Heartland Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Casey, Illinois.
- Location
- 410 Northwest Third, Casey, Illinois 62420
- CMS Provider Number
- 145416
- Inspections on file
- 31
- Latest survey
- October 20, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Heartland Nursing & Rehab during CMS and state inspections, most recent first.
The facility did not maintain full mechanical lifts in safe working order, as several lifts were found to be nonfunctional, with broken emergency releases and makeshift repairs such as adhesive tape. Staff and residents reported frequent problems, and maintenance did not perform routine checks or receive work orders for these issues, resulting in continued use of unsafe equipment for multiple residents requiring lift assistance.
A resident who required a full mechanical lift for transfers, as documented in the care plan due to a right femur fracture, was transferred using a sit-to-stand lift by a CNA when the appropriate lift was not working. The resident expressed concern during the transfer, and staff confirmed that no updated therapy recommendations had been made to change the transfer method. The facility's policy for assessing and documenting transfer needs was not followed.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to insufficient safeguards and oversight by the facility.
A resident with dementia and multiple comorbidities, identified as a fall risk, did not have required fall prevention interventions in place, including non-skid strips, non-slip wheelchair material, and protective leggings and sleeves. The nurse call device was also out of reach. This lack of adherence to the care plan and physician orders resulted in an unwitnessed fall with multiple injuries.
The facility failed to employ a qualified director of food and nutrition services, impacting all 42 residents. The Dietary Manager lacked necessary certifications, holding only a cooking sanitation certificate. The facility used a Registered Dietician one day per month, and the previous Certified Dietary Manager was on leave and not returning. Issues with palatability, sanitation, and meal service were noted.
The facility failed to prevent potential food contamination by improperly storing a measuring scoop in a bulk sugar bin and keeping a broken spatula in a utensil drawer. These deficiencies could affect all 42 residents.
The facility failed to maintain an effective infection prevention and control program, lacking a comprehensive policy and documentation for trending monthly infections. The DON, also the Infection Preventionist, did not maintain a complete infection log, with records only for October and November 2024, and none for employees. No Quality Assurance process was in place for recurring infections, and no infection trending was completed, potentially affecting all 42 residents.
The facility failed to implement an effective infection prevention and control program, specifically lacking an antibiotic stewardship program. The DON admitted that there were no antibiotic protocols or monitoring systems in place. The existing policy, dated 2/7/23, had not been updated annually, potentially affecting all 42 residents.
The facility failed to address grievances from residents and inform them about the grievance process. Residents reported dissatisfaction with meal options and lack of snacks at bedtime. The Dietary Manager acknowledged issues with meal service, and the survey book was found hidden and outdated. The grievance policy was not effectively communicated or implemented.
The facility failed to maintain sanitary conditions for respiratory care equipment for four residents, leading to deficiencies in infection control practices. A resident with COPD had undated oxygen tubing improperly stored, while another with pneumonia used a dirty suction catheter. A third resident's request for less frequent tubing changes was not documented or communicated regarding infection risks, and a fourth resident's oxygen equipment was not changed as required. These issues indicate a failure to adhere to the facility's policy on respiratory equipment sanitation.
The facility failed to contact physicians for unaddressed pharmacist recommendations and did not document physician responses, affecting several residents. For example, a resident on long-term antipsychotic medication lacked an AIMS assessment, and another was prescribed Seroquel without an approved diagnosis. Additionally, a resident's medication review suggested dose reductions due to falls, but the physician's response was delayed and undocumented. The facility did not adhere to its policy requiring regular AIMS assessments.
The facility failed to conduct necessary assessments and maintain accurate documentation for residents on psychotropic medications. Residents with conditions such as Alzheimer's, Dementia, and Major Depression were prescribed medications like Olanzapine, Sertraline, and Quetiapine without required quarterly assessments or attempts at gradual dose reductions. PRN orders lacked specified durations, and AIMS assessments were not completed as per policy, highlighting significant lapses in medication management.
The facility failed to maintain resident dignity by not covering urinary catheter bags for two residents. A resident's catheter bag was observed uncovered, exposing urine, and a caregiver reported inconsistent coverage of another resident's bag. The DON expressed disapproval of the practice, and the facility's policy requires catheter bags to be covered.
A facility failed to request a PASARR Level II Screening for a resident with Schizoaffective Disorder who was receiving antipsychotic medication. The resident's medical records indicated the disorder as a diagnosis during the stay, and observations showed symptoms consistent with the disorder. The facility's President of Clinical Operations confirmed the absence of a PASARR II request and acknowledged the lack of a policy for admissions regarding PASARR screenings.
A facility failed to document a discharge summary for a resident with multiple medical conditions, including Acute Kidney Failure and Heart Failure. The discharge summary was supposed to include a recapitulation of the resident's stay, a final summary of the resident's status, and a post-discharge plan of care. The Director of Nurses confirmed the absence of this documentation, which is crucial for ensuring continuity of care.
A resident with a urinary tract infection did not receive complete doses of prescribed antibiotics due to a failure in medication administration. The resident's MAR showed missing doses, leading to a subsequent infection confirmed by urinalysis. The DON acknowledged the error, noting the potential impact on treatment efficacy.
A resident with a history of tobacco use and other medical conditions was observed smoking unsupervised, despite the care plan indicating supervision was required. The resident kept smoking materials in her room and smoked alone, contrary to documented interventions. Facility staff confirmed the care plan did not match the resident's actual smoking practices, leading to a deficiency in ensuring a safe environment.
A resident experienced a 7.24% weight loss within two weeks of admission, but the facility failed to notify the physician or develop a care plan. The resident, with severe protein-calorie malnutrition and NPO status, was at high risk for weight loss due to multiple health issues. Despite the facility's policy requiring notification for significant weight changes, no new interventions were implemented.
A facility failed to monitor and obtain physician orders for a resident with a gastrostomy tube. The resident, diagnosed with dysphagia and severe protein-calorie malnutrition, was on NPO status and required enteral feeding. Despite this, the resident self-administered feedings and medications without orders for self-administration or staff monitoring. The DON confirmed the lack of orders and documentation for site maintenance or monitoring.
A facility failed to administer medications on time for a resident, with medications scheduled for 8:00 AM not prepared until 10:17 AM. An LPN cited being occupied with another resident's surgery as the reason for the delay. Other LPNs confirmed that late medication administration was common due to staffing challenges. The DON acknowledged that medications should be on time, and the facility's policy requires timely administration, but the MAR did not reflect actual administration times.
The facility failed to obtain physician's orders for supplemental oxygen for three residents, including those with chronic respiratory conditions. Observations revealed that two residents were using oxygen without documented orders, and all three lacked orders specifying when to change oxygen equipment, contrary to facility policy. The DON acknowledged the oversight due to a recent computer program change.
Failure to Maintain Safe and Operable Mechanical Lifts
Penalty
Summary
The facility failed to maintain full mechanical lifts in safe and operable condition, affecting all eight residents reviewed who required the use of these lifts. Multiple residents reported that the full mechanical lifts were not functioning properly, with issues such as the lifts only lowering and not raising, and the emergency release mechanisms being broken. Staff confirmed that one lift had gray adhesive tape around the gear box housing, which had been present for at least three years, and that the emergency release had also been nonfunctional for a significant period. Staff had to use alternative equipment or borrow lifts from other areas due to these malfunctions. The maintenance director stated that no work orders had been received for the lifts and that there were no routine checks performed on the equipment. Upon inspection, the maintenance director confirmed that one lift would not raise and both lifts had nonfunctional emergency releases. Facility policy required that lifts be tested for proper function, including the emergency release, and that non-working lifts be removed from service until repaired. However, these procedures were not followed, and the lifts remained in use despite ongoing mechanical issues.
Improper Transfer Method Used Due to Equipment Failure
Penalty
Summary
A deficiency occurred when a resident, who is cognitively intact and dependent on staff for transfers due to a right femur fracture, was transferred using a sit-to-stand mechanical lift instead of the care plan-specified full mechanical lift. On the day in question, the full mechanical lift on the resident's hallway was not functioning, and maintenance staff were unavailable. The Certified Nursing Assistant (CNA) used the sit-to-stand lift to transfer the resident from the wheelchair to the bed, despite the resident expressing concern about falling. The resident's care plan and Minimum Data Set (MDS) indicated that a full mechanical lift was required for transfers, and there had been no documented change in transfer status from therapy staff. Interviews with facility staff confirmed that the resident's transfer status remained unchanged and that the use of the sit-to-stand lift was not approved for this resident. The CNA acknowledged submitting a work order for the broken lift but proceeded with the alternative transfer method without updated recommendations from therapy or changes to the care plan. The facility's policy requires ongoing assessment and documentation of transfer needs, which was not followed in this instance.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall and accident prevention interventions as outlined in a resident's care plan and physician orders. The resident, who had diagnoses including dementia, major depression, hypertension, and osteoarthritis, was identified as a fall risk and required staff supervision and assistance for all activities of daily living. Despite physician orders and care plan interventions for non-skid strips in front of the recliner, non-slip material in the wheelchair seat, and the use of protective leggings and sleeves, these measures were not in place at the time of observation. The resident's nurse call device was also found out of reach, hanging from a light fixture several feet away from where the resident was seated. The resident experienced an unwitnessed fall from bed, resulting in multiple bruises, abrasions, and a head injury that required emergency department evaluation and treatment. Upon return to the facility, further injuries were noted, including additional bruising and surgical glue applied to wounds. Staff interviews confirmed that required fall prevention interventions were not consistently implemented, and the resident was not wearing the prescribed protective equipment. The lack of adherence to the care plan and physician orders directly contributed to the resident's fall and subsequent injuries.
Facility Lacks Qualified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a qualified director of food and nutrition services, affecting all 42 residents. The Dietary Manager, identified as V5, was observed supervising and directing food preparation and meal services without holding the necessary qualifications. V5 only possessed a cooking sanitation certificate from a national company and did not have a Certified Dietary Manager (CDM) certificate or a Certified Food Protection Professional (CFPP) certificate. Additionally, V5 did not meet the state requirements for a Director of Food Services or the definition of a Dietetic Service Supervisor, lacking a national dietetic school program graduation, relevant experience prior to 1990, or qualifying military experience. The facility utilized the services of a Registered Dietician on a consultant basis for only one day per month. The Regional Dietary Representative, V6, also lacked the necessary certifications but was enrolled in a Certified Dietary Manager course, with plans to enroll V5 after 30 days of employment. The facility's administrator, V1, acknowledged that the previous Certified Dietary Manager was on family medical leave and would not return, leading to V5's hiring. The report also noted issues with palatability, sanitation, lack of alternative menu items, lack of bedtime snacks, and potential contamination in the kitchen and meal services.
Kitchen Utensil Contamination Risk
Penalty
Summary
The facility failed to maintain kitchen utensils in a manner that prevents potential food contamination. During an observation, a metal, long handle measuring scoop was found inside a bulk sugar bin, with the handle in direct contact with and partially buried by the sugar. This was acknowledged by the Dietary Manager and the Regional Dietary Representative, who confirmed that the scoop should not be left in the sugar. Additionally, a silicone blade spatula with a broken corner was found in a kitchen utensil drawer. The broken spatula exposed granulated and rough internal material, which could potentially crumble off and contaminate food during preparation, and was not easily cleanable. These deficiencies have the potential to affect all 42 residents residing in the facility.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of a comprehensive Infection Control Surveillance and Monitoring Policy. The facility did not provide documentation on how it trends monthly infections to prevent further spread throughout the facility. The Director of Nursing, who also serves as the Infection Preventionist, admitted to not maintaining a log for infections for residents, with records only available for October and November 2024, and none for employees. Additionally, there was no Quality Assurance process in place for recurring infections, and no trending of the facility's infections was completed. This deficiency has the potential to affect all 42 residents residing in the facility.
Lack of Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, specifically lacking an antibiotic stewardship program. This deficiency was identified during an interview and record review, where the Director of Nursing (DON) admitted that the facility had not completed an Antibiotic Stewardship Program. There were no antibiotic protocols or systems in place to monitor antibiotic use among the residents. The existing policy, intended to monitor antibiotic use, was dated 2/7/23 and had not been updated annually. This oversight has the potential to impact all 42 residents residing in the facility.
Failure to Address Resident Grievances and Meal Service Issues
Penalty
Summary
The facility failed to adequately address grievances from residents and their families, as well as inform them about the grievance process and the location of the survey book. Four residents expressed that while they could voice complaints, no actions seemed to follow. They were unaware of how to file a grievance form, and the Activity Director, who took their complaints, did not document or follow up on these concerns. Additionally, the residents reported dissatisfaction with meal options and the lack of snacks at bedtime, noting that meals were often late and cold, and that they were not informed about an 'always available' menu. The Dietary Manager acknowledged issues with meal service, including cold and late meals, and stated that the 'always available' menu was not being utilized properly. The survey book, which should be accessible to residents, was found hidden behind decor and was not up to date, containing only surveys from 2022. The facility's grievance policy states that grievances should be directed to the Administrator, who is responsible for addressing them promptly, but this process was not being effectively communicated or implemented.
Deficiencies in Respiratory Equipment Sanitation
Penalty
Summary
The facility failed to maintain sanitary conditions for respiratory care equipment for four residents, leading to deficiencies in infection control practices. Resident R34, diagnosed with Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure, had undated oxygen tubing and nebulizer equipment improperly stored, confirmed by both the resident's daughter and the Director of Nurses. Resident R350, diagnosed with Pneumonia and Sepsis, was using a dirty oral suction catheter that was not covered, and the Director of Nurses confirmed it should have been cleaned and stored properly. Resident R4, who was using continuous oxygen therapy, had requested less frequent changes of his oxygen tubing, which was not documented or communicated to him regarding the infection control risks. The tubing and humidifier bottle were not changed weekly as per the physician's order. Resident R14, with diagnoses including Obstructive Sleep Apnea, had oxygen tubing and a water bottle that were not changed since the previous month, despite using oxygen nightly. These observations indicate a failure to adhere to the facility's policy on changing and storing respiratory equipment, leading to potential infection risks.
Failure to Address Pharmacist Recommendations and Document Physician Responses
Penalty
Summary
The facility failed to ensure that physicians were contacted for unaddressed pharmacist recommendations and did not maintain documented evidence of physician responses to these recommendations. This deficiency affected four residents who were reviewed for unnecessary medications. For instance, a pharmacist recommended an AIMS assessment for a resident on long-term antipsychotic medication, but there was no documented physician response or evidence of the assessment being conducted. Another resident was prescribed Seroquel without an approved diagnosis, and there was no physician response to the pharmacist's request for justification. Additionally, a resident's medication regimen review suggested dose reductions due to self-reported falls, but the physician did not respond timely and provided no documented reason for declining the recommendation. Another resident had multiple pharmacist recommendations for AIMS assessments, yet there was no evidence of these assessments being conducted or any physician response. The facility's policy required AIMS assessments before starting neuroleptic therapy and every six months thereafter, but this was not adhered to, and there was no policy provided regarding following pharmacy recommendations.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to conduct necessary assessments and maintain accurate documentation for residents receiving psychotropic medications. Specifically, the facility did not perform required quarterly psychotropic medication assessments or abnormal involuntary movement scale (AIMS) assessments for residents on antipsychotic medications. For instance, a resident with Alzheimer's Disease and Dementia was receiving Olanzapine and Sertraline without any documented attempts at gradual dose reduction or clinical contraindications for such reductions. Additionally, the resident's electronic medical record lacked any quarterly psychotropic medication assessments or AIMS assessments. Another resident with Major Depression was prescribed Bupropion, yet their electronic medical record did not include any required quarterly psychotropic medication assessments. The Director of Nursing acknowledged that these assessments should be completed quarterly, and AIMS assessments every six months, but they were not found in the records. Furthermore, a resident with Dementia and Irritability was prescribed Quetiapine and Lorazepam on a PRN basis without a specified stop date or duration, contrary to the facility's policy requiring PRN psychotropic medications to be limited to 14 days unless justified by a physician. The facility's failure to adhere to its own policies and regulatory requirements was further evidenced by another resident with Schizoaffective Disorder who did not have any AIMS assessments documented until prompted by the surveyors. Similarly, a resident with Dementia and Major Depression was prescribed Risperidone and Sertraline without any documented AIMS assessments or attempts at gradual dose reductions over the past year. The facility's policies clearly state that psychotropic medications should be prescribed at the lowest possible dosage for the shortest period and are subject to gradual dose reduction and review, which was not followed in these cases.
Failure to Cover Urinary Catheter Bags
Penalty
Summary
The facility failed to protect the dignity of residents by not ensuring that urinary catheter collection bags were covered. This deficiency was observed in two residents, R22 and R33, who were part of a sample list of 26. On December 10, 2024, at 10:50 AM, R33's urinary catheter collection bag was seen under his wheelchair without any covering, exposing approximately 400 cc's of yellow urine. The Director of Nursing, V2, expressed disapproval of the exposed catheter bags, indicating a preference for them to be covered. Additionally, V7, a private caregiver for R22, reported that the staff inconsistently covered R22's catheter bag, leading to situations where R22's family had to search for a covering bag when taking R22 out of the facility. The facility's policy on Quality of Life - Dignity, dated 2001, mandates that residents be cared for in a manner that promotes dignity, explicitly stating that urinary catheter bags should be covered.
Failure to Request PASARR Level II Screening for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to request a Preadmission Screening and Resident Review (PASARR) Level II Screening for a resident diagnosed with Schizoaffective Disorder who was receiving antipsychotic medication. The resident's medical diagnosis sheet, dated December 13, 2024, indicated that the primary medical diagnosis for admission was Interstitial Pulmonary Disease, with Schizoaffective Disorder listed as a diagnosis during the stay. The initial PASARR screening, completed on August 8, 2021, at a different facility, documented that the resident did not need a Level II screening at that time. Observations on December 12, 2024, showed the resident engaging in conversation with an imaginary person, indicating symptoms of Schizoaffective Disorder. The resident's physician's order sheet from December 2024 confirmed the use of Quetiapine Sulfate (Seroquel) for treating Schizoaffective Disorder, with the medication starting on July 1, 2024. The President of Clinical Operations confirmed the absence of a PASARR II request and acknowledged that the facility lacked a policy for admissions regarding PASARR screenings.
Failure to Document Discharge Summary
Penalty
Summary
The facility failed to document a comprehensive discharge summary for a resident, identified as R49, who was reviewed for discharge. The discharge summary was supposed to include a recapitulation of the resident's stay, a final summary of the resident's status, and a post-discharge plan of care. This documentation is crucial for ensuring that necessary information is communicated to the resident and the receiving healthcare provider at the time of a planned discharge. The absence of this documentation was confirmed by the Director of Nurses, who acknowledged that there was no discharge summary available for R49. R49 had multiple medical diagnoses, including Acute Kidney Failure, Unsteadiness on feet, Reduced Mobility, Cognitive Communication Deficit, Depression, and Heart Failure. Despite these complex medical conditions, the electronic medical record for R49 did not contain the required discharge documentation. This oversight has the potential to affect the quality of care and continuity of care for the resident after leaving the facility, as critical information regarding the resident's course of illness, treatment, and current status was not communicated to the next care provider.
Incomplete Antibiotic Administration for UTI
Penalty
Summary
The facility failed to provide complete antibiotic doses for a urinary tract infection for a resident, identified as R42. On November 9, 2024, R42's nursing notes indicated an abnormal urine sample was sent for analysis. By November 12, 2024, a new order for Bactrim DS was received to be administered twice daily for five days. However, the Medication Administration Record (MAR) for November 2024 showed that the doses scheduled for November 16, 2024, were not documented as given, indicating a failure to complete the prescribed antibiotic course. Subsequently, on December 8, 2024, R42's family reported symptoms of abdominal pain and bladder pressure, prompting a new urinalysis. The results on December 11, 2024, confirmed a positive infection, leading to a new prescription for Augmentin due to ESBL resistance. The Director of Nursing acknowledged the error in transcription and administration, noting that the incomplete antibiotic course could have contributed to the untreated infection, which R42 was now being treated for.
Failure to Supervise Resident Smoking
Penalty
Summary
The facility failed to accurately assess and supervise a resident for smoking safety, leading to a deficiency in ensuring a safe environment free from accident hazards. The resident, who has a right artificial shoulder joint, is dependent on renal dialysis, and uses tobacco, was documented in the care plan to be supervised while smoking, with smoking materials kept secured by staff. However, observations and interviews revealed that the resident kept smoking materials in her room and smoked unsupervised, contrary to the care plan interventions. On multiple occasions, the resident was observed smoking alone in the designated smoking area and stated that she was never accompanied by staff while smoking. The facility's staff, including the MDS/Care Plan Coordinator and the Director of Nurses, confirmed that the resident was capable of smoking independently and that the care plan did not reflect the actual practice. This discrepancy between the care plan and the resident's actions indicates a failure to provide adequate supervision and ensure the resident's safety while smoking.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to notify a resident's physician of significant weight loss and did not develop a care plan to address the resident's risk for weight loss. The facility's policy requires notification of the dietician and primary care physician for any weight change of 5% or more, with a loss greater than 5% within one month considered severe. Despite this policy, the facility did not notify the physician or implement new interventions for a resident who experienced a 7.24% weight loss within two weeks of admission. The resident, diagnosed with dysphagia and gastrostomy status, was admitted with severe protein-calorie malnutrition and was NPO with orders for enteral feeding four times a day. The resident's weight decreased from 174 pounds to 161.4 pounds over a short period, indicating severe weight loss. The Director of Nurses confirmed the significant weight loss and acknowledged the lack of notification to the physician and absence of new interventions, despite the resident's high risk for weight loss due to multiple health issues, including recent cancer treatment and severe malnutrition.
Failure to Monitor and Obtain Orders for Gastrostomy Tube Care
Penalty
Summary
The facility failed to monitor and obtain a physician order for a resident with a gastrostomy tube, which is necessary for proper care and management. The resident, diagnosed with dysphagia and gastrostomy status, was on a physician-ordered NPO (Nothing by Mouth) status and required enteral feeding four times a day due to severe protein-calorie malnutrition. Despite this, the resident self-administered her feedings and medications through the gastrostomy tube without any physician orders for self-administration or staff monitoring of the gastrostomy site. The Director of Nurses confirmed the absence of orders for self-administration, site maintenance, or monitoring by staff, and there was no documentation of staff monitoring the gastrostomy site for abnormal signs or symptoms.
Medication Administration Delays
Penalty
Summary
The facility failed to administer medications in a timely manner for one resident, identified as R10, out of a sample of ten residents. R10's Medication Administration Record (MAR) indicated that several medications were scheduled for administration at 8:00 AM, including Ascorbic Acid, Cholecalciferol, Famotidine, Fluoxetine, Furosemide, Gabapentin, Phentermine, Potassium Chloride, Spiriva, Symbicort, Bupropion, Cranberry Tab, and MiraLAX. However, on the day of observation, these medications were not prepared until 10:17 AM by an LPN, who acknowledged that the medications were late due to being occupied with another resident's cataract surgery. The LPN admitted that the MAR was filled in prior to administration, which did not reflect the actual time the medications were given. Further interviews with other LPNs revealed that administering medications late was a regular occurrence, attributed to the size of the building and staffing challenges, such as being the only nurse on duty. The Director of Nursing (DON) confirmed that the facility had only 45 residents and that medications should be administered on time. The facility's policy, revised in December 2012, mandates that medications be administered safely, timely, and within one hour of the prescribed time. However, the MAR did not accurately document the actual administration times, indicating a systemic issue in medication administration practices.
Failure to Obtain Physician's Orders for Supplemental Oxygen
Penalty
Summary
The facility failed to obtain a physician's order for supplemental oxygen for three residents, leading to a deficiency in providing safe and appropriate respiratory care. Resident 5, diagnosed with Chronic Respiratory Failure, was observed using oxygen at three liters per minute without a documented physician's order. Similarly, Resident 6, who has Chronic Obstructive Pulmonary Disease (COPD) and other health issues, was also using oxygen at the same flow rate without a physician's order. Additionally, Resident 1, who has a documented order for oxygen use, did not have a specified order for when the oxygen tubing or humidification bottle should be changed. The Treatment Administration Records (TAR) for all three residents lacked documentation specifying when the oxygen tubing and humidification bottles should be changed, which is a requirement according to the facility's policy. The Director of Nursing confirmed the absence of these orders and attributed the oversight to a recent change in computer programs. The facility's policy on respiratory therapy and infection prevention, revised in November 2011, outlines specific procedures for maintaining oxygen equipment, which were not followed in these cases.
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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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