Helia Healthcare Of Energy
Inspection history, citations, penalties and survey trends for this long-term care facility in Energy, Illinois.
- Location
- 210 East College, Energy, Illinois 62933
- CMS Provider Number
- 146045
- Inspections on file
- 36
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 26 (1 serious)
Citation history
Health deficiencies cited at Helia Healthcare Of Energy during CMS and state inspections, most recent first.
A resident with vascular dementia, mixed incontinence, and moderate cognitive impairment had a care plan directing staff to monitor for UTI signs and notify the provider. After nursing staff reported confusion, hallucinations, and incontinence, an NP ordered a straight cath urine specimen for urinalysis and culture, but there was no documentation that the specimen was obtained, no lab results, and no follow-up communication to the NP when the order was not carried out. Later, the resident was found unresponsive at a meal with abnormal vital signs and was transferred to the ED, where the resident was admitted with disorientation and acute cystitis without hematuria. Facility leadership and policy stated that physician orders must be followed and that the physician and DON must be notified if orders are not carried out.
A resident with dementia and chronic pain experienced verbal and physical abuse from a CNA, who became frustrated after being called names, forcibly transferred the resident to bed, and removed her wheelchair, leaving her distressed and in pain. Multiple staff witnessed or were informed of the incident, recognized the actions as abusive, and reported the event, but there was confusion and delay in the facility's response, with concerns raised about the handling of abuse allegations.
A resident with dementia and a history of falls was placed in bed by a CNA, who then removed her wheelchair and left her room door closed, resulting in the resident being unable to transfer or move safely. The resident was visibly distressed, called for help, and reported pain, while staff interviews confirmed the wheelchair was left outside the room and the incident was not immediately reported. Facility policy and staff acknowledged that this action constituted involuntary seclusion and abuse.
A resident with severe cognitive impairment and multiple leg wounds did not consistently receive prescribed lidocaine cream prior to wound care, resulting in observed pain during treatment. Nursing staff reported running out of wound care supplies and being unable to locate the resident's medication at times, leading to missed or delayed treatments. Facility policy required pain management interventions, but these were not always implemented as ordered.
The facility did not ensure adequate nursing staff coverage, resulting in residents experiencing long wait times for assistance with transfers, call lights, and basic care needs. Staff reported frequent shortages, especially at night and on weekends, with management not consistently providing support or covering shifts. Residents and staff described delays in care, incomplete tasks being passed to subsequent shifts, and ongoing concerns about timely access to assistance.
A nurse assistant was hired and worked as a CNA without having completed the required certification exam. The administrator and DON were aware of her uncertified status but allowed her to work throughout the facility, including on night shifts and in various units, performing CNA duties. The NA's lack of certification was only discovered after she had worked past the allowed 120-day period, and multiple staff confirmed her uncertified status.
Surveyors found that a nurse used unlabeled and expired creams, as well as creams prescribed for other residents, during wound care for two residents with complex medical needs. Multiple medication and treatment carts were observed unlocked and unattended, with medications left on top, contrary to facility policy. The DON confirmed that carts should be locked and medications should not be shared or used past expiration.
The facility did not follow the approved menu or serve correct portion sizes, resulting in residents not receiving required protein options and appropriate meal components. Multiple residents reported not receiving breakfast meat or double protein as needed, and staff confirmed substitutions were made without consulting the dietitian due to ingredient shortages. Resident council records also documented ongoing concerns about menu updates and adherence.
Surveyors found multiple expired food items and improperly labeled containers in the kitchen and storage areas, including expired sausage, glaze, cookie pieces, cornstarch, eggs, and dressings without open dates. The Dietary Manager confirmed these items should not have been kept, and facility policy requires proper dating of food items. These deficiencies were observed with 73 residents present in the facility.
An LPN worked with an expired license, administering medications and performing nursing duties while not actively licensed. Facility staff, including the DON and ADON, were unaware of the lapse, and the process for verifying licensure was inconsistent. This failure had the potential to affect all 73 residents.
Staff reported frequent shortages of washcloths, leading to improvised hygiene care for several residents, while observations confirmed that linen carts and shower rooms often lacked necessary supplies. Multiple residents, including those with cognitive and mobility impairments, were found with call lights out of reach, making it difficult for them to request assistance. The facility lacked a formal process for distributing linens and ensuring call lights were accessible, despite policy requirements.
Several residents did not receive medications and wound care as ordered due to missing pharmacy supplies, with nursing staff using medications labeled for other residents or delaying treatments. Staff interviews confirmed that wound care and medication administration were sometimes postponed or improvised when supplies ran out, and documentation errors occurred when a nurse failed to properly record medication refusals and missed doses.
Surveyors identified that several residents, including those with complex medical needs, were repeatedly served cold food that did not meet the facility's temperature standards. Staff and residents reported frequent complaints about meal temperatures, and direct observations confirmed that food was left out and served below required hot food temperatures. Staff often had to reheat or replace meals after residents reported the issue.
Staff failed to consistently implement enhanced barrier precautions during wound care and high-contact activities for several residents with chronic wounds or infections. Observations included nurses and CNAs not wearing gowns, inconsistent hand hygiene, and improper handling of supplies and equipment, despite facility policies requiring gowns and gloves for such care. Some staff were unaware of EBP requirements, and signage was missing or ignored in multiple cases.
Two residents with severe cognitive impairment did not have their preferences and privacy respected during wound care. One resident was routinely awakened at night for treatments despite expressing a preference for daytime care, while another had wound care performed without the door or curtain closed, exposing them to potential view. Facility staff acknowledged these practices, which did not align with policy requirements for dignity and self-determination.
Two residents experienced failures in timely reporting of alleged abuse and possible misappropriation of property. In one case, a resident with dementia reported being physically harmed and having her wheelchair taken by a CNA, with multiple staff aware but not immediately reporting the incident to the administrator or authorities. In another case, a resident reported missing money, but the administrator did not formally investigate or report the loss to the Department of Public Health, contrary to facility policy.
The facility failed to promptly and thoroughly investigate allegations of abuse and theft involving two residents. In one case, a resident with dementia reported being physically mistreated by a CNA, with multiple staff aware of the incident and the resident left distressed and without her wheelchair. The administrator delayed investigation and did not immediately remove the accused CNA from resident care. In another case, a resident reported missing money, but no formal investigation or required reporting occurred. Facility policies for reporting, investigation, and resident protection were not followed.
A dependent resident with significant physical and cognitive impairments was not provided timely assistance with transfers using a mechanical lift, resulting in the resident remaining in bed and missing breakfast in the dining room. Staff interviews revealed inadequate staffing during morning hours, preventing the required two-person assist for mechanical lift transfers, despite facility policy and leadership statements that sufficient staff should be available.
Two residents did not receive their prescribed morning medications after an LPN was unable to wake them and subsequently forgot to return, yet documented the medications as given in the electronic record. The medications, which included critical drugs such as blood thinners and Depakote, were left in cups in the medication cart. Facility leadership and the physician confirmed this constituted a medication error and that medications should not be left in the cart or documented as given when not administered.
A resident who required substantial assistance for mobility and was dependent on nursing care was transferred into an incorrect high back wheelchair without suitable footrests, rather than her prescribed standard wheelchair. While being moved from a dining room table, she fell forward out of the chair, sustaining facial and upper extremity fractures. Staff and therapy assessments confirmed the wheelchair was inappropriate for her needs, and the facility's fall management policy was not followed.
A resident with severe cognitive impairment and diabetes was mistakenly given another resident's morning medications, including antidiabetic drugs, by an LPN who failed to properly verify the resident's identity. The error resulted in hypoglycemia, requiring emergency intervention and hospitalization.
A resident with a history of mental illness and repeated suicidal ideation experienced ongoing self-injurious behaviors and voiced plans for self-harm, while the facility failed to consistently implement increased monitoring, remove hazardous items from the environment, or ensure referral for recommended counseling services. Staff were unaware of required monitoring protocols, hazardous items remained accessible, and there was no staff training on managing suicidal behaviors, resulting in Immediate Jeopardy.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with severe cognitive impairment and a high fall risk was left unsupervised in a dining area when both the assigned LPN and CNA left the unit without notifying other staff, contrary to facility policy. The resident, known for attempting to stand unassisted, was found on the floor with significant injuries, including rib and hip fractures. Staff interviews and records confirmed that required supervision and coverage procedures were not followed, leading to the incident.
A resident with severe cognitive impairment experienced a fall and was transferred to a hospital, but the POA was not notified by facility staff as required. Although the physician was informed, the POA only learned of the incident from the hospital. Staff interviews confirmed that facility policy mandates immediate notification of both the physician and POA for changes in condition, but documentation of POA notification was lacking.
A resident with multiple chronic conditions, who was cognitively intact, was subjected to verbal abuse by the DON after refusing a vitamin IV therapy. The DON confronted the resident in the dining room, raising her voice and expressing frustration about the cost, in front of other residents and staff. Witnesses described the DON's tone as loud and aggressive, and the resident reported feeling embarrassed and angry as a result.
A staffing deficiency in an LTC facility resulted in inadequate care for residents, with reports of insufficient incontinence care, lack of supplies, and residents being woken up early due to short staffing. Staff interviews confirmed the challenges in meeting residents' needs, despite claims from management that staffing was adequate.
A facility failed to provide timely incontinence care and lacked sufficient supplies, affecting four residents. One resident was found in urine-soaked clothing due to inadequate care and supply shortages. Another resident reported inconsistent perineal care and delays in assistance. Staff confirmed shortages of linens and supplies, impacting care quality. The facility's policies on bathing and perineal care were not followed.
A resident with severe cognitive deficits was woken up early against their preference due to anticipated short staffing in the facility. The CNA confirmed they were instructed to get as many residents up as possible, and the ADON acknowledged the staffing shortage. The DON stated that residents should not be forced to get up early, but the facility's actions did not align with this policy.
The facility failed to identify and treat pressure ulcers for three residents, leading to a deficiency in care. A resident with severe cognitive impairment returned from the hospital with open wounds, but the RN did not notify the medical provider or upload pictures, resulting in delayed treatment. Another resident with stage 4 pressure wounds did not receive treatments despite having orders, as the LPN failed to enter them into the EMR. A third resident's pressure injury was not documented or addressed promptly, violating facility policies.
A resident with multiple diagnoses experienced a decline in condition, including decreased urine output and oral intake, which was not communicated to the physician or nurse practitioner. Despite facility policy requiring immediate notification of changes in condition, staff failed to inform the responsible medical professionals. The resident was eventually hospitalized in a severely compromised state, highlighting a deficiency in the facility's communication and documentation practices.
A resident with a Stage 4 pressure ulcer did not receive the ordered wound care treatments due to a failure in documenting and processing the physician's orders. The resident's treatment plan, which included specific applications like Collagen powder and Silver Sulfadiazine, was not reflected in the MAR, leading to incorrect treatments being administered. The DON and LPN were unaware of the oversight, resulting in the resident being sent to a hospital with inadequate wound dressing.
The facility failed to follow physician orders for two residents, leading to significant health issues. One resident with COVID-19 did not receive a timely chest X-ray due to a fax error, resulting in hospitalization for respiratory failure. Another resident was not placed on hospice care as expected, delaying end-of-life care. The facility did not adhere to its policy on obtaining and following physician orders.
The facility failed to provide adequate staffing, resulting in missed showers and delayed assistance for residents. A resident with chronic conditions reported not receiving a bath for over a month, while another with Parkinson's Disease experienced similar issues. Meal service observations revealed significant delays, with cognitively impaired residents waiting for assistance. CNAs confirmed staffing shortages, impacting their ability to complete tasks, despite the DON's denial of such issues.
The facility failed to maintain a clean and sanitary kitchen environment, affecting all 76 residents. Observations revealed missing drywall, exposed wires, and a buildup of dirt and mold in the kitchen area. The Dietary Manager acknowledged the need for repairs and cleaning, but the facility's policy on maintaining cleanliness was not adhered to.
The facility failed to provide dignified mealtime assistance to residents, including a cognitively impaired resident who ate with her hands without staff intervention, and a visually impaired resident who did not receive necessary guidance to locate food. Multiple residents reported not receiving napkins with meals, and one resident's meal was improperly served. These actions violated the facility's policy on residents' rights to a dignified existence.
The facility failed to provide adequate care for residents, with missed showers and lack of meal assistance. Several residents, including those dependent on staff for daily activities, reported missed showers and inadequate help during meals. Observations confirmed these deficiencies, with residents left without necessary assistance, highlighting staffing shortages and unmet care expectations.
The facility failed to follow physician-ordered dietary plans for four residents, resulting in inconsistencies in providing prescribed double protein portions and specific dietary items. Residents with cognitive impairments and various medical conditions, including dementia and diabetes, reported not receiving the required nutritional enhancements. Observations confirmed these deficiencies, and the Dietary Manager acknowledged the oversight.
The facility failed to provide two residents with the required SNF Beneficiary Protection Notification (CMS 10055) upon discharge from Medicare Part A services before exhausting their benefit days. The residents, diagnosed with conditions such as dementia and fractures, did not receive the necessary forms to inform them of their right to appeal the discharge decision. The facility's administrator acknowledged the absence of the forms but could not explain the oversight.
A resident with serious health conditions was not provided the diet ordered by the discharging hospital, receiving only broth and water for several days. This was due to a miscommunication between the nursing and dietary departments, as the dietary order did not include the necessary supplement. The resident expressed hunger, and the family was concerned about the lack of appropriate nutrition.
A resident received an expired dose of Tramadol, despite the facility's policy against administering expired medications. The medication cart contained Tramadol with an expiration date that had passed, and a dose was administered by an RN. The resident had a history of hemiplegia and neuropathy, with orders for Tramadol as needed for pain. The DON had instructed staff to remove expired medications, but this was not done.
A resident with multiple medical conditions, including diabetes, did not receive food at their preferred temperature. The resident's ice cream was placed on a plate with hot food and covered, causing it to melt by the time it was served. The resident expressed dissatisfaction, and the Dietary Manager confirmed that this practice was incorrect.
Two residents received wound care that did not adhere to infection control protocols. An LPN failed to change gloves or sanitize hands during a dressing change for a resident with a stage 4 pressure ulcer, leading to cross-contamination. Another LPN did not properly clean a bedside table or sanitize scissors during wound care for a resident with a pressure ulcer. The facility lacked a specific wound care policy, despite having a general infection prevention program.
The facility failed to ensure safe resident transfers, resulting in injuries to two residents. One resident sustained a laceration to the foot during a transfer involving an unassessed motorized wheelchair, while another resident suffered a fibula fracture due to entanglement in wheelchair footrests during transfers. Staff did not follow policies on mobility aides and change in condition, leading to these incidents.
The facility failed to administer medications according to professional standards for two residents. One resident received over-the-counter medications and borrowed medications from other residents due to a delay in delivery, while another resident's records showed medications were administered before they were delivered. The facility did not follow its own medication administration policy.
Failure to Follow Provider Order for Urine Testing Related to UTI Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to prevent urinary tract infections for one resident with mixed incontinence and vascular dementia. The resident’s MDS documented moderate cognitive impairment and urinary continence with occasional incontinence, and the care plan included an intervention to observe for signs and symptoms of UTI and notify the physician as indicated. On 11/27/2025, an RN documented that a NP, via secure messaging, ordered a straight catheter urine specimen for urinalysis and culture in response to a prior shift nurse’s report that the resident was confused, hallucinating, and incontinent. There was no documentation of urinalysis or culture results from that date, nor any follow-up documentation to the NP regarding the ordered urine specimen. The RN later stated she remembered making the note about the straight catheter order but did not recall obtaining the urine sample and indicated she would have reported it to the day shift nurse. The NP confirmed she had documentation of the order for a straight catheter urine sample due to confusion, hallucinations, and incontinence, and that there were no urinalysis results from that date. Leadership, including the DON, Assistant DON, and Administrator, stated their expectation that nursing staff follow physician orders and notify the NP if the urine sample could not be obtained, consistent with the facility’s policy requiring physician orders to be obtained and followed, and that the physician and DON be promptly notified if orders are not followed for any reason. Subsequently, the resident was found by an RN passed out in a dinner plate with bradycardia and was sent to the emergency department, where hospital records documented admission for disorientation and acute cystitis without hematuria.
Failure to Prevent Verbal and Physical Abuse of Resident by Staff
Penalty
Summary
A deficiency occurred when facility staff failed to prevent verbal and physical abuse of a resident with dementia, resulting in psycho/social harm. The resident, who had a history of dementia, anxiety, depression, and chronic pain, was involved in an incident with a CNA who was also the administrator's son. The resident reported being taken into her room, having her arms and chest squeezed from behind until it hurt, and having her wheelchair taken away. Multiple interviews with staff and the resident indicated that the CNA became frustrated after being called names by the resident, took her to her room, and removed her wheelchair, leaving her upset and unable to move independently. The resident continued to complain of pain in her right shoulder following the incident. Several staff members witnessed or were made aware of the incident, with some hearing the resident yelling for her wheelchair and help. Staff statements described the CNA as having dumped the resident into bed, taken her wheelchair, and made threatening remarks about further retaliation if the resident continued to call him names. The resident was visibly upset, refused medications from one LPN due to distress, and was later moved to another unit for the remainder of the night. Staff also reported that the CNA admitted to taking the wheelchair and expressed frustration with the resident's behavior, while other staff recognized the removal of the wheelchair as a form of restraint and abuse. Despite multiple staff being aware of the incident and reporting it to administration, there was confusion and delay in the facility's response. The administrator, who was also the CNA's father, did not arrive at the facility until later in the day and took over the investigation. Some staff expressed concerns that reports of abuse were not taken seriously and that there was a culture of discouraging reporting. The resident's ongoing complaints of pain and distress, as well as the corroborating staff statements, demonstrate a failure to protect the resident from abuse and neglect as required by facility policy.
Involuntary Seclusion and Removal of Mobility Device
Penalty
Summary
A deficiency occurred when a resident with dementia and a history of falls was subjected to involuntary seclusion and had her wheelchair, her only means of mobility and safe transfer, taken away by a CNA. The resident was placed in her bed, her wheelchair was removed from her reach, and her room door was closed, leaving her unable to transfer or move safely. Multiple staff members observed or were informed of the incident, with some hearing the resident calling for help and expressing distress at being left without her wheelchair. The resident was visibly upset, crying out in fear, and reported pain in her shoulder following the incident. The resident's care plan specifically required that assistive devices be kept at bedside due to her high risk for falls and impaired cognition. Despite this, the CNA removed the wheelchair after a verbal altercation, and the resident was left in bed without means to get up or move independently. Staff interviews confirmed that the wheelchair was left outside the room and that the resident was yelling for help. The incident was not immediately reported by all staff, and some staff expressed concern that the action constituted a restraint and involuntary seclusion. The facility's own policy prohibits abuse, neglect, and involuntary seclusion, and staff, including the DON, acknowledged that removing a resident's wheelchair in this manner would be considered abuse or seclusion. The resident experienced emotional distress, pain, and fear as a result of being left without her wheelchair and confined to her room. The incident was reported to the administrator and law enforcement, and multiple staff statements corroborated the sequence of events that led to the resident's involuntary seclusion and emotional harm.
Failure to Administer Ordered Pain Medication Prior to Wound Care
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple leg wounds did not consistently receive pain management as ordered. The resident had physician orders for lidocaine cream to be applied topically to right lower extremity wounds prior to wound care, as well as PRN hydrocodone-acetaminophen for pain. Documentation showed that lidocaine cream was not always applied before wound treatments, as observed during a wound care procedure where the resident exhibited signs of pain, such as grimacing, grabbing her leg, and verbalizing discomfort. The resident also reported that there were times when wound treatments were missed or delayed, and that the medication for her wounds had run out on occasion. Interviews with nursing staff confirmed that wound care supplies, including prescription creams like lidocaine, sometimes ran out, resulting in wound care being postponed to the next shift. One LPN reported being unable to find the resident's prescribed lidocaine cream in the treatment cart, and only found an unlabeled tube in the medication cart. The Director of Nursing acknowledged that lidocaine should be applied as ordered and that each resident's medication should be labeled and supplied by the pharmacy. The attending physician stated that he expected all ordered medications and treatments to be administered as prescribed, specifically noting that lidocaine was intended to help with pain during wound care. Facility policy required the assessment and management of pain using both pharmacological and non-pharmacological interventions, consistent with the resident's care plan and physician orders. Despite these policies and orders, the resident experienced pain during wound care procedures due to the failure to consistently administer topical lidocaine as ordered, as well as issues with medication availability and administration practices.
Failure to Provide Sufficient Nursing Staff for Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents in a timely manner, as evidenced by multiple observations, interviews, and record reviews. Several residents reported long wait times for assistance, including delays in being transferred out of bed, call light responses, and receiving basic care such as water or showers. One resident, who required a mechanical lift and two-person assistance for transfers, was left in bed during breakfast because there was not enough staff available to help, despite her preference to eat in the dining room. Staff interviews confirmed that when staffing was low, residents requiring more assistance were sometimes left in bed, and priority was given to residents who needed less help. Staff members, including CNAs and LPNs, consistently reported frequent staffing shortages across all shifts, particularly at night and during weekends. They described situations where only one CNA was available per unit, and management did not consistently provide support or cover the floor when call-ins occurred. Staff also reported that management would sometimes instruct them to pass incomplete care tasks, such as dressing changes, to the next shift due to time constraints and insufficient staffing. This led to uncertainty about whether essential care tasks were completed for residents. Resident council minutes and referral forms documented ongoing concerns from residents about long wait times for call lights, delays in receiving showers, and urinals not being emptied at night. The facility census indicated that 73 residents were present at the time of the survey. Multiple staff and resident interviews corroborated that these issues were persistent and affected the quality and timeliness of care provided to all residents in the facility.
Uncertified Nurse Assistant Worked as CNA Without Proper Credentials
Penalty
Summary
The facility failed to ensure that all staff had the appropriate competencies and skill sets to provide care and meet residents' needs. Specifically, a nurse assistant (NA) was hired and worked as a Certified Nursing Assistant (CNA) without having completed the required certification exam. The administrator and director of nursing were aware that the NA had not yet taken the certification test but allowed her to work as a CNA, with the understanding that she would take the test soon. The NA worked throughout the facility, including on the night shift and in various units, performing CNA duties despite not being certified. The facility's policy required state certification for CNAs, but this was not enforced in this instance. Interviews and record reviews revealed that the NA was listed as eligible for hire on the CNA registry, but it was later discovered that she had not shown up for her certification exam, as indicated by the 'NS' (no show) status on the registry. The administrator was initially unaware of the meaning of this status and only clarified it after contacting the registry. The NA continued to work past the 120-day period allowed for uncertified nurse assistants to obtain certification. Multiple staff members confirmed that the NA worked as a CNA without certification, and the administrator was unsure of the specific duties she performed during her shifts.
Improper Medication Labeling, Storage, and Administration
Penalty
Summary
Surveyors identified multiple failures related to the storage, labeling, and administration of medications and creams within the facility. During wound care for a resident with severe cognitive impairment and multiple diagnoses, a registered nurse used a tub of silver sulfadiazine cream that was not labeled with a resident's name, stating she did not know who it belonged to but used it because she could not locate the correct cream. In another instance, the same nurse used silver sulfadiazine cream labeled for a different resident, which was also expired, for a resident with intact cognition and chronic wounds. The nurse admitted to sometimes using other residents' supplies if the correct ones could not be found and acknowledged that expired cream should not have been used. Additionally, surveyors observed several instances where medication and treatment carts were left unlocked and unattended in various hallways, with medications and creams left on top of the carts. In each case, no nurse was present in the area, and only certified nursing assistants were observed nearby. The nurse later stated that she usually locks the medication cart but sometimes forgets. The Director of Nursing confirmed that medication and treatment carts should be locked when unattended and that medications or creams should not be borrowed from other residents or used past their expiration date. Facility pharmacy policies require that all medications be labeled with the resident's name and expiration date, and that medication carts remain locked and inaccessible when not in use. The facility census at the time documented 73 residents who could potentially be affected by these practices. The survey findings were based on direct observation, staff interviews, and review of medical records and facility policies.
Failure to Follow Approved Menu and Serve Correct Portion Sizes
Penalty
Summary
The facility failed to follow the approved menu by not providing the specified protein options and not serving the correct portion sizes to residents. On multiple occasions, residents were served scrambled eggs, hot cereal, and toast for breakfast instead of the menu-approved options, which included a choice of cereal, biscuits and gravy, and breakfast meat. Several residents reported not receiving meat with their breakfast for an extended period, despite menu requirements and personal dietary needs, such as a resident who required double protein and milk but did not consistently receive them. Staff interviews confirmed that breakfast meats were unavailable for about a week, and substitutions were made without consulting the dietitian. During lunch and dinner services, similar deviations from the approved menu were observed. For example, when chicken was unavailable for lunch, Salisbury steak was served instead, and for dinner, residents received only four small pieces of sausage instead of the required whole sausage portion. The dietary manager acknowledged that the correct portion sizes were not served and attributed the shortages to ordering issues related to the holiday schedule. Cooks and dietary staff confirmed that menu substitutions were made based on available ingredients, and the dietitian was not consulted regarding these changes. Resident council meeting minutes and referral forms documented ongoing concerns about menus not being updated or followed, with specific complaints referred to the dietary manager. Facility policies require that menus be followed as written and reviewed by a registered dietitian, and that any changes be approved and revised as necessary. Despite these policies, the facility did not ensure that residents received meals consistent with the approved menu, affecting all 73 residents in the facility.
Expired and Unlabeled Food Items Found in Kitchen and Storage
Penalty
Summary
Surveyors observed multiple food items in the facility's kitchen and storage areas that were past their expiration or use-by dates. Specifically, an unopened bag of crumbled sausage, a container of strawberry glaze, a bottle of chocolate fudge, several bags of cookie pieces, and boxes of cornstarch were all found with expiration dates that had already passed. Additionally, an opened bag of tortilla chips lacked an open date, and several cartons of eggs in the refrigerator were also expired. The Dietary Manager acknowledged the presence of expired food and confirmed that such items should not have been kept. Further observations revealed a container labeled 'Manwich' in the refrigerator without a date indicating when it was placed or opened, as well as two large open containers of coleslaw and Italian dressing that were missing open dates. The facility's policy requires that cans and dried goods be dated with both the date received and the date opened. At the time of the survey, there were 73 residents in the facility, and the failure to properly discard expired food and label opened items was directly observed by surveyors.
LPN Worked with Expired License
Penalty
Summary
The facility failed to ensure that all licensed staff maintained a current and active license while working, as required by state law. An LPN worked at the facility with an expired license, performing nursing duties such as administering medications and providing resident care. Multiple observations confirmed the LPN was actively working on various units and administering medications to residents during the period when her license was not active. Interviews with facility staff revealed gaps in the process for verifying and monitoring licensure status. The Administrator acknowledged that the LPN's license had expired at the beginning of the year and that she continued to work and perform nursing duties during the lapse. The Director of Nursing was unaware of the expired license and stated that corporate typically checks licenses at hire and at renewal, but did not retain proof of renewal. The Assistant Director of Nursing also was not aware of the lapse until after the LPN was suspended. Documentation reviewed included the LPN job description, which requires a current, valid state license, and census records confirming the facility had 73 residents at the time. The failure to ensure all licensed staff had current credentials had the potential to affect all residents in the facility.
Failure to Provide Adequate Linens and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of residents by not supplying adequate linens, specifically washcloths, and by not ensuring that call lights were within reach for multiple residents. Certified Nursing Assistants (CNAs) reported running out of washcloths over a period of weeks, resorting to using pillowcases, cutting up towels, or purchasing wipes with their own money to provide basic hygiene care. Observations confirmed that linen carts and shower rooms were frequently empty of washcloths and towels, and residents were unable to obtain necessary items for personal care, such as shaving. The facility administrator acknowledged awareness of supply issues and stated that linens are delivered daily to an off-site laundry house, but there was no formal process or designated responsibility for restocking linen carts or rooms, leading to inconsistent availability of supplies. Multiple residents were observed with call lights out of reach, either placed on the floor, clipped high on curtains, or wrapped around fixtures, making it difficult or impossible for them to summon assistance when needed. Residents with varying degrees of cognitive impairment and physical limitations, including those at risk for falls, expressed frustration and concern about their inability to access call lights. Staff interviews corroborated that call lights were not always left within reach, and residents sometimes had to attempt to retrieve them, increasing their risk of harm. The facility's own policy requires that call lights be within easy reach of residents when they are in bed or confined to a chair. Despite this, both staff and residents reported ongoing issues with call light accessibility. The lack of a structured process for linen distribution and call light placement directly contributed to the deficiencies observed, affecting residents with significant medical histories such as orthopedic injuries, chronic diseases, cognitive impairment, and mobility challenges.
Failure to Provide Timely and Accurate Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services that met the needs of several residents by not acquiring medications from the pharmacy in a timely manner, administering medications as ordered, and properly documenting medication administration. In multiple instances, nursing staff used medications prescribed for one resident to treat another, due to missing or unavailable supplies. For example, a registered nurse was observed using silver sulfadiazine cream labeled for a different resident on a patient with a pressure ulcer, stating she could not locate the correct cream. Another resident received wound care with a tub of cream that had no identifying label, and the nurse admitted she did not know to whom it belonged but used it because the resident's own supply was missing. Residents also reported missed treatments and delays in wound care due to running out of prescription creams and wound supplies. One resident stated that wound care was skipped for several days because the necessary medication was unavailable, and staff confirmed that they sometimes borrowed supplies from other residents or postponed care until the next shift. Staff interviews revealed that this practice of borrowing or delaying treatments occurred when supplies were not available, and the Director of Nursing acknowledged that residents should not run out of medications if staff communicated the need for reordering. Additionally, there were failures in medication administration and documentation. One resident did not receive their scheduled morning medications because the nurse forgot to administer them and only realized the omission later. After consulting with a nurse practitioner, the nurse attempted to administer the medications, but the resident refused most of them due to the delay. The nurse then incorrectly documented the refusal in the electronic health record and was unable to correct the error. The nurse also failed to notify the physician or physician assistant about the missed doses, as required by facility policy. These deficiencies were observed and confirmed through interviews, record reviews, and direct observation.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
Surveyors found that the facility failed to maintain food items served to residents at palatable and hot temperatures, as required by policy. Multiple residents reported receiving cold food, particularly at breakfast, and observations confirmed that food was left uncovered and unattended for extended periods before being served. For example, one resident's meal was left on a table for at least 25 minutes before being delivered to her room, at which point the food temperatures were measured and found to be below the facility's required standard of 120 degrees Fahrenheit for hot foods. Staff interviews confirmed that complaints about cold food were common, and staff often had to reheat meals or replace trays after residents reported the issue. The residents affected had significant medical histories, including multiple sclerosis, malnutrition, pressure ulcers, diabetes, and cancer, and some were at risk for impaired nutrition and hydration. Despite these vulnerabilities, food was not consistently served at safe and appetizing temperatures. Staff acknowledged the recurring problem of cold food, with several CNAs and an LPN stating that residents frequently complained about the temperature of their meals. The facility's own policy required hot food to be served at 120 degrees or higher and cold food at 50 degrees or lower, but these standards were not met during the survey period.
Failure to Implement Enhanced Barrier Precautions During Wound and High-Contact Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during wound care and high-contact resident care activities for five residents observed for wound care. Surveyors observed multiple instances where staff did not don gowns and, in some cases, failed to perform hand hygiene between glove changes or after removing gloves. For example, a registered nurse performed wound treatments on a resident with multiple wounds and an EBP sign posted, but did not wear a gown, changed gloves without hand hygiene, and left the room with contaminated gloves to retrieve supplies. The nurse also handled supplies and equipment with soiled gloves and did not clean the treatment cart after use. Another resident on EBP for a skin tear and on isolation for a respiratory virus received wound care from staff who wore gloves and masks but did not wear gowns as required. Staff entered the room and performed wound care without donning gowns, and hand hygiene was inconsistently performed between residents and glove changes. In a separate case, a resident with multiple wounds did not have an EBP sign posted, and the nurse did not wear a gown or perform hand hygiene after care. The nurse admitted to forgetting to wear a gown and not always using hand sanitizer between glove changes. Additional observations included a nurse using uncleaned scissors on a resident's wounds and not wearing a gown, as well as certified nursing assistants performing incontinent care on a resident with an EBP sign posted but not wearing gowns or understanding the meaning of EBP. Facility policies required the use of gowns and gloves for high-contact care activities for residents meeting EBP criteria, but these protocols were not consistently followed, as evidenced by direct observation, staff interviews, and record review.
Failure to Honor Resident Preferences and Privacy During Wound Care
Penalty
Summary
The facility failed to respect resident preferences and privacy for two residents with severe cognitive impairment. For one resident with diagnoses including cellulitis, weakness, depression, and bilateral hearing loss, wound care was routinely performed during late night hours, waking the resident from sleep. The resident expressed a preference to have wound care performed while awake, but staff continued to conduct treatments at night for convenience, without prior consultation or consideration of the resident's wishes. The Director of Nursing confirmed that wound care has been performed at night for years and that residents are not typically asked if they consent to being awakened for treatments. For another resident with Alzheimer's disease, diabetes, malnutrition, pain, and cellulitis, wound care was observed to be performed without adequate privacy. The nurse exposed the resident's abdomen facing the door without closing the door or pulling the privacy curtain. The Director of Nursing acknowledged that the door should be closed to provide privacy during such procedures. Facility policy requires respect for resident dignity, self-determination, and privacy, but these standards were not upheld in the observed incidents.
Failure to Timely Report Alleged Abuse and Misappropriation of Property
Penalty
Summary
The facility failed to immediately report an allegation of staff-to-resident abuse to the administrator and did not identify or report an incident of possible misappropriation of a resident's property to the Illinois Department of Public Health for two residents. In the first case, a resident with moderately impaired cognition and multiple diagnoses, including dementia and chronic pain, reported that a Certified Nurse Assistant (CNA), who was also the administrator's son, took her into her room, shut the door, grabbed her around the arms and chest, squeezed her until it hurt, and then took her wheelchair away. Multiple staff members were aware of the incident, with some hearing the resident yelling for help and others being told directly about the incident. However, several staff did not report the incident immediately, either because they were unaware of the reporting requirements or assumed someone else had already reported it. The administrator was not informed until the following morning, and there was a delay in initiating an investigation and notifying authorities. In interviews, the CNA involved denied harming the resident but admitted to taking her to her room, raising his voice, and removing her wheelchair. Other staff corroborated that the resident was upset and that her wheelchair was taken away, with one LPN stating that removing the wheelchair constituted a restraint. The administrator, upon being notified, did not arrive at the facility until later in the day and did not immediately report the incident to the Department of Public Health. The facility's policy requires immediate internal and external reporting of any allegations or suspicions of abuse, neglect, or misappropriation, but this protocol was not followed in this case. In the second case, another resident reported that $200 was stolen from his room while he was hospitalized. The resident stated he reported the missing money to the administrator. Staff were aware of the missing money, but the administrator claimed not to know the amount and did not conduct a formal investigation or report the incident to the Department of Public Health. The only documentation was a grievance form, and there was no paper trail of any investigation or communication with authorities. The facility's policy mandates immediate reporting and thorough investigation of such allegations, but this was not adhered to in this instance.
Failure to Investigate Abuse Allegations and Protect Residents
Penalty
Summary
The facility failed to thoroughly and immediately investigate allegations of abuse and potential theft, and did not prevent further potential abuse or neglect by allowing staff to continue direct care with residents after allegations were made. In one case, a resident with dementia and a history of behavioral issues reported being physically mistreated by a CNA, who was also the administrator's son. Multiple staff members were aware of the incident, which involved the CNA allegedly grabbing, squeezing, and pinching the resident, removing her wheelchair, and shutting her in her room. The resident was left upset and without her wheelchair, and staff reported hearing her call for help. The CNA admitted to being frustrated and taking the wheelchair, and other staff confirmed the resident was visibly distressed. Despite these reports, the administrator did not initiate an immediate or thorough investigation, and the CNA was not removed from resident care until later. The administrator also failed to ensure all staff involved were interviewed promptly, and there was confusion and delay in reporting the incident to authorities. In another instance, a resident reported $200 missing from his room, which he had kept in a cup on his bedside table. The administrator acknowledged being told about the missing money but did not conduct a formal investigation, did not document interviews or findings, and did not report the incident to the state health department as required. Staff were aware of the missing money, but there was no paper trail or evidence of a thorough inquiry. The only documentation was a grievance form stating the resident had no money, with no further follow-up or investigation recorded. Facility policy requires immediate reporting and investigation of all allegations of abuse, neglect, or misappropriation of property, and mandates that accused employees be removed from resident contact during investigations. However, in both cases, these procedures were not followed. The facility did not ensure prompt and complete investigations, failed to protect residents from further potential harm, and did not maintain adequate documentation of the incidents or the investigative process.
Failure to Provide Timely ADL Assistance with Transfers for Dependent Resident
Penalty
Summary
A dependent resident with multiple diagnoses, including multiple sclerosis, anxiety disorder, chronic pain syndrome, abnormal posture, repeated falls, muscle weakness, ataxic gait, and fatigue, was not provided timely assistance with activities of daily living (ADLs), specifically with transfers. The resident was documented as fully dependent for transfers and required the use of a mechanical lift with the assistance of two staff members. On the morning in question, the resident's breakfast was left untouched in the dining room because she had not been transferred out of bed. Staff interviews revealed that there was only one CNA available on the floor during the early morning hours, making it impossible to perform the required two-person mechanical lift transfer. As a result, the resident remained in bed and was unable to join the dining room for breakfast, despite expressing her preference to do so and being alert and oriented during the interview. Further interviews with staff indicated that the night shift did not get any two-assist residents up in the morning, and the available CNA prioritized getting up residents who required only one-person assistance. The Director of Nursing and the Administrator both stated that there should always be enough staff in the building to assist with mechanical lift transfers, and that no resident should be left in bed due to staffing issues. Facility policy requires two qualified staff for mechanical lift transfers. The failure to provide timely ADL assistance with transfers for this dependent resident was directly observed and confirmed through staff interviews and record review.
Failure to Administer Prescribed Medications and Inaccurate Documentation
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed for two residents. During a medication administration observation, an LPN was found to have placed two cups containing morning medications for two residents in the medication cart drawer after being unable to wake the residents to administer their medications. The LPN admitted to forgetting to return and administer the medications and had already documented in the electronic medical record that the medications had been given, despite not administering them. The Director of Nursing observed the cups and confirmed that medications should not be popped and left in the cart, and that not administering medications constitutes a medication error. One resident had multiple diagnoses including anemia, vitamin D deficiency, hypokalemia, psychotic disorder, dementia, chronic kidney disease, and diabetes, with a severely impaired cognitive status. The other resident had diagnoses such as malignant neoplasm of the lung, Alzheimer's disease, atherosclerosis, chronic heart failure, and chronic kidney disease, with intact cognition. Both residents were scheduled to receive several medications each morning, including critical medications such as blood thinners, cardiac medications, and Depakote sprinkles. The LPN did not notify the physician or nurse practitioner about the missed doses and did not document the omission in the residents' charts. Interviews with facility leadership confirmed that medications should not be left in cups in the medication cart and that any missed or late medication should be considered a medication error. The facility's policy requires medications to be administered as prescribed and any omission to be reported. The physician stated that missing certain medications, such as Depakote, could be significant and expects to be notified of any missed doses.
Failure to Use Appropriate Wheelchair Results in Resident Fall and Fractures
Penalty
Summary
A resident with cerebral palsy, weakness, anxiety, and diabetic neuropathy, who was cognitively intact but required substantial to maximal assistance for mobility and was dependent on nursing for all aspects of care, was not transported in the appropriate wheelchair. The resident's care plan specified the use of a standard wheelchair with footrests and proper body alignment. However, on the day of the incident, the resident was transferred by a CNA using a mechanical lift into a high back wheelchair that belonged to another resident. This high back wheelchair did not have footrests suitable for the resident, whose legs were too short to reach them, and the chair's design pushed on the back of the resident's head, forcing her forward. While being moved away from the dining room table by another CNA, the resident fell forward out of the high back wheelchair, hitting her face and left arm on the floor. The fall resulted in a left nasal bone deformity and fractures of both the ulnar and olecranon in the left upper extremity. Occupational therapy and nursing staff confirmed that the high back wheelchair was not appropriate for the resident due to her lack of core muscle control and inability to reposition or balance herself. The facility's own policy required assessment and management of falls through prevention and intervention, but the failure to use the correct wheelchair and ensure proper supervision directly led to the accident and resulting injuries.
Medication Error Leads to Hospitalization for Hypoglycemia
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including Type 2 diabetes mellitus and Alzheimer's disease, was inadvertently administered another resident's morning medications by an LPN. The LPN, unfamiliar with some residents due to infrequent work shifts, asked the resident her name, received the name of a different resident, and proceeded to give her that resident's medications. The error was only discovered after a CNA identified the resident and the LPN realized the mistake. The medications administered included several drugs, notably antidiabetic agents such as Januvia and Metformin, which were not prescribed for the resident. Following the administration of the incorrect medications, the resident was found to have a critically low blood glucose level (44 mg/dL), for which she was given orange juice to raise her blood sugar. Despite this intervention, the resident remained lethargic and more confused than her baseline. Emergency services were called, and the resident was transported to the hospital, where she was admitted for hypoglycemia. Hospital records confirmed the resident had been given another resident's medications, resulting in hypoglycemia that required intravenous dextrose and close monitoring until her blood sugars stabilized. The facility's medication administration policy requires verification of the five rights (right resident, right drug, right dose, right route, right time) with a triple check process, but this protocol was not followed in this instance. The LPN did not verify the resident's identity beyond asking her name, which was unreliable due to the resident's severe cognitive impairment. Additionally, the facility was unable to provide a specific policy for medication errors when requested during the survey.
Failure to Provide Behavioral Health Services and Ensure Resident Safety
Penalty
Summary
The facility failed to provide necessary behavioral health services and to maintain or improve the psychosocial well-being of a resident with significant mental health diagnoses, including bipolar disorder, depression, generalized anxiety disorder, personality disorder, suicidal ideations, and a history of intentional self-harm. The resident experienced frequent and escalating episodes of suicidal ideation, self-injurious behaviors such as punching herself and banging her head, and made multiple statements about plans to strangle herself. Despite these ongoing behaviors and repeated hospitalizations, the facility did not consistently implement increased monitoring, remove hazardous objects from the resident's environment, or ensure referral for recommended counseling services as documented in medical records and care plans. Staff interviews and record reviews revealed a lack of awareness and follow-through regarding physician orders for 15-minute checks, inconsistent or absent documentation of monitoring, and confusion among staff and leadership about when and how increased supervision was to be provided. Hazardous items such as cords, blankets, plastic bags, and a folding chair were observed in the resident's room, and staff were unaware of the presence of some of these items, including a call light cord in the bathroom. The resident was often left unsupervised despite expressing active suicidal ideation and having a clear plan, and staff had not received training on managing suicidal behaviors or behavioral health care. The facility also failed to make or follow up on referrals for counseling services as recommended by outside providers. Interviews with facility leadership, nursing staff, and consulting psychiatric professionals confirmed that the facility was not equipped to meet the resident's behavioral health needs and that there was a lack of appropriate interventions and staff training. The resident continued to experience frequent crises, including multiple transfers to emergency rooms and psychiatric facilities, and voiced ongoing feelings of isolation and suicidal thoughts. The failure to provide necessary behavioral health care and to maintain a safe environment resulted in an Immediate Jeopardy situation, as the resident remained at risk for self-harm due to the facility's inaction and lack of appropriate behavioral health interventions.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Adequate Supervision Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of falls, and significant physical limitations was not provided with the necessary supervision to prevent accidents. The resident, who had diagnoses including Alzheimer's disease, dementia, and a previous right femur fracture, was assessed as a high fall risk and required frequent observation and placement in supervised areas when out of bed. Despite these documented needs, the resident experienced multiple falls within a month, including incidents resulting in a laceration and a left hip fracture. On the day of the most serious incident, both the assigned LPN and CNA left the unit floor without notifying other staff, contrary to facility policy requiring staff to ensure coverage when leaving their assigned area. The resident was left unsupervised in the dining room, seated in a wheelchair, and was later found on the floor by another CNA who responded to calls for help. Staff interviews confirmed that the resident was known to attempt to stand unassisted and should not have been left out of sight due to her impulsive behavior and high fall risk. Documentation and staff statements revealed that the facility's process for ensuring adequate supervision and staff coverage was not followed, resulting in the resident being left alone and sustaining injuries including rib fractures and a left femoral neck fracture. The facility's policies required adequate staffing and supervision, especially for residents at high risk for falls, but these procedures were not adhered to at the time of the incident.
Failure to Notify POA of Resident Fall and Change in Condition
Penalty
Summary
The facility failed to notify the designated Power of Attorney (POA) of a resident's fall and subsequent change in condition, despite the resident having severe cognitive impairment and being unable to make her own decisions. The resident, who had diagnoses including a displaced intertrochanteric fracture of the right femur, altered mental status, Alzheimer's disease, and dementia, experienced a fall that resulted in a transfer to a local hospital. The facility's records showed that the physician was notified, but there was no evidence that the POA was contacted prior to the hospital reaching out. The POA reported not receiving any calls or messages from the facility and only learned of the incident from the hospital emergency room. Staff interviews revealed inconsistent practices regarding family notification. One LPN stated she attempted to contact the POA twice without success and did not leave a voicemail or attempt to reach other emergency contacts. Other nursing staff and facility leadership confirmed that the policy requires immediate notification of the physician and POA in the event of a change in condition, such as a fall. The facility was unable to provide documentation that the required notification to the POA was made prior to the hospital's contact.
Verbal Abuse by DON Following Resident's Refusal of IV Therapy
Penalty
Summary
A resident with diagnoses including Muscular Dystrophy, Adjustment Disorder, Multiple Sclerosis, and Major Depressive Disorder, who was cognitively intact, experienced verbal abuse from the Director of Nursing (DON). The incident occurred when the resident refused a vitamin IV therapy due to feeling unwell. The DON confronted the resident in the dining room, raising her voice and expressing frustration about the cost incurred by the facility due to the refusal. Multiple witnesses, including other residents and a CNA, confirmed that the DON's tone was loud, aggressive, and could be heard across the dining room. The resident reported feeling embarrassed and angry as a result of the public confrontation. The DON acknowledged having the conversation in the dining room and admitted that her delivery was inappropriate, stating that her voice is sometimes loud. She later apologized to the resident in the same public setting. The administrator was aware of a misunderstanding regarding the IV therapy program but was not informed of the specific incident between the DON and the resident. The facility's abuse prevention policy defines abuse to include verbal abuse and intimidation resulting in mental anguish, which aligns with the events described.
Staffing Deficiency Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to provide timely care for residents, as evidenced by observations, interviews, and record reviews. On the night of the survey, a resident was found in bed with urine-soaked clothing and stained sheets, indicating a lack of timely incontinence care. The CNA responsible for the resident admitted to providing care hours earlier and noted a shortage of supplies, such as washcloths and towels, which hindered proper care. The RN on duty acknowledged that staffing was insufficient, leading to only basic care being provided without any extra attention. Another resident reported that there was not always enough staff to assist with daily activities, such as showering and toileting, resulting in inconsistent pericare. This resident, who is dependent on staff for toileting, expressed frustration over having to wait for assistance with a bedpan. Similarly, another resident was woken up early against their preference due to anticipated short staffing on the day shift, as confirmed by the Assistant Director of Nurses. Additional interviews with staff revealed ongoing issues with staffing and supplies, impacting the ability to provide adequate care. CNAs reported working alone with a high number of residents, leading to delays in incontinence care and repositioning. The Director of Nurses and Administrator both claimed that staffing was adequate, despite evidence to the contrary, and noted that department heads would assist on the floor if necessary. However, the lack of timely care and insufficient supplies were clear indicators of the staffing deficiency.
Inadequate Incontinence Care and Supply Shortages
Penalty
Summary
The facility failed to provide timely incontinence care and lacked sufficient supplies to meet the needs of residents, as observed in four out of five residents reviewed. Resident 1, who is cognitively intact and frequently incontinent, was found in urine-soaked clothing and stained bed linens. Despite being checked at 2:30 AM, the resident was not provided with adequate incontinence care until much later, and staff reported a shortage of necessary supplies such as washcloths and towels. This resulted in the resident remaining in soiled clothing for an extended period. Resident 3, who is also cognitively intact and dependent on staff for toileting, reported inconsistent perineal care and delays in being assisted with a bedpan. The resident expressed concerns about the lack of staff and the impact on the quality of care received. Similarly, Resident 8, who is frequently incontinent, reported that staff shortages affected the timeliness of care, particularly at night. Resident 11, who requires substantial assistance with toileting, experienced delays in response to call lights, leading to incontinence episodes. Staff members confirmed the shortage of linens and supplies, which hindered their ability to provide adequate care. The Director of Nursing acknowledged the issue but stated that staff had not communicated the shortages effectively. The facility's policies on bathing and perineal care were not adhered to, contributing to the deficiencies observed.
Failure to Accommodate Resident's Morning Routine Preferences
Penalty
Summary
The facility failed to accommodate the preferences of a resident, identified as R4, regarding the time they wished to get up in the morning. R4, who has a severe cognitive deficit and requires assistance with activities of daily living, expressed dissatisfaction with being woken up early. On the morning of February 18, 2025, R4 was observed sitting at the dining room table and stated that they did not want to be up so early, but were woken up regardless. This was corroborated by a Certified Nursing Assistant (CNA), who mentioned that they were instructed to get as many residents up as possible due to anticipated short staffing on the day shift. The Assistant Director of Nurses (ADON) confirmed that the facility was aware of the staffing shortage for the day shift starting at 6:00 AM on February 18, 2025. The Director of Nurses (DON) acknowledged that residents should not be forced to get up early against their wishes and stated that staffing levels are generally good, although some days are better than others. Despite this, the facility's actions on the morning in question did not align with the resident's preferences, leading to a deficiency in accommodating resident rights.
Failure to Identify and Treat Pressure Ulcers
Penalty
Summary
The facility failed to identify and treat pressure wounds for three residents, leading to a deficiency in pressure ulcer care. Resident 1, who had severe cognitive impairment and was at risk for pressure ulcers, returned from the hospital with open wounds on the sacrum. The registered nurse who assessed the resident did not notify the medical provider or upload pictures of the wounds into the electronic communication system, resulting in a lack of treatment orders. The wound nurse was not informed of the wounds until 19 days later, and no treatments were completed until the wound physician's visit. Resident 2, who was cognitively intact, had a stage 4 pressure wound on the left ischium and sacrum. Despite having treatment orders from the wound physician, the facility did not complete any treatments or apply dressings to the wounds. The resident resorted to using antiseptic lotion from home. The wound nurse failed to enter the treatment orders into the electronic medical record, and the resident did not receive wound treatments for a week after admission. Resident 3, who was cognitively intact, had a pressure injury on the sacrum. A certified nursing assistant notified a registered nurse of the wound, but the nurse did not document it or take necessary actions to address it. The wound nurse was informed two days later, and treatment orders were delayed. The facility's policies on wound management and change in condition were not followed, contributing to the deficiency in pressure ulcer care.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident, identified as R1, who was part of a sample of seven residents reviewed for physician notification of change in condition. R1 was admitted to the facility with multiple diagnoses, including pressure ulcer, hypertension, anxiety, asthma, dementia, and urinary tract infection. Despite being cognitively intact, as indicated by a BIMS score of 15, R1 experienced a decline in condition, which was not communicated to the physician or nurse practitioner in a timely manner. Interviews with staff revealed that R1's condition had been deteriorating over the weeks leading up to her hospitalization. A Certified Nurse Assistant (CNA) noted a significant decrease in R1's urine output and oral intake, which was reported to the nurses. However, the Registered Nurse (RN) and Licensed Practical Nurse (LPN) who regularly cared for R1 could not recall notifying the physician about these changes. The facility's policy requires immediate notification of the primary physician or designated alternate in the event of a change in a resident's condition, but this protocol was not followed. R1 was eventually sent to the hospital in a severely compromised state, with hypoglycemia, hypotension, and a low rectal temperature. The physician and nurse practitioner responsible for R1's care were not informed of her declining condition prior to her transfer to the hospital. The facility's failure to document and communicate R1's change in condition, as well as the lack of physician notification, contributed to the deficiency identified in the report.
Failure to Implement Ordered Wound Care Treatments
Penalty
Summary
The facility failed to implement ordered treatments for wound care for a resident with a Stage 4 pressure ulcer. The resident, who was admitted with a pressure ulcer of the sacral region, had a treatment plan that included the application of Collagen powder, Silver Sulfadiazine, and Alginate Calcium, among other treatments. However, these orders were not documented in the resident's Physician Order Sheet or Medication Administration Record (MAR), leading to a lack of proper treatment for the pressure ulcer. The Director of Nursing (DON) and the Licensed Practical Nurse (LPN) responsible for processing the wound physician's orders were unaware that the orders were not being followed. The LPN confirmed that the MAR did not include the new orders for the Stage 4 wound, and the treatments being administered were not the correct ones as ordered by the wound physician. The resident's condition was further compromised when they were sent to a local hospital with a dressing that did not adequately cover the wound. Interviews with the wound physician and nursing staff revealed a breakdown in communication and order processing. The wound physician expected the nurses to follow his orders, but the DON admitted there was no ongoing process to monitor the completion of treatments. The failure to implement the ordered wound care treatments resulted in the resident not receiving the necessary care for their pressure ulcer, as evidenced by the hospital's assessment of the inadequate dressing and multiple lesions around the wound.
Failure to Follow Physician Orders and Provide Timely Care
Penalty
Summary
The facility failed to follow physician orders and provide timely care for two residents, leading to significant health issues. Resident R80, who had multiple diagnoses including COVID-19, was not given a timely chest X-ray despite showing symptoms of respiratory distress. The X-ray was ordered but not completed due to a fax error, and there was a lack of documentation and follow-up on the resident's respiratory status. This oversight resulted in the resident being taken to the emergency department by family members and subsequently admitted to the hospital for hypoxemic respiratory failure. Resident R81, who had a history of serious health conditions including malignant neoplasm of the liver, was not placed on hospice care as expected. Despite family discussions and a decision for hospice care, the facility did not initiate the hospice consult or admission. The family was under the impression that hospice care was already in place, but the facility had not communicated or acted on this decision, leading to a delay in the resident receiving appropriate end-of-life care. The facility's policy on obtaining and following physician orders was not adhered to in these cases, resulting in a failure to provide necessary and timely medical interventions. The lack of communication and follow-up on physician orders and family requests contributed to the deficiencies observed in the care of both residents.
Inadequate Staffing Leads to Missed Care and Delays
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its 76 residents, as evidenced by multiple instances of missed care and delayed assistance. Resident R4, who is dependent on staff for personal care due to conditions such as a chronic ulcer and diabetes, reported not receiving a bath or shower for over a month and experiencing long wait times for call light responses. Similarly, Resident R39, who requires assistance due to Parkinson's Disease and other conditions, also reported missing showers and experiencing delays in care due to insufficient staffing. Both residents indicated that they had communicated these issues to the Director of Nursing, but no improvements were observed. During meal service observations, significant delays were noted in serving and assisting residents with their meals. On one occasion, a cognitively impaired resident, R9, waited 27 minutes for assistance with eating, while another resident, R52, who requires setup and cleanup assistance, began eating with her hands and did not receive help for 45 minutes. Staff members, including CNAs V7, V8, and V13, confirmed the facility's staffing shortages, which impacted their ability to complete assigned tasks such as showers and timely meal service. Despite these reports, the Director of Nursing denied any staffing issues, contradicting the observations and statements from both residents and staff.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the kitchen, which has the potential to affect all 76 residents. During an observation, it was noted that the kitchen back wall had a missing area of drywall where the wall meets the floor, measuring approximately 2 feet by 6 to 8 inches. This area was uneven and broken, exposing the end of a cement block. Additionally, the wall between the dish machine and the food service area had communication wires extending out of the wall to the floor, with the wire housing sitting on the floor. The hole in the wall where the wire housing should be located was approximately 18 inches by 4 inches and contained a buildup of dirt and mold. The area around the hole, approximately six inches out, also had an accumulation of dirt and mold, and the wiring housing on the floor was similarly dirty. The Dietary Manager acknowledged that the area of the wall along the floor where the drywall is missing should be repaired, and the area where the wires are hanging out of the wall should be cleaned and repaired. The facility's policy, dated January 2012, titled 'Cleaning and Sanitation - General,' states that the kitchen will be maintained in a clean and sanitary condition, adhering to state and federal food codes. However, the observations made during the survey indicate that these standards were not met, leading to the deficiency.
Failure to Provide Dignified Mealtime Assistance
Penalty
Summary
The facility failed to uphold the dignity of residents during mealtimes, as observed in multiple instances involving ten residents. One resident, who was severely cognitively impaired and required setup and cleanup assistance for eating, was repeatedly observed eating with her hands without receiving any assistance or prompting from staff. Despite being provided with silverware, she continued to eat with her fingers, resulting in food on her clothing, hands, and face. Staff did not intervene to assist her in using utensils or to ensure she was finished eating before removing her food. Another resident, who was visually impaired but cognitively intact, was not provided with the necessary assistance to locate and identify food items on his plate. He relied on other residents to help him identify his food, as staff did not offer the required guidance. This resident was also observed without a clothing protector, leading to food spillage on his clothing, and he was not provided with a napkin despite requesting one. Additionally, several residents reported not receiving napkins with their meals for over a month, which was confirmed through observations. One resident's meal was improperly served with dessert stacked on top of his food, causing his bread to be pushed into the rest of his meal. The facility's policy on residents' rights emphasizes the importance of a dignified existence, yet these observations indicate a failure to adhere to this policy, as residents were not provided with basic dining assistance and dignity during meals.
Deficiencies in Resident Care and Assistance
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living for several residents, as evidenced by missed showers and lack of assistance during meals. Resident R4, who is dependent on staff for showering, reported not having a bath or shower in over a month, despite being scheduled for showers twice a week. Documentation revealed that R4 received only a fraction of the scheduled showers in October and November. Similarly, Resident R39, also dependent on staff for showers, reported missing several scheduled showers, with records confirming that only a few were completed in the same period. Staff interviews corroborated the issue, with multiple CNAs acknowledging the facility's staffing shortages and the resulting inability to complete all assigned showers. Resident R52, who is severely cognitively impaired and requires assistance with eating, was observed eating with her hands without receiving any help or prompting from staff. During multiple meal observations, R52 was not provided with a clothing protector and was left to eat with her fingers, resulting in food on her clothing and hands. Despite staff acknowledging R52's tendency to eat with her hands, no consistent efforts were made to assist or encourage the use of utensils. This lack of assistance persisted over several days, with staff failing to offer help even when R52 was visibly struggling. Resident R9, who is cognitively impaired and dependent on staff for eating, was left without assistance during meals, leading to concerns about her safety and comfort. On multiple occasions, R9 was observed slouched in her chair at an inappropriate angle for eating, yet staff did not attempt to reposition her. Additionally, R9 expressed dissatisfaction with the food and concerns about choking, but staff continued feeding her without addressing these issues. Resident R23, who is visually impaired and requires some assistance during meals, was also left without adequate help. Observations showed R23 struggling to locate food on his plate, with other residents stepping in to assist. Despite the expectation for staff to assist residents in need, as stated by the Director of Nursing, these deficiencies in care were evident across multiple residents.
Failure to Follow Physician-Ordered Dietary Plans
Penalty
Summary
The facility failed to adhere to dietary orders prescribed by physicians for four residents, leading to deficiencies in the nutritional care provided. Resident R50, who is severely cognitively impaired and diagnosed with dementia and protein-calorie malnutrition, was ordered a regular diet with specific enhancements for added calories, including double portions of meat and health shakes. However, observations on multiple occasions revealed that R50 did not receive the prescribed double portions of protein, as confirmed by the resident's statement. Similarly, Resident R39, who is cognitively intact and has a history of Parkinson's disease and diabetes, was prescribed a regular diet with consistent carbohydrates and double protein portions. Despite this, R39 reported not consistently receiving the double protein portions as ordered. Observations during meal times corroborated this inconsistency, as the meals provided did not align with the dietary orders. Resident R43, with moderate cognitive impairment and chronic respiratory issues, and Resident R53, who is cognitively intact and has diabetes and peripheral vascular disease, also experienced similar issues. Both residents were prescribed diets with double protein portions, yet they reported and were observed not receiving the prescribed portions consistently. The Dietary Manager acknowledged that residents with orders for double protein portions and specific items like ice cream should receive them, indicating a lapse in following dietary orders.
Failure to Provide SNF Beneficiary Protection Notification
Penalty
Summary
The facility failed to provide written notice of potential liability for non-covered stays to two residents, R71 and R73, as required by the SNF Beneficiary Protection Notification. R71, diagnosed with a fracture of the left pubis, dementia, and a fracture of the sacrum, was discharged from Medicare Part A services before exhausting her benefit days without receiving the CMS 10055 form, which would have informed her of her right to appeal the decision. Similarly, R73, diagnosed with dementia, obesity, and essential hypertension, was also discharged from Medicare Part A services before exhausting her benefit days without receiving the necessary CMS 10055 form. The facility's administrator, V1, acknowledged the absence of the forms for both residents but could not provide an explanation for the oversight.
Failure to Provide Ordered Diet to Resident
Penalty
Summary
The facility failed to provide the diet as ordered for a resident, identified as R81, who was admitted with multiple serious health conditions including iron deficiency anemia, liver cancer, and type 2 diabetes mellitus. Upon admission, R81's care plan included encouraging good oral intake, and the diet order from the discharging hospital specified a full liquid diet with a nutritional health drink supplement. However, observations revealed that R81 was only provided with broth and water for several meals over a period of three and a half days. This inadequate provision of nutrition led to the resident expressing hunger and the family expressing concern over the lack of appropriate food. The facility's failure to provide the correct diet was attributed to a miscommunication between the nursing and dietary departments. The dietary manager confirmed that R81 received only broth due to the nursing staff not including the supplement in the dietary order. The facility's policy required the charge nurse to complete a diet order and communication form to ensure both departments were aware of any new admission diet orders, but this process was not followed correctly, resulting in the deficiency.
Expired Medication Administered to Resident
Penalty
Summary
The facility failed to discard expired medications for a resident, identified as R8, who was reviewed for expired medications. During an observation on November 20, 2024, it was found that the A Hall medication cart contained a card of R8's Ultram (Tramadol) 50mg with an expiration date of November 9, 2024. Despite this, a dose was signed out and administered on November 19, 2024, by a registered nurse, V25. R8's medical records indicate a history of hemiplegia affecting the right dominant side and idiopathic progressive neuropathy, with active orders for Tramadol 50mg to be given as needed for moderate to severe pain. The Director of Nursing, V2, had instructed staff to remove expired medications from the carts the day before the observation. The facility's policy mandates that expired medications should not be administered and must be removed and destroyed, which was not adhered to in this instance.
Failure to Serve Food at Preferred Temperature
Penalty
Summary
The facility failed to serve food at a preferred temperature for a resident, identified as R53, who was cognitively intact and had multiple medical conditions including type 2 diabetes mellitus and peripheral vascular disease. R53 had a dietary order for regular consistency with thin liquids, ice cream at lunch, and double protein portions at all meals. On the specified date, a CNA placed R53's ice cream on a plate with hot food and covered it, which resulted in the ice cream melting by the time it was served. R53 expressed dissatisfaction with the melted ice cream, stating it was a frequent occurrence. The Dietary Manager confirmed that frozen or cold food should not be placed with hot food under a plate cover, acknowledging that residents should not have to eat melted ice cream.
Infection Control Deficiencies in Wound Care
Penalty
Summary
The facility failed to implement proper infection prevention strategies during wound care for two residents, R1 and R66. R1, who has severe cognitive impairment and multiple diagnoses including a stage 4 sacral pressure ulcer, received wound care from an LPN who did not follow proper infection control procedures. The LPN placed supplies on an uncleaned bedside table, failed to change gloves or perform hand hygiene after removing soiled dressings, and cross-contaminated clean and dirty items, including the treatment cart. The Wound Care RN observed these actions and acknowledged the cross-contamination. For R66, who is cognitively intact and has a pressure ulcer on the right buttock, wound care was performed by another LPN who also did not adhere to infection control protocols. The LPN used a bedside table that was not properly cleaned before placing supplies, used unlabeled wound cleanser, and failed to cleanse the wound before applying new dressings. Additionally, the LPN did not sanitize scissors used during the procedure and returned the resident's food to the bedside table without cleaning it after the procedure. The facility's administrator was unable to provide a specific wound care policy, although the facility has a general infection prevention and control program. The program emphasizes cleanliness and infection prevention strategies, including hand hygiene as a standard precaution. However, the observed deficiencies indicate a lack of adherence to these protocols during wound care procedures.
Failure to Ensure Safe Resident Transfers
Penalty
Summary
The facility failed to ensure safe resident transfers, resulting in injuries to two residents. One resident, R1, sustained a laceration to the right foot requiring sutures during a transfer using a mechanical lift. The incident occurred when the resident's motorized wheelchair, which had not been assessed for safety, moved unexpectedly, causing the resident's foot to be lacerated by the bedframe. Staff involved in the transfer did not ensure the motorized wheelchair was turned off prior to the transfer, and the Therapy Director was not aware of the motorized wheelchair's presence until after the incident. Another resident, R2, sustained a fibula fracture, which was discovered after staff noticed bruising and swelling on the resident's right ankle. The investigation revealed that R2's feet would often get entangled in the wheelchair footrests during transfers, causing a twisting motion that likely led to the fracture. Despite multiple staff members being aware of the resident's difficulty with transfers, there was no documentation or immediate action taken to address the issue until the injury was discovered. The facility's policies on motorized mobility aides and change in condition were not followed, leading to these incidents. Staff failed to notify the Director of Nursing about the introduction of the motorized wheelchair and did not ensure a safety assessment was conducted. Additionally, there was a lack of timely communication and documentation regarding the change in condition for R2, resulting in a delay in identifying and treating the injury. These failures highlight significant lapses in supervision and adherence to safety protocols within the facility.
Failure to Administer Medications According to Professional Standards
Penalty
Summary
The facility failed to administer medication in accordance with professional standards for two residents. For Resident 3, the facility did not have the prescribed medications delivered on time, and the nurse administered over-the-counter medications from stock instead. Additionally, the nurse borrowed medications from other residents to administer to Resident 3, which is against the facility's policy. The Director of Nursing confirmed that the medications were not stock medications and should not have been borrowed from other residents. The electronic medication cabinet log showed no medications had been extracted for Resident 3, and the Pharmacy Nurse Consultant confirmed that the medications had not been delivered to the facility as of the date of the surveyor's visit. For Resident 1, the facility's records showed that the prescribed medications were delivered, but the Medication Administration Record indicated that the medications were administered before they were delivered. The Director of Nursing stated that if a medication was unavailable, staff should extract it from the electronic medication cabinet or call the resident's medical provider for an equivalent medication. The facility's policy explicitly states that medications supplied for one resident should never be administered to another resident. The surveyor's findings indicate that the facility did not follow its own medication administration policy, leading to the deficiency.
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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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