Hickory Vlg Nrsg & Rhb
Inspection history, citations, penalties and survey trends for this long-term care facility in Hickory Hills, Illinois.
- Location
- 9246 South Roberts Road, Hickory Hills, Illinois 60457
- CMS Provider Number
- 145866
- Inspections on file
- 30
- Latest survey
- June 17, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Hickory Vlg Nrsg & Rhb during CMS and state inspections, most recent first.
Surveyors observed multiple unsanitary conditions in common areas, including dirt-stained floors, dried substances on walls and floors, and a bathroom with fecal matter and strong odors. A resident reported emotional distress due to the lack of cleanliness, and staff confirmed the presence of stains and odors, indicating a failure to maintain a clean and comfortable environment as required by facility policy.
A facility failed to maintain an accurate account of a resident's personal funds, with discrepancies noted in the trust fund balance. The resident was unsure of his account balance, and the Business Office Manager initially reported a balance of $1,510.13, later correcting it to $754.00. The facility's policy requires accurate accounting and monthly audits, but they could not provide documentation of an accurate account for the resident's trust fund.
A facility failed to refer a resident with a mental health diagnosis for a PASARR level 2 screening. The Social Service Director admitted that the resident, diagnosed with serious mental illness, was not referred due to an oversight. The resident's records showed a diagnosis of depression.
A resident with a history of alcohol abuse was inadequately supervised, allowing them to obtain and consume alcohol-based mouthwash, leading to hospitalization and death. The facility's staff failed to enforce policies on checking belongings and were unclear about the resident's community pass status, contributing to the incident.
A resident identified as a high fall risk was left unattended on an elevated bed by a CNA during incontinence care, resulting in an unwitnessed fall and a pelvic fracture. The resident, who was dependent on staff for bed mobility and toileting, was turned to their side and left while the CNA retrieved linen, leading to the fall and subsequent hospitalization.
A resident experienced a fall while receiving care, but the responsible nurse failed to notify the family, physician, or management as required by the facility's guidelines. The incident was not documented in the medical record on the day it occurred, leading to the nurse's termination.
A cognitively intact female resident reported an incident where a male resident with mental health issues entered her room and kissed her on the cheek without consent. This was witnessed by another resident who asked the male resident to leave. The incident was reported to staff, and the facility's administrator confirmed the abuse allegation based on consistent testimonies, indicating a failure to protect the resident from inappropriate behavior.
The facility failed to implement abuse prevention strategies, leading to incidents of aggression among residents. A male resident with a history of violent behavior was involved in a physical altercation with his roommate, who was not informed of potential triggers. Another female resident exhibited aggressive behavior, but her care plan lacked interventions for identified behaviors. The facility's failure to update care plans and educate residents on triggers contributed to these incidents.
A facility failed to report an incident of resident-to-resident abuse involving a resident with mental health disorders and another with PTSD and blindness. The incident, where one resident scratched another, was not documented in the progress notes or reported in the facility's abuse investigation reports. The administrator was informed days later, highlighting a lapse in following the facility's abuse reporting policy.
The facility failed to create comprehensive care plans for two residents, neglecting to include identified interests and behaviors from their Level II PASRR screenings. One resident's care plan omitted his interest in sports, while another's did not address her mental health symptoms. Staff acknowledged the oversight, citing a lack of communication and delays in updating care plans.
A resident with complex psychiatric conditions experienced multiple hospitalizations due to aggressive behaviors, as the LTC facility failed to provide sufficient social services staffing. Despite the resident's need for regular mental health follow-up, interactions with social services were infrequent, and staff acknowledged the inability to meet the resident's needs due to limited staffing.
A resident with mental health issues reported verbal abuse by staff members during an overnight shift. The resident was subjected to teasing and derogatory comments, and despite requests to return to bed, was kept in the dining room all night. Another resident corroborated the incident, noting that the nurse on duty did not intervene. The facility's investigation led to the termination of the involved staff for mental abuse and failure to supervise.
The facility failed to maintain sanitary conditions in the kitchen, with observations of residue, rust, and buildup on equipment, improperly stored food, and staff not performing necessary hand hygiene. The Dietary Manager and Administrator acknowledged the deficiencies, which were contrary to the facility's policies on infection control, cleaning assignments, and handwashing.
The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program. The Assistant Director of Nursing, who has been serving as the IP for approximately four years, had only completed the CDC Nursing Home Infection Preventionist Training Course on the same day the certificate was reviewed. Additionally, the facility did not provide a policy for infection preventionist qualifications when requested.
The facility had a 14.81% medication error rate during a medication pass observation. An LPN prepared and almost administered incorrect medications to two residents and did not follow proper infection prevention practices. The LPN also failed to report all medication errors to the DON.
Failure to Maintain Clean and Sanitary Common Areas
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in its common areas, affecting all 69 residents. Observations included dirt-stained floors in the dining room and hallways, dried brown substances dripping on walls, a dried yellow stain at the entrance to the men's restroom, and large dried red and brown stains in the group room. These conditions were confirmed by the facility administrator, who acknowledged that the floors and common areas should be cleaned daily but was unable to identify the substances causing the stains. Additionally, a resident with a BIMS score indicating cognitive intactness reported feeling that the facility was never cleaned or repaired, expressing emotional distress about the environment. Further inspection revealed a bathroom with a toilet bowl and seat covered in a dried brown substance, identified as fecal matter, and a strong odor of feces. Staff members, including an activity aide and the activity director, confirmed the presence of these stains and odors, with uncertainty about how long the stains had been present. The facility's own housekeeping policy requires a clean, odor-free, and comfortable environment, and resident rights documents mandate that the facility be safe, clean, and homelike. Despite these policies, the observed conditions demonstrated a failure to meet these standards.
Inaccurate Accounting of Resident Trust Fund
Penalty
Summary
The facility failed to maintain an accurate account of a resident's personal funds, as evidenced by discrepancies in the reported balance of the resident's trust fund account. During an interview, the resident expressed uncertainty about his trust fund statement and account balance, stating that he only receives $30 a month. The Business Office Manager initially presented documentation showing a balance of $1,510.13 in the resident's trust fund account, but later corrected this to $754.00, admitting to not keeping an accurate account of the resident's funds. The facility's policy on resident personal trust funds requires the Business Office Manager to maintain a full and separate accounting of each resident's personal funds, in accordance with generally accepted accounting principles. The policy also mandates monthly audits and balancing of the personal funds bank account. However, the facility was unable to provide documentation of an accurate account for the resident's trust fund upon the exit of the survey, indicating a failure to adhere to their own policy and maintain proper financial records for the resident.
Failure to Refer Resident for PASARR Level 2 Screening
Penalty
Summary
The facility failed to refer a resident with a mental health diagnosis for a PASARR level 2 screening. This deficiency was identified for one of three residents reviewed for PASARR screening and assessments. The Social Service Director acknowledged that the resident, who had a diagnosis of serious mental illness (SMI), was not referred for the necessary screening due to an oversight. The resident's face sheet indicated a diagnosis of depression, and the Minimum Data Set (MDS) section I confirmed this diagnosis.
Failure to Supervise Resident with Alcohol Abuse History
Penalty
Summary
The facility failed to effectively supervise a resident with a history of alcohol abuse, leading to a serious incident. The resident, who had a restricted community pass, was able to independently access the community and obtain two 1.0-liter bottles of alcohol-based mouthwash. Upon returning to the facility, the resident was found yelling and screaming with altered mental status, and was later hospitalized with a high alcohol level of 183, which is significantly above the normal range of 0-10. The resident subsequently passed away, with the death certificate citing cardiopulmonary arrest due to acute kidney failure and alcohol abuse as the cause of death. Interviews and record reviews revealed that the facility's staff, including the Director of Nursing (DON) and Certified Nurse Aide (CNA), were aware of the resident's behaviors and the presence of mouthwash in the resident's room. However, there was a lack of effective monitoring and intervention to prevent the resident from consuming the mouthwash. The facility's policy required staff to check residents' belongings upon their return from outside passes, but this was not adequately enforced, allowing the resident to possess and consume the mouthwash. Additionally, there was confusion among the staff regarding the resident's community pass status. The Social Services staff indicated that the resident did not have an independent pass, yet records showed that the resident had been signed out on independent passes multiple times. This inconsistency in the resident's care plan and community access privileges contributed to the failure in preventing the resident from obtaining and consuming alcohol, ultimately leading to the resident's hospitalization and death.
Removal Plan
- Ambulance was contacted for R1 nonemergent transfer to the hospital for behaviors. R1 was evaluated at the emergency room.
- Facility identified residents who are at risk for obtaining contraband. This was determined by diagnosis of history of substance abuse. Independent passes were reviewed. Current substance abuse was assessed.
- Residents were interviewed and asked if they were in possession of any contraband. All residents interviewed denied having any contraband.
- Residents consented for room search with resident present and no contraband was identified.
- Residents have been offered counseling with facility counselor.
- Facility will conduct random checks with resident present to ensure no contraband is in room. Random checks will be completed once per week.
- Staff will check residents' bags upon return from out on pass to ensure no contraband is in bags. Any items identified as contraband will be removed from bags and placed in social service office.
- Alcohol based mouthwash will be considered contraband for residents with a substance abuse diagnosis.
- DON and Administrator will educate staff including staff on leave and on vacation on facility's prohibited (contraband) items.
- Staff will complete test to gauge understanding of teachings.
- All facility staff including staff on leave and on vacation will be educated and trained on signs and symptoms of alcohol intoxication and alcohol poisoning.
- Staff will complete test to gauge understanding of teachings.
- DON will in-service all nurses including nurses on leave and on vacation on Change of Condition Policy.
- Staff will complete test to gauge understanding of teachings.
- Residents who have an independent pass and DX of substance abuse will be re-assessed for Community Pass. Completed by Social Service Director.
- Residents who go out on pass supervised or independent will be subject to a search of bags that were brought in.
- Prohibited items will be removed immediately and kept at social service office.
- Staff will inventory bags brought in from community.
- Designee will review items that were brought in the next day for compliance.
- Social service will provide list of residents who are on Community Pass Restriction to Nurses to communicate any updates to ensure residents who are on restriction do not leave for independent pass.
- Nurses will be in-serviced on process.
- It is not a new procedure to notify nurses of resident's pass privilege. Community Pass Policy Updated to reflect notification to nurses of resident's pass privilege.
- Community Pass Privilege or Restriction of Community Pass will be documented in the resident's physician orders. Community Pass Policy updated to reflect documentation in physician orders of pass status.
- Facility held resident counsel to discuss facility's prohibited and contraband items. All residents attended.
- Residents will complete test to gauge resident's understanding of teachings.
- Facility will place the list of prohibited items at the back entrance to inform family and visitors.
- Medical Director made aware of IJ.
- Administrator coordinator or designee will conduct QA studies: A QA study will be performed at random weekly to ensure residents who are at risk of obtaining contraband do not have prohibited items in room. The QA will be completed weekly for 3 months.
- A QA study will be performed random twice weekly to ensure staff knowledge of signs and symptoms of alcohol intoxication and alcohol poisoning. The QA will include 5 staff members twice weekly for 3 months.
- A QA study will be performed random twice weekly to ensure residents do not bring in prohibited items from the community. The QA will include 5 residents twice weekly for 3 months.
- A QA study will be performed random twice weekly to ensure that a physician order reflecting residents community pass privilege is up to date, reviewing community pass logs to ensure residents sign in and out from pass, and to ensure nurses are aware on who is restricted from community pass.
- QA audits will be presented and reviewed at the facility monthly QA meetings for three months to ensure maintained compliance, and on an as needed basis thereafter as deemed necessary by the QA committee.
- An emergency QAPI was conducted.
Failure to Supervise High Fall Risk Resident Leads to Injury
Penalty
Summary
The facility failed to adequately supervise a resident identified as a high fall risk, who was dependent on staff for bed mobility and toileting. The resident was left unattended on their side on an elevated bed by a CNA, who had turned the resident to their side to provide incontinence care. The CNA raised the bed to waist level and turned the resident away from her, leaving the resident on their side while she went to retrieve linen from a dresser. During this time, the resident fell from the bed, resulting in an unwitnessed fall. The resident, who was cognitively intact and had a history of rheumatoid arthritis, depressive disorder, bilateral osteoarthritis of the knees, restless leg syndrome, and fibromyalgia, was subsequently transferred to the hospital. An X-ray confirmed an acute fracture in the left pubic bone, extending to the left superior pubic ramus. The incident was documented in the facility's accident management meeting form, which identified the root cause as the CNA stepping away from the resident during care, leading to the fall.
Failure to Notify Physician and Family of Resident Fall
Penalty
Summary
The facility failed to adhere to its notification of change guidelines by not promptly reporting a resident's fall to the physician and resident representative. The incident involved a resident who was admitted with multiple diagnoses, including rheumatoid arthritis and fibromyalgia, and was cognitively intact. On December 25, 2024, the resident experienced a witnessed fall while staff was providing care. However, the nurse responsible, identified as V5, did not notify the family, physician, or management about the fall on the day it occurred. The Director of Nursing confirmed that the facility's procedure requires immediate notification of the family, physician, and management in the event of a fall, and this should be documented in the medical record. The nurse, V5, admitted to forgetting to complete an incident report or notify the necessary parties. The facility's event report and progress notes corroborated the lack of notification. As a result of this failure to follow protocol, V5 was terminated from her position.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident, identified as R2, from abuse by another resident, R1. R2, a cognitively intact female with multiple diagnoses including Alzheimer's disease and bipolar disorder, reported an incident where R1, a male resident with a history of mental health issues, entered her room and kissed her on the cheek without her consent. This incident was witnessed by another resident, R3, who asked R1 to leave. R2 immediately reported the incident to a Certified Nursing Assistant (V5) and a Licensed Practical Nurse (V4). The facility's administrator (V1) was informed of the incident and conducted interviews with R2 and R3, both of whom provided consistent accounts of the event. The facility's abuse policy, revised in October 2022, emphasizes the residents' right to be free from abuse, including sexual harassment and non-consensual contact. Despite the policy, the facility substantiated the abuse allegation based on the corroborated testimonies of R2 and R3, highlighting a failure to protect R2 from inappropriate behavior by R1.
Failure to Implement Abuse Prevention Strategies
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not implementing strategies to reduce the likelihood of abuse and failing to identify behaviors in residents that could lead to abuse. This deficiency was observed in four out of six residents reviewed for abuse. One resident, a male with a history of schizoaffective disorder and violent behavior, was involved in a physical altercation with his roommate. The altercation resulted in the roommate sustaining a small abrasion. The facility did not educate the roommate on potential triggers for aggression, which could have prevented the incident. Another resident, a female with a history of bipolar disorder and schizophrenia, exhibited aggressive behavior by scratching a staff member and another resident. Her care plan did not include interventions for behaviors identified in her preadmission screening, indicating a lapse in updating care plans to reflect current needs and behaviors. The facility's psychosocial services director acknowledged being behind in updating care plans, which contributed to the oversight. The facility's abuse policy emphasizes the importance of creating a resident-sensitive environment to prevent abuse. However, the failure to assess and document residents' triggers and behaviors, as well as the lack of education provided to potential roommates, demonstrates a significant gap in the facility's approach to abuse prevention. This oversight led to incidents of aggression and physical altercations among residents, highlighting the need for comprehensive care planning and staff education.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedures for abuse reporting by not ensuring an incident of resident-to-resident abuse was reported to the administrator or the state agency. This deficiency involved two residents, a female with a history of Bipolar Type Schizoaffective Disorder, Schizophrenia, Epilepsy, and Dementia, and another female with a history of Post Traumatic Stress Disorder, Bipolar Disorder, Depression, Anxiety Disorder, Blindness in One Eye, and Seizures. The incident occurred when the first resident scratched the second resident, as well as a Certified Nursing Assistant, during an interaction. The progress notes for the second resident did not document the incident of being scratched, and the facility's abuse investigation reports for September did not include this event. The administrator was only informed of the incident several days later, and it was noted that the nurse on duty would be counseled on the importance of reporting such incidents immediately. The facility's abuse policy requires employees to report any potential abuse to a supervisor, who must then report it to the administrator or a designated individual in the administrator's absence, and any non-serious incidents must be reported to the state agency within 24 hours.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, R1 and R4, as required by their care planning policy. R1, a male resident with a history of mental health disorders, was admitted with a Level II PASRR that identified his interests in sports, particularly soccer, and the need for socialization and recreation activities. However, his care plan did not include these interests, focusing instead on arts and crafts, which he declined to participate in. The Activities Director, V8, was unaware of R1's interest in sports and stated that she only included information directly provided by residents. The Administrator, V1, acknowledged that past medical records should be considered in care planning, as residents may not always communicate their interests due to discomfort or communication challenges. R4, a female resident with a history of bipolar disorder, schizophrenia, epilepsy, and dementia, was admitted with a Level II PASRR that documented her mental health symptoms, including being easily upset and having rapid emotional changes. Despite these identified behaviors, her care plan did not include interventions to address them. The Psychosocial Services Rehabilitation Director, V7, admitted that the behaviors listed in R4's PASRR should have been included in her care plan but stated he was behind in updating care plans. The facility's care planning policy emphasizes the need for individualized comprehensive care plans that incorporate identified problem areas, risk factors, and residents' needs and preferences.
Insufficient Social Services Staffing for Behavioral Health Needs
Penalty
Summary
The facility failed to ensure sufficient social services staff to meet the behavioral health needs of its residents, specifically impacting a resident with a complex psychiatric history. This resident, a male with diagnoses including Schizoaffective Disorder, Schizophrenia, and Major Depressive Disorder, exhibited violent and aggressive behaviors, leading to multiple hospitalizations over a few months. Despite the resident's documented need for routine mental health follow-up, the facility's social services staff interacted with him only three times between June and September 2024. The resident's care plan and PASRR Level II assessment highlighted his history of aggressive behavior and the necessity for regular mental health professional follow-up. However, the facility's records show that the resident experienced mood instability, hallucinations, and aggressive outbursts, resulting in several emergency hospitalizations. These incidents included calling 911 due to dissatisfaction with his medication and exhibiting violent behavior towards family members during visits. Interviews with facility staff revealed that the social services team, consisting of only two members, was unable to provide the necessary support and frequent check-ins for the resident. The Psychosocial Services Rehabilitation Director acknowledged the resident's need for more frequent interaction but cited staffing limitations as a barrier. The facility's policy mandates the provision of medically related social services to help residents achieve their highest practicable mental and psychosocial well-being, which was not met in this case.
Staff Verbal Abuse and Inaction Leads to Deficiency
Penalty
Summary
The facility failed to adhere to its abuse policy, resulting in a deficiency where a staff member was allowed to tease and laugh at a resident, identified as R2. R2, a resident with a history of bipolar disorder, schizophrenia, and drug-induced parkinsonism, reported that staff members V5, V8, and V9 were verbally inappropriate during an overnight shift. R2 claimed that the staff called R2 names, made derogatory comments about R2's mother, and laughed at R2. This incident was corroborated by another resident, R3, who witnessed the staff's behavior and confirmed that R2 was being bullied and disrespected. The incident occurred when R2 was being monitored in the dining room due to being a potential fall risk. Despite R2's requests to be put back to bed, the staff refused, and R2 had to remain in the dining room all night. R3, who was present in the dining room, reported that the CNAs V5 and V8 were making rude comments and that the nurse, V9, did not intervene. R3 also noted that V9 made a comment suggesting that the situation was meant to teach R2 a lesson. R2 was visibly nervous and shaking, but the staff only instructed R2 to calm down without offering further assistance. The facility's investigation revealed that V5, V8, and V9 were terminated following the incident. The termination reports indicated that V5 and V8 were dismissed for mental abuse, while V9 was terminated for failing to supervise and stop the inappropriate behavior. The facility's policies on resident rights and abuse prevention emphasize the importance of treating residents with dignity and respect, and the failure to uphold these standards led to the deficiency.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to follow its policy and procedures to ensure food was prepared under sanitary conditions. During a kitchen tour, the surveyor observed multiple instances of unsanitary conditions, including an ice machine with residue, rust, and black buildup, improperly stored and labeled food items, and dirty kitchen equipment. The Dietary Manager admitted that the ice machine is cleaned every six months and that all kitchen staff are responsible for daily cleaning, but the observed conditions indicated a lack of adherence to these protocols. Additionally, the kitchen environment was not maintained to prevent contamination, with cracked floor tiles, rust, buildup, and residue observed in various areas, including the three-compartment sink, water temp booster, and dishwashing machine area. The Dietary Manager acknowledged that the kitchen requires more attention due to the lack of ventilation and the age of the building, which contributes to the buildup of dust and residue. Further observations revealed that the dietary staff did not perform hand hygiene when necessary, as evidenced by a Dietary Aide who dropped a water pitcher lid, picked it up, and continued to fill water pitchers without washing her hands. The Cook also used a food processor to make peach puree without allowing it to air dry completely after washing it in the dishwashing machine. The Administrator confirmed that holes should be sealed for pest control and that the food processor must be air-dried between uses to prevent cross-contamination. The facility's policies on dietary infection control, weekly cleaning assignments, and handwashing were not followed, leading to unsanitary conditions and potential risks for foodborne illnesses. The facility's Dietary Infection Control Policy and Weekly Cleaning Assignments outline the requirements for maintaining a clean and sanitary kitchen environment, including labeling and dating food, cleaning equipment thoroughly between uses, and discarding contaminated food. The Handwashing Policy mandates that food and nutrition service employees wash their hands after touching anything unsanitary. However, the observed deficiencies indicate that these policies were not adhered to, resulting in unsanitary conditions that could affect the health and safety of the 66 residents receiving food from the facility.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program. The Assistant Director of Nursing, who has been serving as the Infection Preventionist (IP) for approximately four years, had only completed the CDC Nursing Home Infection Preventionist Training Course on the same day the certificate was reviewed. Additionally, the facility did not provide a policy for infection preventionist qualifications when requested.
Medication Error Rate and Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 14.81% error rate during a medication pass observation. An LPN was observed preparing and almost administering incorrect medications to two residents. For one resident, the LPN prepared and nearly administered Norco 5/325 mg instead of Lorazepam 1 mg, and also gave Cyanocobalamin 100 mcg instead of the prescribed Cyanocobalamin ER 1000 mcg. For another resident, the LPN prepared and almost omitted Atenolol 25 mg and administered Cyanocobalamin 100 mcg instead of the prescribed Cyanocobalamin 500 mcg. These errors were identified and stopped by the surveyor before the incorrect medications were fully administered. The LPN did not follow proper infection prevention practices during medication administration, as she did not wash her hands or use alcohol-based hand rub between administering medications to five residents. Additionally, the LPN improperly handled medications by using her bare hands to return a pill to its original container, which is against the facility's medication administration policy. The LPN also failed to report all medication errors to the Director of Nursing (DON) and only reported one error to the front office. The facility's policies and procedures for medication administration and infection control were not adhered to by the LPN. The Director of Nursing confirmed that medication administration should follow the five rights, infection control standards, and that any medication errors should be immediately reported to the attending physician, DON, and pharmacist. The facility's medication administration policy explicitly states that no medication may be returned to its original container once removed, and all medication errors must be documented and reported immediately.
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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