Heather Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Harvey, Illinois.
- Location
- 15600 South Honore Street, Harvey, Illinois 60426
- CMS Provider Number
- 145173
- Inspections on file
- 35
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Heather Health Care Center during CMS and state inspections, most recent first.
The facility failed to provide timely incontinence and toileting care at least every two hours for four dependent residents. One resident with severe cognitive impairment was observed walking with visibly wet clothing, and multiple residents who were dependent or required maximum assistance for toileting were not checked during an extended observation period. When care was eventually provided, one resident’s brief was heavily saturated despite dry outer clothing and a skin indentation was noted, another resident was found with a saturated brief while requiring a mechanical lift and two staff, and a fourth resident was discovered sitting in urine with saturated clothing and sling. The DON confirmed that staff are expected to check and change residents every two hours and as needed.
Two residents with known histories of aggression engaged in a verbal and physical altercation after one attempted to obtain juice from a cart, resulting in one resident sustaining a swollen, bruised, and lacerated eye. Staff were not present to prevent or immediately intervene in the incident, and the facility's initial abuse investigation inaccurately reported that no physical contact had occurred.
Multiple residents reported and surveyors observed unsanitary conditions, unrepaired damage, and lack of basic amenities such as working televisions in their rooms. Issues included stained linens, broken furniture, holes in walls, water damage, persistent odors, and inadequate housekeeping, with maintenance requests left unresolved for extended periods. Residents with complex medical and psychiatric needs were affected, and staff interviews revealed inconsistent monitoring and communication regarding room conditions.
Staff failed to administer scheduled medications on time for several residents, with an LPN giving medications hours after the scheduled time and inaccurately documenting administration in the MAR. Residents receiving medications for seizures, blood pressure, and diabetes expressed concern about the delays. The DON confirmed that such delays are not acceptable and that facility policy requires medications to be given within one hour of the scheduled time.
Two residents with significant medical needs were unable to access their call lights because the cords were not within reach, contrary to their care plans and facility policy. One resident reported a broken call light cord for a week, and staff were aware of the issue. Another resident was observed with the call light cord out of reach, and a CNA confirmed it should have been accessible.
A facility failed to provide post-surgical wound care according to a physician's orders for a resident with a left foot wound. The wound care coordinator did not apply collagen powder and antibiotic ointment as prescribed, despite the resident's medical history and specific wound care instructions. The facility's policies require adherence to physician orders, which was not followed in this instance.
A resident suffered fractured ribs after a CNA failed to use a gait belt during a transfer, resulting in a fall. The resident, who requires substantial assistance, experienced leg spasms during the transfer, and the CNA attempted to lower the resident to the floor without proper equipment. The incident was not immediately reported, and the resident was sent to the hospital after later complaining of pain. Facility policies require the use of a gait belt during transfers, but this was not adhered to, leading to the injury.
A resident with a history of falls and rib fractures experienced a fall during a transfer, but the physician was not notified until six hours later when the resident reported new pain. The staff initially failed to recognize the incident as a fall, leading to a delay in appropriate medical evaluation. The facility lacked a post-fall policy, contributing to the miscommunication and delay in reporting.
A resident fell in the bathroom due to improperly installed toilet handlebars and a sink that detached from the wall. The resident, who was cognitively intact and at risk of falling due to medical conditions, was found on the floor with back pain. Staff interviews confirmed the broken fixtures, and the incident was documented as a fall caused by the bathroom basin detaching from the wall.
A visually and cognitively impaired male resident was physically assaulted by another male resident with a known history of aggression. Despite the vulnerable resident's need for supervision, there was no care plan addressing the aggressive resident's behavior. The incident occurred in the early morning, leading to the injured resident's hospitalization. Staff, including an LPN and CNA, were unaware of the altercation until the injured resident was found. Initial reports mischaracterized the incident, but further investigation revealed the assault. The facility's lack of monitoring and intervention for the aggressive resident, combined with the decision to house both residents together, contributed to the failure to protect the vulnerable resident.
A resident with Schizophrenia, Schizoaffective Disorder, Dementia, and Atherosclerotic Heart Disease eloped from a secured Memory Care Unit. The resident, known for previous elopement history, left unnoticed and was later found in a local hospital after crossing a busy street. Staff members, including an LPN and a CNA, were unaware of the resident's elopement risk, citing her compliance and non-disruptive behavior as factors.
The facility failed to provide necessary care for a resident with chest pain who eloped and was hospitalized, and did not monitor another resident's escalating aggressive behavior, resulting in an assault. Both incidents highlight deficiencies in monitoring and addressing residents' changes in condition and behavior.
A resident with a history of Schizophrenia, Dementia, and Atherosclerotic Heart Disease reported severe chest pain but did not receive appropriate care, leading to her elopement from the facility and subsequent hospitalization. The facility failed to follow its pain management and change of condition policies, resulting in the resident seeking emergency medical attention on her own.
The facility failed to protect a cognitively impaired resident from physical abuse by another aggressive resident, did not adequately supervise a resident at risk for elopement, and failed to conduct a pain assessment for a resident with chest pain. These deficiencies highlight significant lapses in resident care and supervision.
Failure to Provide Timely Incontinence and Toileting Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinence care and assistance with toileting at least every two hours for four residents who were dependent or required maximum staff assistance for ADLs. One resident with severe cognitive impairment and dependent on staff for toileting was observed ambulating in the halls with sweatpants visibly wet in the buttocks, groin, and upper thighs. Continuous observations conducted over several hours on the same unit showed that this resident, along with three others who were either dependent or required maximum assistance for toileting, were not checked by staff for incontinence care during the observation period. Another resident with severe cognitive impairment and dependent on staff for toileting was left waiting in the hallway, during which a CNA walked past and remarked that she was not rushing before later providing care. When care was finally given, the resident’s pants were dry but the brief was heavily saturated with urine, and a linear indentation was noted on the proximal left leg, which the CNA attributed to sitting in the wheelchair. A third resident, requiring maximum assistance for toileting and not assisting with care, was found with a saturated brief when transferred to bed with a mechanical lift and two staff. A fourth resident, dependent on staff for toileting, was found with a small puddle of urine and a deep indentation on the chair cushion; the sling and clothing were saturated and dripping urine during transfer to bed. The DON stated that staff should be checking and changing residents every two hours and as needed.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to follow its abuse policy and did not protect residents from abuse, resulting in a physical altercation between two residents. Both residents involved had documented histories of verbal and physical aggression, as well as care plans identifying them as at risk for abusive behaviors. On the day of the incident, one resident attempted to obtain juice from a cart after lunch, which led to a verbal exchange with another resident. The situation escalated when one resident threw a cup of juice at the other, who then responded by striking the first resident in the face. Staff interviews and observations revealed that the altercation occurred in a common area near the dining room, with both residents in wheelchairs. Housekeeping staff witnessed the incident, while the assigned CNAs were providing care to other residents and did not hear the commotion. An LPN became aware of the situation only after hearing a disturbance and intervened after the physical contact had already occurred. The injured resident was observed with a swollen, bruised, and lacerated left eye following the incident. Both residents had care plans and risk assessments indicating a history of aggression and potential for abusive behavior. Despite these documented risks, staff were not present to prevent or immediately intervene in the altercation. The facility's initial abuse investigation report to the State Surveying Agency inaccurately noted that no physical contact had occurred, despite evidence and witness statements to the contrary. The facility's abuse policy affirms residents' rights to be free from abuse, but this policy was not effectively implemented in this instance.
Failure to Maintain Clean, Safe, and Comfortable Resident Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment for its residents, as evidenced by multiple observations of unsanitary and poorly maintained resident rooms. Residents reported and surveyors observed stained sheets, broken or missing furniture handles, holes in walls, non-functioning televisions, water damage, missing baseboards, and broken grab bars in shared bathrooms. Additionally, there were reports of excessive heat due to non-functioning windows, dust and grime on curtains, and persistent unpleasant odors such as urine. Maintenance logs confirmed that many of these issues had been outstanding for several months without resolution. Several residents, including those with complex medical and psychiatric histories such as schizophrenia, bipolar disorder, dementia, and heart failure, expressed dissatisfaction with the cleanliness and repair of their living spaces. Observations included holes in walls, chipped paint, stained pin boards, dirty floors, and buildup on radiator vents and bathroom vents. Residents also reported that maintenance was aware of these issues but had not addressed them, and that housekeeping was insufficient, with visible stains and residue remaining for multiple days. The facility's maintenance and housekeeping policies require prompt attention to repairs and regular cleaning, but interviews with staff revealed gaps in communication and follow-through. The maintenance manager relied on nurse logs and did not routinely inspect all resident rooms, focusing instead on common areas. There was also a lack of clarity regarding work orders, as seen in the case of a resident who waited three weeks for a television after being moved to a new room. The facility's failure to address these environmental deficiencies affected all nine residents reviewed for this issue.
Failure to Administer Scheduled Medications on Time
Penalty
Summary
Staff failed to administer scheduled medications on time for multiple residents, as observed and documented by surveyors. On the morning of 4/6/2025, an LPN was seen administering medications to several residents well past the scheduled 0900 time, with medication administration records (MAR) inaccurately reflecting that medications were given on time. Medication audits revealed actual administration times ranging from 10:40AM to 1:18PM, despite MAR entries indicating 0900. Residents affected included those receiving critical medications for conditions such as seizures, blood pressure, and diabetes. Two residents specifically voiced concerns about receiving their medications late, citing worries about seizure control and blood pressure management. The LPN acknowledged being behind schedule and confirmed she still had additional residents to medicate late into the medication pass. The Director of Nursing (DON) confirmed that late medication administration is unacceptable and that medications should be given within one hour of the scheduled time, as per facility policy. The DON also stated that nurses are regularly in-serviced on timely medication administration and can request assistance if running behind. Facility policy requires medications to be administered within one hour of the prescribed time unless otherwise specified by the physician.
Failure to Ensure Call Lights Were Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were able to operate their call lights by not placing them within reach, as required by their care plans and facility policy. One resident, a male with multiple diagnoses including COPD, heart failure, hemiplegia, diabetes, hypertension, depression, end-stage renal disease on dialysis, and a history of falls, reported that his call light cord was broken and unusable while he was in bed. This condition had persisted for a week, and staff were aware of the issue. Observation confirmed the call light cord was disconnected and hanging from the bed. The resident's care plan specified that the call light should be within reach. Another male resident with diagnoses including diabetes, peripheral vascular disease, congestive heart failure, chronic kidney disease, bilateral below-knee amputations, adult failure to thrive, osteoarthritis, and shoulder impingement was observed in bed with the call light cord not within reach. A certified nursing assistant confirmed that the call light should be accessible to the resident. This resident's care plan also required the call light to be within reach. The facility's policy stated that call lights must be placed within resident reach at all times.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to provide post-surgical wound care according to the current physician's orders for a resident who had undergone outpatient surgery for the excision of a bone spur on the left foot. The resident, who had a history of chronic kidney disease, hypertension, and other medical conditions, was observed with a painful wound on the left foot. The wound care physician had provided specific orders for wound care, including the use of antiseptic povidone-iodine solution, collagen powder, silver alginate, and antibiotic ointment, to be applied daily. On a particular day, the wound care coordinator performed wound care on the resident's left foot but did not follow the updated physician's orders. The coordinator cleansed the wound with antiseptic povidone-iodine and normal saline, applied silver alginate, and wrapped the wound with gauze, but failed to apply the collagen powder and antibiotic ointment as ordered. The coordinator later acknowledged misreading the order and not seeing the new treatment instructions on the treatment administration record. The facility's policies require that wound treatment be performed as per medical doctor orders and that medications and treatments be administered only upon clear and complete orders from an authorized prescriber. The assistant director of nursing confirmed that nurses are expected to follow physician orders precisely, and any changes to orders should be obtained from the physician. The failure to adhere to these orders was identified as a deficiency during the survey.
Failure to Use Gait Belt Results in Resident Injury
Penalty
Summary
The facility failed to utilize a gait belt during a transfer for a resident, identified as R2, who requires substantial or maximum assistance. This failure resulted in R2 suffering three fractured ribs after falling to the floor during the transfer. The incident was not immediately reported to the nurse, and R2 was sent to the hospital for further evaluation only after complaining of pain later in the day. Hospital records confirmed the diagnosis of closed fractures of multiple ribs. R2 reported that during the transfer, a CNA, identified as V8, attempted to transfer R2 from the bed to the wheelchair without using a gait belt. R2, who has limited mobility due to arthritis, stated that V8 refused to listen to instructions on how to properly transfer R2. During the transfer, R2 experienced leg spasms, and V8 attempted to lower R2 to the floor, resulting in a fall. V8 initially claimed that R2 requested to be set on the floor, but later admitted that a gait belt was not used during the transfer. Interviews with staff revealed inconsistencies in the reporting and handling of the incident. V8 and another CNA, V10, assisted R2 back into the wheelchair without using a gait belt. The incident was not reported to the nurse until R2 complained of pain hours later. The facility's policies require the use of a gait belt during transfers to ensure resident safety, but this protocol was not followed, leading to the injury.
Delayed Physician Notification After Resident Fall
Penalty
Summary
The facility failed to notify a physician promptly after a resident, identified as R2, experienced a fall. R2, who has a history of falling, muscle weakness, and multiple rib fractures, fell during a transfer from bed to wheelchair. The incident occurred in the early morning hours, but the physician was not notified until approximately six hours later when R2 began complaining of new pain. The delay in notification was due to the staff's initial failure to recognize the incident as a fall. R2 reported that during the transfer, a CNA attempted to assist R2 without listening to R2's instructions, resulting in R2 being dropped to the floor. Despite R2's immediate lack of pain, R2 later experienced significant pain, leading to a hospital visit where multiple rib fractures were diagnosed. The staff involved, including CNAs and nurses, did not immediately report the incident as a fall, and there was confusion about whether the incident constituted a fall, which contributed to the delay in notifying the physician. The facility lacked a post-fall policy to guide staff on the necessary steps following a fall, which may have contributed to the miscommunication and delay in reporting. The Director of Nursing and the Nurse Practitioner both acknowledged that the incident should have been considered a fall and reported immediately. The care plan for R2 indicated a risk for injury and required assessment for injuries following a fall, but this was not adhered to promptly due to the staff's initial misjudgment of the situation.
Improperly Installed Bathroom Fixtures Lead to Resident Fall
Penalty
Summary
The facility failed to ensure that bathroom fixtures, specifically the toilet handlebars and sink, were properly installed to prevent accidents, leading to a fall incident involving a resident. The resident, who was cognitively intact with a BIMS score of 15, experienced a fall in the bathroom when the sink detached from the wall. The resident was found on the floor, complaining of back pain, with the sink on the floor nearby. The incident was documented as a fall, and the resident was subsequently transferred to a hospital with diagnoses including intractable back pain and lumbar radiculopathy. Interviews with staff revealed that the CNA on duty responded to the resident's call light and found the resident on the bathroom floor. The Building Manager confirmed that the sink and toilet rails were broken and required immediate repair. The Director of Nursing noted that there was no evidence of the resident dismantling the sink, and the incident was reported as a fall due to the bathroom basin detaching from the wall. The resident's care plan highlighted an increased risk of falling due to heart failure, hypertension, and reliance on a quad cane. The care plan included interventions such as encouraging the use of a cane and ensuring the call light was within reach. However, the failure to maintain the bathroom fixtures contributed to the resident's fall, indicating a lapse in the facility's maintenance and safety protocols.
Failure to Protect Resident from Physical Abuse Due to Inadequate Monitoring and Care Planning
Penalty
Summary
The facility failed to protect a cognitively and visually impaired resident (R1) from physical abuse by another resident (R2) with a known history of aggressive behavior. R1, a visually impaired male with severe cognitive impairment, was physically assaulted by R2, a male resident with intact cognition but a history of aggression and violence. Despite R1's vulnerability and documented need for supervision due to his visual impairment, there was no care plan addressing R2's aggressive behavior prior to the incident. R2's behavior, including aggression, agitation, and intimidating actions, was observed by staff and other residents, indicating a pattern of concerning behavior that was not adequately addressed. The incident occurred in the early hours of the morning, resulting in R1 being hospitalized with injuries consistent with physical assault. Staff members, including a Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA), were unaware of the altercation until R1 was found injured. The facility's response to the incident was initially framed as a fall by R1 and later as an unsubstantiated allegation of abuse by R2. However, subsequent investigations, including interviews with residents and staff, revealed a different narrative of R2 physically assaulting R1. The lack of appropriate monitoring and intervention for R2's escalating behavior, as well as the decision to place R1 and R2 in the same room despite R2's history of aggression, contributed to the failure to protect R1 from abuse. The facility's failure to address the risks associated with housing a vulnerable resident like R1 with a resident exhibiting aggressive behavior like R2 highlights systemic deficiencies in resident assessment, care planning, and monitoring. The incident underscores the importance of thorough risk assessments, individualized care planning, and vigilant monitoring to ensure the safety and well-being of residents in long-term care facilities. The lack of proactive measures to prevent abuse and address behavioral concerns among residents, particularly those with a history of aggression, led to a serious breach in resident safety and regulatory compliance.
Elopement Incident Involving Resident with Cognitive Impairment
Penalty
Summary
The deficiency identified in the report pertains to the failure of a long-term care facility to provide adequate supervision and monitoring for a resident assessed to be at risk for elopement. The resident in question, R5, a female with a complex medical history including diagnoses of Schizophrenia, Schizoaffective Disorder, Dementia, and Atherosclerotic Heart Disease, was known to be at risk for elopement due to cognitive impairment and previous history of elopement from a different nursing home. Despite being placed in a secured Memory Care Unit, R5 managed to elope from the facility unnoticed and unsupervised on the night of 04/06/24. The incident unfolded when a staff member observed the alarm on the back door sounding, prompting a Code Green for elopement. Despite efforts to conduct a headcount and search for the missing resident, R5 was found to have left the facility and was later discovered in a local hospital after crossing a busy street intersection without shoes and allegedly experiencing chest pain. Staff members involved in the incident, including a Licensed Practical Nurse (V4) and Certified Nurse Aide (V3), expressed unawareness of R5's history of elopement and highlighted her compliance and lack of disruptive behavior as contributing factors to the oversight.
Failure to Monitor and Address Changes in Condition and Behavior
Penalty
Summary
The facility failed to provide necessary care and treatment during a change in condition for a resident (R5) who complained of chest pain and subsequently eloped from the facility. R5, a female resident with a history of schizophrenia, schizoaffective disorder, dementia, and atherosclerotic heart disease, was admitted to the facility with a known risk of elopement. Despite this, the staff did not adequately monitor her, and she was able to leave the facility unnoticed. R5 was found wandering in traffic and was taken to the hospital, where she reported experiencing severe chest pain, shortness of breath, and left upper extremity pain. She stated that she had informed the nursing home staff of her symptoms but did not receive proper care, prompting her to leave the facility on her own to seek medical attention. The facility also failed to monitor and address the escalation of maladaptive behavior in another resident (R2). R2, a male resident with a history of schizoaffective disorder, anxiety disorder, encephalopathy, and hypertension, exhibited increased wandering, pacing, and aggressive behavior. Despite having a history of aggression and violence, there was no care plan in place to monitor R2's behavior prior to an incident on 03/17/2024, where R2 committed an assault. Staff interviews revealed that R2's aggressive behavior was known, but there were no documented interventions or increased monitoring to address his behavior. R2 continued to display aggressive and intimidating behaviors, making other residents and staff uncomfortable. The facility's failure to provide necessary care and treatment for R5's chest pain and to monitor R2's escalating behavior resulted in significant safety concerns. R5's elopement and subsequent hospitalization for chest pain, as well as R2's aggressive behavior and assault, highlight the facility's deficiencies in monitoring and addressing residents' changes in condition and behavior. The lack of appropriate interventions and monitoring for both residents led to serious incidents that could have been prevented with proper care and attention.
Failure to Conduct Pain Assessment and Provide Necessary Care
Penalty
Summary
The facility failed to conduct a proper pain assessment and provide necessary care and treatment for a resident (R5) who complained of severe chest pain. R5, a female resident with a history of Schizophrenia, Schizoaffective Disorder, Dementia, and Atherosclerotic Heart Disease, reported chest pain to the nursing staff but did not receive appropriate attention. Consequently, R5 eloped from the facility without shoes and went to the nearest emergency room for further evaluation and treatment. The hospital records confirmed that R5 had been experiencing chest pain for three days and had alerted the nursing home staff of her symptoms before deciding to leave the facility due to inadequate care. On the night of the incident, the alarm on the back door of the facility went off, and a Code Green for elopement was called. The staff conducted a headcount and discovered that R5 was missing. Shortly after, the hospital contacted the facility to inform them that R5 was in the emergency room. Interviews with the staff revealed that R5 had asked for a brief and a blanket earlier in the evening but did not explicitly mention chest pain to the LPN on duty. However, R5 later stated that she had informed the nurse about her chest pain, but he did not pay attention, prompting her to leave the facility. The facility's policies on pain management and change of condition were not followed, as the staff failed to assess R5's pain and notify the physician. The care plans for R5 included monitoring for pain and changes in cardiac status, but these interventions were not implemented. The facility's failure to address R5's chest pain and provide appropriate care led to her elopement and subsequent hospitalization for chest pain.
Multiple Failures in Resident Supervision and Care
Penalty
Summary
The facility failed to protect a cognitively and visually impaired resident's right to be free from physical abuse from another resident with a known history of aggressive behavior. The aggressive resident, who had a history of agitation and violence, was not adequately monitored, and no care plan was in place to address his aggressive behavior. This led to an incident where the aggressive resident physically assaulted the impaired resident, causing significant injuries. Staff were unaware of the aggressive resident's history and did not provide the necessary supervision or intervention to prevent the assault. The facility also failed to provide adequate supervision and monitoring for a resident assessed to be at risk for elopement. Despite being identified as an elopement risk, the resident was able to leave the facility unnoticed and unsupervised. The resident, who had a history of elopement and was cognitively impaired, left the facility due to unaddressed chest pain. The staff were unaware of the resident's elopement risk and did not follow the facility's elopement policy, which included procedures for monitoring and reporting. Additionally, the facility failed to conduct a pain assessment and provide necessary care and treatment for a resident complaining of chest pain and during a change in condition. The resident reported severe chest pain and other symptoms to the staff, but the staff did not take appropriate action to assess and address the pain. This lack of response led the resident to leave the facility and seek medical attention at a nearby hospital. The facility's failure to monitor and address the resident's pain and change in condition highlights a significant deficiency in the quality of care provided.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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