Helia Healthcare Of Newton
Inspection history, citations, penalties and survey trends for this long-term care facility in Newton, Illinois.
- Location
- 300 S Scott Street, Newton, Illinois 62448
- CMS Provider Number
- 145807
- Inspections on file
- 22
- Latest survey
- September 22, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Helia Healthcare Of Newton during CMS and state inspections, most recent first.
The facility failed to provide 8 hours of consecutive RN coverage, affecting all 36 residents. The Administrator acknowledged shifts without the required coverage, with the Director of Nursing working weekends but leaving for several hours on one occasion. Nursing schedules confirmed non-consecutive RN coverage on multiple dates, contrary to facility policy.
The facility failed to provide adequate staffing, affecting all 32 residents. Instances included a resident with severe cognitive deficits waiting an hour for toileting assistance and another resident with multiple health issues waiting over 15 minutes. Interviews revealed frequent staffing shortages, particularly on weekends and night shifts, with only one CNA and one nurse available at times.
The facility failed to provide the required 8 hours of daily RN coverage, affecting all 32 residents. Multiple days in June, July, and August 2024 lacked RN coverage. The administrator acknowledged the issue, citing difficulties in recruiting RNs, but mentioned recent hires to improve coverage.
The facility failed to maintain kitchen sanitation, potentially affecting all 32 residents. Observations included unsanitary conditions such as a dirty dish machine, food debris on surfaces, and improper food handling by a cook. The Dietary Manager admitted the cleaning schedule was not followed.
A facility failed to transmit a resident's MDS assessment within the required timeframe. The resident, with conditions including dementia and Alzheimer's, had an assessment completed in May, but it was not transmitted until September due to a misunderstanding by the MDS Nurse about transmission requirements for private pay discharges. The facility lacked a specific policy on MDS transmission, relying on the RAI manual.
The facility failed to update care plans for two residents, leading to deficiencies in their care. One resident's plan did not reflect the need for an alternative alert system due to a choking risk, while another's plan lacked updates for a new antipsychotic medication and non-pharmacological interventions. The facility did not provide a policy for updating care plans.
A facility failed to implement fall precautions for a resident with muscle weakness, gait abnormalities, and vascular dementia by not ensuring the call light was within reach. Despite a care plan requirement, the call light was observed out of reach on multiple occasions. A CNA mentioned the family’s concern about strangulation, and no alternative call light solution was provided, with staff checking on the resident every two hours.
A facility failed to ensure a resident was free from unnecessary medications by not implementing a Gradual Dose Reduction (GDR) for Risperidone, despite the absence of behaviors. The resident, diagnosed with vascular dementia and anxiety, was prescribed Risperidone 1 mg as needed, but there was no documentation of GDR attempts or recommendations. Behavior tracking showed no occurrences, and staff confirmed the absence of behaviors, yet the facility's system did not allow individualized tracking, and the care plan did not reflect any medication reduction efforts.
The facility failed to provide adequate direct care staffing, with multiple instances of only one CNA and one nurse available for 37 residents, leading to significant delays in call light responses and unmet care needs. Despite hiring new CNAs, the problem persisted, with staff frequently working double shifts and the MDS/Care Plan Coordinator also taking on CNA duties.
The facility failed to provide adequate direct care staffing, leading to delays in resident care and missed showers. On Easter Sunday, the Administrator and a Registered Nurse had to perform all resident care due to staff call-ins. Multiple staff and residents reported ongoing issues with insufficient staffing, impacting the quality of care provided.
The facility failed to provide a full-time DON, affecting all 36 residents. The former DON left without notice, and no replacement has been found. Other nurses and corporate staff have taken over some duties, but no one has been assigned to Infection Control Preventionist duties.
The facility failed to provide sufficient kitchen staff when one cook called in sick, leading the uncertified Administrator to prepare meals that did not fully adhere to the menu. This affected all 36 residents.
The facility failed to maintain proper sanitation and food safety standards in the kitchen, affecting all 36 residents. Observations revealed grime and food debris on various surfaces and equipment, improper food storage, and inadequate sanitization practices. The dietary manager and cook were unaware of how to check sanitizer levels, indicating a lack of training and adherence to policies.
The facility failed to serve the appropriate portions for a lunch meal according to the menu spreadsheet for four residents. The cook used a 4-ounce scoop instead of the specified 8-ounce ladle for the ham and au gratin potato casserole entree. The affected residents had various medical conditions and physician orders for a regular texture diet, but they received only half of the prescribed portion size during the observed meal service.
The facility failed to provide twice-weekly showers for three dependent residents due to staffing shortages and lack of proper documentation. Despite the administrator's claim that there were no issues, both residents and CNAs reported missed showers, highlighting a significant gap in meeting basic hygiene needs.
The facility failed to safely transfer a resident requiring a mechanical lift, as only one staff member was available for transfers despite the policy requiring two. Both the CNA and the resident confirmed that single-staff transfers occurred, although no negative outcomes were reported.
The facility failed to provide nutritional supplements according to physician's orders for four residents with various diagnoses. Observations revealed that these supplements were missing from lunch trays on multiple occasions, and the dietary manager confirmed a supply issue. One resident was unaware she was supposed to receive a supplement.
A resident with Diabetes Type 2 experienced a significant medication error when a registered nurse administered Insulin Lispro late, leading to elevated blood glucose levels. The nurse faced multiple distractions, causing the delay, and subsequently had difficulty contacting the physician for further instructions. The resident remained alert and oriented with no immediate negative effects reported.
Failure to Provide 8 Hours of Consecutive RN Coverage
Penalty
Summary
The facility failed to provide 8 hours of daily Registered Nurse (RN) coverage, which has the potential to affect all 36 residents residing in the facility. The Administrator, identified as V1, acknowledged that there were shifts without the required 8 hours of RN coverage. V1 mentioned that the Director of Nursing, V2, had been working weekends to ensure RN coverage, but on one occasion, V2 left the facility for several hours before returning, resulting in non-consecutive RN coverage hours. V1 was unaware that the RN coverage hours needed to be consecutive. A review of the nursing schedules for December 2024, January 2025, and February 2025 confirmed the lack of consecutive RN coverage on several dates. Specifically, on December 7, 2024, only four hours of RN coverage were provided, and on December 8, 2024, only two and a half hours were covered. Additionally, on December 21 and 22, 2024, only five hours of RN coverage were documented. The facility's policy requires scheduling a registered nurse for 8 consecutive hours each day, which was not adhered to, as evidenced by the employee timecard showing non-consecutive hours worked by V1 on February 16, 2025.
Inadequate Staffing Leads to Delays in Resident Care
Penalty
Summary
The facility failed to provide adequate direct care staffing to meet the needs of its residents, affecting all 32 residents. The report highlights specific instances where residents experienced delays in receiving assistance due to insufficient staffing. For example, one resident with a history of cerebral infarction, chronic obstructive pulmonary disease, and congestive heart failure, who is totally dependent on staff for activities of daily living, had to wait over 15 minutes for assistance with toileting after activating the call light. Another resident with severe cognitive deficits and dependent on staff for various needs experienced a delay of an hour for toileting assistance during a family member's visit. Interviews with staff and family members revealed that there were times when only one CNA and one nurse were available to care for the entire facility, particularly on weekends and night shifts. The facility's administrator acknowledged that staffing shortages occur, especially during certain shifts, and that corporate guidelines limit the number of CNAs that can be scheduled based on the resident census. The facility's nursing and CNA schedules for several months documented multiple instances where staffing was insufficient, with only one CNA and one nurse on duty for the entire facility during various shifts.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required 8 hours of daily Registered Nurse (RN) coverage, which has the potential to affect all 32 residents residing in the facility. The deficiency was identified through a review of the nursing schedules for June, July, and August 2024, which documented multiple days without RN coverage. Specifically, there was no RN coverage on 06/19/2024, 06/29/2024, 07/13/2024, 07/14/2024, 07/17/2024, 07/27/2024, 07/28/2024, 08/03/2024, 08/04/2024, 08/17/2024, and 08/18/2024. The facility administrator acknowledged the lack of RN coverage on certain shifts and stated that the facility uses agency nurses to fill in gaps. The administrator also mentioned that it has been challenging to recruit RNs, but recent hires should improve coverage. The administrator verified the accuracy of the nursing schedules for the months in question.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a safe and sanitary manner, which could potentially affect all 32 residents. During an initial kitchen tour, several issues were observed, including a layer of flaky dried matter on top of the dish machine, a scoop with a handle found inside the bulk thickener touching the food item, and dusty bottom shelves of stainless steel tables with old/dried food debris. Additionally, bulk food containers were sticky to the touch with dried spills, and a container on the cook's table holding various utensils and seasonings had crumbs and food debris at the bottom. The steam table had dried/black food substance burnt to the bottom of all inserts, and the side of the stove had old/dried food spills. The floor under the stove and cook's stainless steel table had spilled food, food debris, and paper products, and the kitchen floor was unswept with food and paper products scattered everywhere. The stove top was full of old dried spilled food on the burners and under the burners near the flame. Further observations included a cook, V10, pureeing the lunch meal without washing hands or using gloves, and using a scoop from the bulk food thickener without a clean barrier. V10 also placed the measuring cup on the table without a clean barrier and returned the scoop to the container after use. Additionally, V10 was observed stirring cherries on the stove with a spatula picked up off the stove top burner without a clean barrier. The Dietary Manager, V4, acknowledged that the cleaning list was supposed to be completed weekly but was not done, and could not confirm how long it had been since the stove was cleaned.
Failure to Transmit MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that assessments were successfully transmitted within 14 days of completion for a resident. The resident, who was admitted with diagnoses including dementia, Alzheimer's disease, benign prostatic hyperplasia, and essential hypertension, had an admission assessment on May 3, 2024, and a discharge assessment completed on May 24, 2024. However, the Minimum Data Set (MDS) Nurse initially did not transmit the assessment, mistakenly believing it was not required for a private pay discharge. This misunderstanding was later corrected, and the assessment was transmitted on September 11, 2024. The facility's administrator was initially unaware of the requirement to transmit the MDS and planned to consult the corporate office for clarification. The facility did not have a specific policy regarding MDS transmission, relying instead on the Resident Assessment Instrument (RAI) manual as their guideline. The Centers for Medicare & Medicaid Services (CMS) MDS 3.0 Nursing Home Final Validation Report confirmed the late submission of the resident's assessment. According to the RAI Manual, nursing homes are required to submit MDS records for all residents in Medicare- or Medicaid-certified beds, regardless of the pay source.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to update comprehensive care plans for two residents, R15 and R21, leading to deficiencies in their care. R15, who has multiple diagnoses including major depressive disorder and dementia, had a care plan addressing fall prevention. However, the care plan did not reflect the family's request to avoid using a standard call light due to the risk of choking, nor did it include an alternative alert system for R15 to request assistance. This oversight was confirmed by both the Administrator and a Certified Nurse Assistant, who noted the absence of an updated care plan to address these specific needs. Similarly, R21, diagnosed with Parkinson's disease and major depressive disorder with psychotic features, had a care plan that did not include the recent addition of an antipsychotic medication, Seroquel, which was prescribed months prior. The care plan also lacked individualized non-pharmacological interventions for managing behaviors. The Minimum Data Set Coordinator acknowledged that the care plan had not been updated to reflect these changes. The facility did not provide a policy or procedure for updating comprehensive care plans, contributing to these deficiencies.
Failure to Implement Fall Precautions for a Resident
Penalty
Summary
The facility failed to implement fall precautions for a resident, identified as R15, by not ensuring the call light was within reach. R15, who has a diagnosis of muscle weakness, gait abnormalities, and vascular dementia, was admitted on an unspecified date and has a care plan addressing fall risks with a goal to remain injury-free. The care plan, initiated on 8/18/22, specifically requires the call light to be within reach at all times. However, observations on 9/10/24 and multiple times on 9/11/24 revealed that R15 was in her recliner without the call light within reach, as it was placed on top of her personal refrigerator. A Certified Nurse Assistant (CNA) stated that the family did not want R15 to have a call light due to concerns about potential strangulation, and there was no alternative call light solution in place, with staff checking on her every two hours instead.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R2, was free from unnecessary medications. R2 was admitted with a diagnosis of vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident was prescribed Risperidone 1 mg as needed, starting on 9/6/2023, with a scheduled Gradual Dose Reduction (GDR) evaluation due in December 2024. However, there was no documentation of any previous GDR attempts or recommendations, and the column labeled 'Last GDR' was left blank. The pharmacist, V11, stated that GDRs are reviewed every five months, but there was no evidence of such reviews in R2's medical record. Additionally, behavior tracking for R2 from 8/13/2024 to 9/12/2024 showed no occurrences of behaviors, and staff interviews confirmed the absence of behaviors. Despite this, the facility's tracking system did not allow for individualized behavior tracking, and R2's care plan did not reflect any behaviors or attempts to reduce psychotropic medications. The Minimum Data Set Coordinator, V2, noted that R2's previous behaviors had improved, but there was no documentation of this improvement or any related medication reduction efforts. The facility's document titled 'Gradual Dose Reduction Schedule' indicated that there should be an attempt to reduce antipsychotic and anxiolytic medications during the first year of use, which was not adhered to in R2's case.
Inadequate Staffing Levels
Penalty
Summary
The facility failed to provide adequate direct care staffing to meet the needs of its 37 residents. The report documents multiple instances where only one CNA and one nurse were available to care for all residents, particularly during evening and overnight shifts. This staffing shortage led to significant delays in responding to call lights, with some residents reporting waits of up to an hour. The facility's administrator acknowledged the staffing issues but stated that they were unable to mandate staff to work or secure additional CNAs from the staffing agency. Despite hiring three new CNAs, the problem persisted, with staff frequently working double shifts and the MDS/Care Plan Coordinator also taking on CNA duties to cover gaps in staffing. Several residents and their representatives expressed concerns about the inadequate staffing levels. One resident's Power of Attorney reported having to transfer the resident herself due to the lack of available CNAs, leading to the decision to discharge the resident to home care. Other residents confirmed the ongoing staffing issues, noting that call lights were often unanswered for extended periods, especially during night shifts. Staff members corroborated these accounts, describing the difficulty of meeting all resident care needs when working alone or with minimal support. The facility's corporate regional director of operations dismissed the concerns, attributing them to a perception issue rather than a real problem. However, the ombudsman confirmed receiving complaints about long call light response times and staffing shortages, indicating that these issues were ongoing. The facility's nursing and CNA schedules for April and May documented specific dates and times when only one CNA and one nurse were on duty, further substantiating the claims of inadequate staffing.
Inadequate Staffing Levels
Penalty
Summary
The facility failed to provide adequate direct care staffing to meet the needs of its 36 residents. On Easter Sunday, the facility experienced a significant staffing shortage when the two CNAs and one nurse scheduled for the 6am to 2pm shift called in sick. The Administrator and a Registered Nurse/Minimum Data Set Coordinator had to perform all resident care from 6:00am to 2:00pm. This resulted in residents not receiving timely care, such as having breakfast in bed and delays in getting dressed. Multiple staff members and residents reported that this was not an isolated incident, with several occasions where only one CNA and one nurse were available to provide care, leading to missed showers and inadequate assistance with mechanical lift transfers. The facility's staff schedule for March 2024 documented several instances of insufficient staffing on the 10pm to 6am shift, further corroborating the ongoing issue of inadequate staffing levels. Residents and staff expressed concerns about the impact of the staffing shortages on the quality of care. One resident reported not receiving a shower, bath, or bed bath since admission, while another mentioned not getting showers twice a week due to the lack of staff. The Housekeeping Supervisor and Social Services Designee also confirmed witnessing instances of inadequate staffing. The Administrator stated that she had been requesting additional staff from corporate, and only recently received approval to use a staffing agency again. The Ombudsman noted that residents had complained about the facility being short-staffed, highlighting the widespread nature of the issue.
Failure to Provide Full-Time Director of Nursing
Penalty
Summary
The facility failed to provide the services of a full-time Director of Nursing (DON), which has the potential to affect all 36 residents living at the facility. The former DON, V2, left the position without notice on 3/24/24, citing exhaustion from having to frequently work the floor in addition to her DON duties. Since V2's departure, the facility has not found a replacement, and other nurses and corporate staff have had to take over some of the DON duties. However, no staff member has been assigned to take over the Infection Control Preventionist duties previously handled by V2. Interviews with the facility's staff revealed that the remaining nurses, including V9, the Registered Nurse/Minimum Data Set Coordinator, are unsure who is performing the DON duties and are not interested in applying for the position due to staffing issues. The facility's administrator, V1, confirmed the lack of interested applicants and the challenges faced in maintaining the required nursing leadership. The deficiency was identified through interviews and record reviews, highlighting the facility's failure to comply with the requirement of having a full-time DON.
Insufficient Kitchen Staff and Uncertified Food Preparation
Penalty
Summary
The facility failed to provide sufficient kitchen staff to carry out nutrition services on the specified date. The long-term Dietary Manager had recently passed away, and a new Dietary Manager had just started. On the day in question, one of the two full-time cooks called in sick, and the other cook was scheduled to come in later in the day. As a result, the Administrator, who did not have certification in food sanitation, had to prepare breakfast and lunch for the residents. The breakfast provided did not fully match the menu, and lunch consisted of pizza and breadsticks instead of the planned meal. The Administrator did check food temperatures and followed some procedures, but the lack of certified staff was a significant issue. The menu for the day documented specific items for breakfast and lunch that were not fully adhered to. The Administrator acknowledged the deviation from the menu and the lack of certification in food sanitation. The facility's guidelines require a current Food Services Sanitation certificate and relevant job experience for the position, which the Administrator did not possess. This deficiency had the potential to affect all 36 residents living at the facility.
Failure to Maintain Sanitation and Food Safety Standards
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in the kitchen, which has the potential to affect all 36 residents. Observations revealed that all cabinets in the kitchen were covered with grime, floors were sticky with dried food debris, and various kitchen equipment, including the steam table, drawers, and shelves, were dirty. The cooler doors, microwave, and stove were also noted to be grimy and covered with food debris. Additionally, open bins containing food items were found to be contaminated, and plastic silverware was stored in unsanitary conditions. The cook was observed using a thermometer without proper sanitization, and the dietary manager and cook were both unaware of how to check the sanitizer levels in the dish machine and sanitizing bucket, indicating a lack of training and adherence to the facility's cleaning and sanitation policies. Further inspection of the dry food storage area revealed that shelving and floors were covered with grime, and several food items were stored open to air, increasing the risk of contamination. The facility's Cleaning and Sanitation Policy and Machine Ware Washing Policy were not being followed, as evidenced by the lack of proper sanitization practices and the absence of a documented kitchen cleaning schedule. The dietary manager and cook both admitted to not knowing how to check the dish machine or sanitizer bucket, and the cook stated that he had never been trained on these procedures.
Inadequate Meal Portions Served
Penalty
Summary
The facility failed to serve the appropriate portions for a lunch meal according to the menu spreadsheet for four residents. During an observation of the lunch service trayline, the cook used a 4-ounce scoop to portion the ham and au gratin potato casserole entree, while the menu spreadsheet specified an 8-ounce ladle for regular texture diets. The affected residents had various medical conditions, including Atherosclerotic Heart Disease, Hypertension, Heart Failure, Anxiety Disorder, a left femur fracture with surgical repair, and Alzheimer's Disease. All four residents had physician orders for a regular texture diet, but they received only half of the prescribed portion size during the observed meal service.
Failure to Provide Twice-Weekly Showers
Penalty
Summary
The facility failed to provide twice-weekly showers for three dependent residents, R4, R12, and R13, as required. R4, who has diagnoses including Anxiety Disorder, Hypertension, and Osteoarthritis, did not receive the mandated showers on multiple weeks in March and April 2024. R4 reported that she missed a scheduled shower due to a lack of hot water and was not offered an alternative. R13, admitted with a Left Femur Fracture, did not receive any showers or bed baths since her admission, and no staff asked if she wanted one. R12, diagnosed with Congestive Heart Failure, Major Depressive Disorder, and Osteoporosis, only received two showers in March and April 2024. R12 attributed the lack of showers to staff shortages, a sentiment echoed by CNAs V7 and V13, who confirmed that staffing issues often prevent residents from receiving their scheduled showers. The facility's administrator, V1, claimed there were no issues with residents not receiving twice-weekly showers, suggesting that staff might be forgetting to document them. However, the ombudsman, V6, confirmed that R12 had complained about not receiving the required showers. The CNAs acknowledged the problem, citing insufficient staffing as the primary reason for the missed showers. This discrepancy between the administrator's statement and the staff's accounts highlights a significant gap in the facility's ability to meet the residents' basic hygiene needs.
Failure to Safely Transfer Resident with Mechanical Lift
Penalty
Summary
The facility failed to safely transfer a resident requiring the use of a mechanical lift. The resident, identified as R13, has a history of Cervical Spine Fusion following a Wedge Compression Fracture and is dependent on two or more staff members for transfers, as documented in the Minimum Data Set and Physical Therapy Evaluation. Despite this requirement, it was found that at times there is only one nurse and one CNA per shift, leading to situations where a single CNA has had to perform mechanical lift transfers alone, contrary to the facility's policy. Both the CNA and the resident confirmed that these single-staff transfers have occurred, although no negative outcomes were reported by either party. The facility's Mechanical Lift Policy, dated 9/8/23, clearly states that two staff members are required when transferring a resident with a mechanical lift to ensure safety and security. However, the interviews and record reviews revealed that this policy was not consistently followed, leading to a deficiency in providing adequate supervision and safe transfer practices for residents requiring mechanical lifts. This lapse in adherence to policy was identified during a survey conducted on 4/4/24 and 4/10/24.
Failure to Provide Nutritional Supplements
Penalty
Summary
The facility failed to provide nutritional supplements according to physician's orders for four residents. During lunch trayline observation, it was noted that residents who were supposed to receive liquid nutritional supplements did not have them on their trays. Specifically, residents with diagnoses such as Atherosclerotic Heart Disease, Hypertension, Alzheimer's Disease, and Arthritis were affected. The dietary manager confirmed that the facility did not receive the nutritional supplements they had ordered, and the administrator mentioned that staff could use petty cash to buy needed food items or prepare liquid supplements using a recipe. One resident, who was alert and oriented, stated she was not aware she was supposed to be getting a supplement as she had never received one. The failure to provide these supplements as ordered by physicians was observed on multiple occasions, indicating a systemic issue in the facility's dietary management and supply chain processes. This deficiency directly impacted the nutritional care of the residents involved.
Failure to Ensure Timely Administration of Insulin
Penalty
Summary
The facility failed to ensure residents are free from significant medication errors, specifically for one resident with Diabetes Type 2 and Diabetic Neuropathy. The resident had a physician's order for Humalog U-100 Insulin per sliding scale and Insulin Lispro to be administered three times daily. On the day of the incident, the registered nurse was observed administering the morning dose of Insulin Lispro late due to multiple distractions. The resident's blood glucose level was 172 at 6:00 am, and the insulin was administered much later than the prescribed time. Subsequently, the resident's blood glucose level spiked to 424, prompting the nurse to contact the physician for further instructions. The physician ordered a recheck in one hour, but due to technical difficulties and the physician's office being closed for lunch, the nurse could not immediately follow up. The resident's blood glucose level remained elevated until the physician was contacted again, and new orders were received to administer additional insulin before supper. The Medication Administration Record and Nursing Progress Notes documented the late administration and subsequent high blood glucose levels. The resident was observed to be alert and oriented, with no immediate negative effects reported. The facility's policy on medication administration emphasizes the 'Five Rights' of medication administration, which were not adhered to in this instance. The registered nurse involved in the incident terminated her employment abruptly on the day of the surveyor's interview. The deficiency highlights a significant lapse in the timely administration of medication, leading to elevated blood glucose levels in the resident.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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