one resident who was started on Ceftriaxone for a urinary tract infection (UTI), the Infection Preventionist (IP) Nurse identified that the McGeer Criteria assessment form was not completed to determine if the prescribed antibiotic was appropriate. Additionally, the urinalysis specimen was not analyzed for sensitivity as ordered, and the assessment form lacked documentation to confirm a review of the antibiotic's appropriateness. The resident's urinalysis was collected and reported without sensitivity analysis, and the antibiotic order remained active without proper review. For another resident receiving both Vancomycin and Meropenem, the IP Nurse was unsure of the indication for Vancomycin and noted that the McGeer assessment form was only initiated for Meropenem, not Vancomycin. The form for Meropenem was incomplete and did not clarify the reason for its use, as there was confusion regarding whether it was prescribed for MRSA in the blood, urine, or both. The facility's policy requires documentation of dose, route, duration, and indication, as well as reassessment of antibiotic use after three days, but these steps were not followed for the residents reviewed.
Failure to Document and Treat Resident's Wound
Penalty
Summary
The facility failed to assess and treat a wound on a resident's scrotum when it was first identified. The resident, who was admitted with diagnoses including Alzheimer's, pressure ulcer, contractures of the legs, failure to thrive, and was under palliative care, was dependent on staff for all activities of daily living. The wound was first noticed by the resident's family member during incontinence care, and it was reported to the state health department. Despite the Certified Nursing Assistant (CNA) stating that the wound had been reported weeks ago and documented in the Electronic Health Record (EHR), there was no documentation of the wound in the resident's records. On a subsequent visit by the state surveyor, the wound was assessed by the Wound Care Director and the Wound Care Nurse Practitioner, who were both unaware of the wound prior to this assessment. The wound was identified as moisture-associated skin damage (MASD) and measured 3.0 cm by 1.5 cm. The facility's wound report and Treatment Administration Record (TAR) showed no documented wounds or treatments for the resident's scrotum. The facility's Wound Care Guideline policy requires that skin alterations be documented in the resident's clinical records, which was not adhered to in this case.
Improper Handling of Soiled Items Leads to Cross-Contamination Risk
Penalty
Summary
The facility failed to handle soiled cleaning supplies and soiled bedding properly, leading to potential cross-contamination. During an observation, a CNA was providing incontinence care to a resident who had a bowel movement. The CNA placed the resident's soiled bedding on the floor and a stool-covered washcloth on the bedside nightstand. Additionally, the resident's name band had a brown smear that appeared to be feces, which was not removed by the CNA. A Licensed Practical Nurse later confirmed the substance on the name band appeared to be feces. The resident's family member also reported that during a visit, the resident's hands and name band were covered in stool, requiring two washcloths to clean. The Director of Nursing stated that all soiled items should be placed directly into a plastic bag to prevent cross-contamination, as per the facility's policy.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in an incident where one resident, with diagnoses including hemiplegia, hemiparesis, depression, dementia, and PTSD, engaged in a physical altercation with two other residents. The incident occurred when the resident obtained a decorative flagstick and used it to hit two other residents on the head. One of the affected residents, who had a history of hemiplegia, hemiparesis, dementia, anxiety disorder, PTSD, and mild cognitive impairment, was hit on the head but did not sustain any injuries. The other resident, with a history of scalp contusion, epilepsy, and falls, was hit on the head with headphones, resulting in a small skin tear and bleeding. The incident was witnessed by staff members, including LPNs and CNAs, who responded by separating the residents and calling for assistance. The facility's Abuse Investigation Report and staff interviews indicate that the resident who initiated the altercation was agitated and had severely impaired cognition. The facility's policy on abuse and neglect defines abuse as the willful infliction of mistreatment or injury, and the policy emphasizes providing care in an environment free from abuse. Despite these policies, the facility's failure to prevent the altercation led to the physical abuse of two residents.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by an agency CNA. The incident occurred when the CNA punched the resident in the face and grabbed her lower arm, resulting in bruising on her face and arm. The resident reported that the abuse happened after she expressed discomfort with the way the CNA was changing her. Despite her pleas for the CNA to stop, the abuse continued, causing significant physical and psychological harm to the resident. The resident, who has multiple diagnoses including dementia, depression, and chronic pain syndrome, was found with dark purple bruising under her left eye, above her right eye, across the bridge of her nose, and on her left forearm. The resident recounted the incident, stating that the CNA hit her with a pillow multiple times before punching her in the face. The resident did not use her call light due to fear and later requested pain medication from an LPN, who then discovered the injuries and reported the incident. The facility's records show that the resident is cognitively intact and requires substantial assistance with daily activities. The resident's care plan includes specific instructions to create a warm and safe environment, emphasizing dignity and patience. However, these guidelines were not followed by the CNA, leading to the abusive incident. The facility's policy on abuse and neglect clearly defines physical abuse and outlines the need for professional care free from any type of abuse, which was not adhered to in this case.
Removal Plan
- R1 remains in the facility with psychosocial services available to R1.
- R1 was seen by a psychotherapist and wellness checks by the Social Services Department have been ongoing and will continue three times a week for 30 days.
- V3 (Agency CNA) was removed and placed on the do not return list and has not returned to the facility since. Police were notified.
- The facility notified the staffing agency that V3 was asked not to return due to an abuse allegation.
- The facility opened an abuse allegation related to R1 and this investigation was concluded and substantiated. V3 (Agency CNA) was reported to the State Agency Healthcare Worker Registry.
- All agency staff will be provided abuse training prior to the start of their shift by the DON (Director of Nursing) or designee. This will include an audit questionnaire to validate return demonstration of understanding.
- Staff were re-educated on the facility Abuse and Neglect Policy by the Administrator and/or designee and is ongoing. This re-education will continue and be completed. Return demonstration of understanding was provided by way of conducting an audit questionnaire.
- An audit was conducted on all residents cared for by V3 (Agency CNA) to ensure abuse did not occur with anyone else.
- Residents with specific preferences and/or behaviors are being identified. Care cards listing these items will be placed in a binder at the nurse's station on each floor for staff knowledge. This will be updated as needed by the Social Services Department.
- All staff, including agency staff will be educated on the care card location, and to check the care card prior to providing care.
- Quality assurance audit will be conducted daily by the Administrator and/or designee to ensure agency staff have been educated on abuse with return demonstration of understanding. All identified trends will be reviewed by the monthly QAPI (Quality Assurance and Performance Improvement) Committee, and a plan will be discussed and implemented until resolution.
- The incident and abatement plan will be discussed and reviewed with the facility Medical Director.
- Emergency QAPI meeting will be conducted.
Failure to Provide Hand Splints as Recommended
Penalty
Summary
The facility failed to ensure a resident was provided with hand splints to prevent further decrease in range of motion as recommended by the Therapy Department. The resident, who was in a persistent vegetative state and dependent on staff for all activities of daily living, was observed multiple times without the prescribed hand splints. The resident's care plan indicated the need for bilateral resting hand orthotics for six hours per day, but there was no documentation to show that the splints were applied on several dates in April 2024. The Director of Rehab confirmed that the resident was recommended to wear hand splints to prevent contractures and further decline. The facility's Restorative Nurse acknowledged that the hand splints had not been placed on the resident due to the absence of a restorative aide. Additionally, the Regional Nurse Consultant identified a glitch in the electronic medical record system that prevented nursing staff from seeing the task for applying the hand braces. The facility's policy on the Restorative Nursing Program emphasized the need for comprehensive assessments and appropriate restorative services, including splint/orthotic management, but these were not consistently provided to the resident.
Failure to Administer Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure a resident received scheduled pain medication as ordered. The resident, who has multiple diagnoses including traumatic subdural hemorrhage, respiratory failure, and is in a persistent vegetative state, was prescribed Norco to be administered twice daily via gastrostomy tube for pain management. However, the facility's records show that the medication was not administered on multiple occasions, specifically on April 3, 4, 6, 11, 12, 13, 14, 15, 16, 19, and 26, 2024, at 9:00 PM. The Medication Administration Record (MAR) for these dates remained unsigned, indicating the medication was not given as ordered, and there were no nursing progress notes explaining the omission. The resident's daughter expressed concerns about the resident experiencing pain, noting facial grimaces when touched or when her hair was combed, which further underscores the importance of the prescribed pain management regimen. The Nurse Practitioner (NP) who examined the resident noted that the resident had sinus tachycardia and ordered Norco for pain management, as the resident is unable to communicate pain levels due to her condition. The Director of Nursing (DON) acknowledged the failure to administer the medication as ordered and confirmed that the facility staff should have documented the removal and administration of the medication. This deficiency highlights a significant lapse in the facility's adherence to prescribed pain management protocols for a resident with complex medical needs.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to identify, report, assess, and obtain physician orders for new skin breakdowns, and did not ensure that treatment dressings were in place or that soiled dressings were changed for residents with stage 3 and stage 4 pressure ulcers. This resulted in several residents having untreated wounds, some of which contained necrotic tissue. For instance, one resident had an unidentified right ischium wound with 25% necrotic tissue that was uncovered and without treatment, while another resident had a right ischium wound with necrotic muscle tissue exposed and no treatment. Additionally, a third resident had a right ischium wound that increased in size from previous assessments and was also without treatment. These deficiencies were observed in 5 out of 5 residents reviewed for pressure ulcers in a sample of 30 residents. The facility's failure to implement pressure ulcer interventions and maintain proper wound care protocols was evident in multiple cases, leading to the deterioration of residents' conditions. For example, one resident was found with a soiled dressing and an open wound on the right ischium without a treatment dressing in place. The wound care nurse admitted it was her first time seeing the wound and had to request an assessment from the wound nurse practitioner. Another resident had a sacrum and left ischium dressing that was saturated and had a foul odor, with the right ischium wound exposed and necrotic muscle tissue visible. The wound care nurse acknowledged that the wounds should have been covered and that the floor nurses were expected to change soiled dressings as ordered. In another instance, a resident's right ischium pressure ulcer was observed without a treatment dressing and was soiled with stool. The wound care nurse confirmed that the wound should have been covered as per the treatment order. The facility's documentation and communication regarding wound care were also found to be lacking. For example, one resident's electronic medical record did not show a treatment order for a newly identified left heel wound and right ischium wound. Another resident's care plan and order review report did not reflect the current status of their wounds, and the wound care nurse was unaware of the new wounds until they were discovered during the survey. Additionally, the facility's policy on wound care guidelines was not consistently followed, as evidenced by the lack of timely assessment, documentation, and communication of new wounds to the physician or wound care specialist.
Failure to Obtain Physician Orders and Complete Self-Administration Assessments
Penalty
Summary
The facility failed to obtain physician orders for resident medications to be kept at the bedside and did not complete self-administration of medication assessments for four residents. Specifically, medications were found on the bedside tables of residents R62, R109, R21, and R88 without proper physician orders or assessments. These residents, who were cognitively intact according to their BIMS scores, reported that they self-administered their medications without any instruction or supervision from the nursing staff. The medications included inhalers, nasal sprays, eye drops, and various pills, all of which were not authorized to be kept at the bedside according to the residents' Physician Order Sheets (POS) and medical records. Additionally, the facility's policy on self-administration of medication was not followed, as no assessments were uploaded into the electronic medical record system for these residents. Interviews with the nursing staff, including an LPN and the Director of Nursing (DON), revealed that the facility did not consistently follow its own procedures for evaluating residents' ability to self-administer medications. The DON confirmed that nurses are required to obtain a physician's order and complete a self-administration assessment, which should be documented in the electronic medical record. However, these steps were not taken for the residents in question. The facility's policy mandates that the Interdisciplinary Team (IDT) evaluate the resident's capability to safely administer medication and obtain a physician's order for bedside storage, which was not adhered to in these cases.
Unqualified Staff Administering IV Medications
Penalty
Summary
The facility failed to ensure that intravenous medications were administered by qualified staff, specifically Licensed Practical Nurses (LPNs) who were not authorized to perform this task. This deficiency was observed in five residents (R24, R95, R476, R477, and R478) who were receiving intravenous therapy. On multiple occasions, an agency LPN (V24) reconstituted and administered intravenous medications to these residents without supervision. The Director of Nursing (DON) confirmed that LPNs should not be administering IV medications as it is outside their scope of practice, which is supported by the facility's job description and the Illinois Nurses Act. The medications administered included Micafungin, Meropenem, Cefepime, Cefiderocol, and Zyvox, all of which were given through midline catheters, a procedure that should only be performed by Registered Nurses (RNs). The facility's documentation and interviews with staff confirmed that these actions were not in compliance with professional standards of quality care. The report highlights specific instances where the LPN administered intravenous medications to residents without proper authorization. For example, R477 received Micafungin IV medication administered by V24, and R24 received Meropenem IV medication from the same LPN. Additionally, R95, R476, and R478 also received various intravenous medications from V24 and another agency LPN (V37). The facility's Director of Nursing acknowledged that these actions were outside the LPNs' scope of practice, and the facility's job description for LPNs did not include the administration of IV medications. This failure to adhere to professional standards of quality care was identified through observations, interviews, and record reviews conducted by the surveyors.
Failure to Provide Timely Incontinence Care and Respond to Call Lights
Penalty
Summary
The facility failed to provide timely incontinence care and respond to call lights, affecting eight residents. Observations revealed that residents were left in saturated disposable briefs, with some wearing two briefs at once, which is against facility policy. For instance, one resident was found with two urine-soaked briefs, and another had a wet bed sheet from urine. These incidents indicate that residents were not being changed frequently enough, leading to potential skin integrity issues. Several residents, including those with severe cognitive impairments and extensive care needs, were found in unsanitary conditions. One resident had dried stool on her buttocks, and another had a urine-soaked bed sheet. Interviews with CNAs revealed that they were not familiar with the residents and denied placing two briefs on them. The Director of Nursing confirmed that residents should not wear two briefs and emphasized the need for more frequent toileting or changing for heavy wetters. During a Resident Council Meeting, multiple residents expressed concerns about the slow response times from agency CNAs, particularly during the 3 PM - 11 PM shift. They reported that CNAs often took breaks simultaneously, leaving no staff to assist residents. One resident mentioned waiting 2.5 hours for toileting assistance. The Ombudsman and Resident Council Meeting minutes corroborated these complaints, highlighting ongoing issues with agency staff not performing ADL care adequately, especially during the night shift.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain proper hand hygiene and infection control practices for four residents. In one instance, a respiratory therapist (RT) did not change gloves or perform hand hygiene while performing multiple tasks, including handling soiled items and sterile equipment for a resident with a tracheostomy. The RT admitted to not following sterile technique and the Director of Respiratory Therapy confirmed the breach in protocol. The Director of Nursing (DON) acknowledged that such lapses increase the risk of infection for residents. In another instance, a Certified Nursing Assistant (CNA) was observed providing incontinence care to a resident and handling soiled briefs without changing gloves or performing hand hygiene. The CNA placed soiled items on the floor and on a roommate's overbed table, then continued to provide care without proper sanitation. The DON confirmed that these actions were against infection control policies and could spread contaminants. A third incident involved the same CNA providing care to another resident, where she again failed to follow proper hand hygiene and infection control practices. The CNA placed soiled linens and briefs on the floor and on surfaces used by residents, then continued care without changing gloves or performing hand hygiene. The DON reiterated that these actions violated the facility's infection control policies, which require hand hygiene before and after direct patient contact and after handling soiled items.
Failure to Utilize McGeer's Criteria for Antibiotic Use
Penalty
Summary
The facility failed to utilize a standardized tool, specifically McGeer's criteria, to determine the necessity of antibiotics prescribed to residents. This deficiency was identified for four residents who were prescribed antibiotics within the last three months. During the review of the infection control binder, it was found that there were no McGeer's criteria forms for these residents. The Infection Preventionist, who was covering for the previous infection preventionist, confirmed that the forms were not completed and stated that the facility had not been utilizing McGeer's criteria due to the presence of many agency nurses who were not performing this task. Additionally, the facility did not have a policy regarding the use of McGeer's criteria for antibiotics. The specific cases reviewed included a resident prescribed Levaquin for an infection, another resident prescribed Levofloxacin intravenously for leukocytosis, a third resident prescribed Amoxicillin-Potassium Clavulanate for a soft tissue infection, and a fourth resident prescribed Cefiderocol Sulfate Tosylate intravenously for an intra-abdominal infection. In all these cases, the required McGeer's criteria forms were not uploaded into the residents' medical records. The Infection Preventionist acknowledged the oversight and indicated that the facility was working on addressing the issue.
Failure to Ensure Call Lights Were Within Residents' Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to potential delays in care. On multiple occasions, surveyors observed that call lights were either on the floor or placed on a dresser, making them inaccessible to the residents. One resident, who requires assistance with incontinence care, stated that staff often forget to place the call light within reach. Another resident demonstrated that her call light was not within reach, and she expressed frustration about having to wait for staff to come to her room before she could receive help. The third resident also reported that staff do not always place the call light within reach, despite her need to use it for assistance. The residents involved had varying levels of cognitive impairment but no upper extremity impairments, indicating they were capable of using the call lights if they were accessible. The facility's Director of Nursing confirmed that call lights should always be within reach to ensure prompt care and prevent residents from attempting to do things on their own, which could lead to falls. The facility's Call Light Policy, revised in 2023, mandates that call lights be placed within reach of residents at all times, but this policy was not followed in these instances.
Failure to Document Pacemaker Details
Penalty
Summary
The facility failed to have the required documentation in the medical records of residents who had pacemakers. This deficiency was identified in two residents out of a sample of 30. For one resident, the Physician Order Sheet (POS) did not include an order for the pacemaker or parameters for checking it. The resident's admission assessment incorrectly indicated that the resident did not have a pacemaker, and the care plan lacked details such as the model, make, serial number, date of insertion, and the place it was inserted. The Director of Nursing confirmed that the nurse responsible for the admission should obtain this information from the Power of Attorney or the hospital and ensure it is included in the POS and care plan. However, this was not done for the resident in question, leading to incomplete documentation and care planning for the pacemaker management. Another resident's records showed that the pacemaker had only been checked once since admission, and the care plan did not specify the make, model, and serial number of the pacemaker. The facility's policy on pacemakers, which was reviewed recently, requires detailed documentation of the pacemaker, including the date of insertion, physician, place of insertion, make, model, serial number, and orders for how often the pacemaker should be checked and by whom. This policy was not followed, resulting in incomplete documentation and potential gaps in the monitoring and management of the resident's pacemaker.
Failure to Adhere to Midline Catheter Care Policy
Penalty
Summary
The facility failed to change a resident's midline catheter dressing, measure, and document the external length of the catheter and arm circumference as per facility policy. The resident, who was admitted with multiple diagnoses including an intra-abdominal infection, had a midline catheter with a transparent dressing dated 3/24/2024. Observations on 4/02/2024 and 4/04/2024 confirmed that the dressing had not been changed since 3/24/2024, despite the facility's policy requiring dressing changes every 7 days. Additionally, the resident's Treatment Administration Records for March and April 2024 did not show any documentation of the required dressing changes or measurements of the external catheter and arm circumference. The Infection Preventionist (IP) acknowledged that the midline catheter dressing should be changed every 7 days to prevent infection. The IP stated that the dressing change was missed because the resident had gone to the hospital and it was overlooked upon their return. The facility's Intravenous Therapy policy, revised on 8/07/2023, mandates weekly dressing changes and measurements to monitor for edema and catheter movement, which were not adhered to in this case.
Failure to Address Resident's Pain Promptly
Penalty
Summary
The facility failed to immediately address a resident's pain, as evidenced by the continuous screaming of a resident (R75) on the memory care unit. R75, who has diagnoses including congestive heart failure, anxiety, severe intellectual disabilities, schizoaffective disorder, and type 2 diabetes, was observed yelling and screaming from her room for over an hour. Despite the care plan indicating that R75 is at risk for pain and requires pain assessments every shift, the staff did not promptly respond to her distress. The resident pointed to a blue transfer sling under her, stating it was causing her pain. A CNA confirmed that the sling should not have been left under the resident, and the RN acknowledged that the last administration of Acetaminophen for pain was several days prior, on 3/24/24. The resident's pain was only addressed after the surveyor's intervention, and the resident felt better after receiving medication through her feeding tube. The Director of Nursing (DON) confirmed that staff should check on residents immediately if they hear screaming and that transfer slings should not be left under residents due to the risk of discomfort and potential injury. The facility's pain policy mandates that all residents be assessed for pain in situations where there is a potential for pain, which was not adhered to in this case. The failure to promptly address the resident's pain and discomfort constitutes a deficiency in providing appropriate pain management and care for the resident.
Failure to Dispose of Controlled Medications Properly
Penalty
Summary
The facility failed to dispose of controlled medications per its policy, as observed in three residents. For Resident 58, a lorazepam 0.5mg medication punch card was found with a pill slot punched open and taped over, despite no order for lorazepam in the resident's Order Review Report. Similarly, Resident 108's hydrocodone-APAP 5-325mg medication punch card had a pill slot punched open and covered with a band-aid, even though there was an active order for Norco Oral Tablet 5-325 MG. The Registered Nurse present during the observation acknowledged that the medications should have been wasted appropriately and not placed back into the punch cards. For Resident 4, a tramadol 50mg medication punch card was observed with a pill slot punched open and taped over. The Registered Nurse present confirmed that the medication should have been wasted and the medication log updated. The Director of Nursing stated that controlled medications should not be returned to the medication punch cards and should be discarded appropriately, witnessed by two nurses, and discontinued medications should be given to her for proper destruction. The facility's policy on Medication Storage, Labeling, and Disposal mandates that controlled medications be disposed of properly to prevent accidental exposure and diversion using Drug Buster or Rx Destroyer.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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