Hope Creek Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in East Moline, Illinois.
- Location
- 4343 Kennedy Drive, East Moline, Illinois 61244
- CMS Provider Number
- 145269
- Inspections on file
- 55
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Hope Creek Nursing & Rehab during CMS and state inspections, most recent first.
A cognitively impaired, high fall-risk resident who required assistance with transfers fell in her room and sustained a comminuted right humerus fracture requiring surgery after being found on the floor next to her bed. Her care plan called for cues to ask for help, non-skid strips at bedside and toilet, a low bed, a call light within reach, and floor mats, but observation of her memory care room showed these interventions were not in place. Staff interviews revealed inconsistent awareness of her fall risk and transfer status, with some CNAs believing she was independent and safe to self-transfer and not checking the electronic health record, while nursing leadership stated she had a history of falls and self-transferring and required staff assistance and supervision.
Surveyors found that the facility failed to promptly identify and manage a stage 3 sacral pressure injury in a high-risk, bedbound resident and did not consistently use heel protector boots, leaving the resident’s heels directly on the mattress despite care plan directions to assess and provide pressure-relieving devices. A wound care nurse reported the sacral wound was first noted only after a CNA reported it, and an LPN indicated weekly skin checks were expected but did not believe the resident routinely wore heel protectors. For another resident with an unstageable coccyx/sacral pressure injury, the air mattress was set on firm rather than to the resident’s weight, and the wheelchair pressure-relief cushion was flattened, torn, and leaking foam. Documentation showed an exacerbated pressure injury and an order for a low air loss mattress, but the care plan lacked specific pressure-ulcer preventive measures or pressure-relieving devices, contrary to the facility’s preventative skin care policy requiring individualized offloading and immediate reporting of skin changes.
Three residents with severe cognitive impairment and high fall risk experienced multiple falls, injuries, and hospitalizations due to the facility's failure to maintain a safe environment, provide adequate supervision, and implement timely fall prevention interventions. Care plans and the electronic Kardex were not updated promptly, and staff were often unaware of residents' care needs or fall precautions, leading to repeated incidents and inadequate documentation.
A resident was not allowed to receive visits from his significant other, despite facility policy supporting visitation rights and no legal documentation prohibiting visits. Staff were instructed to deny entry and involve police if necessary, and the care plan did not address any visitation restrictions.
A resident with a physician-ordered therapeutic diet did not receive the correct meal, as only one corndog was served instead of the required double protein portion. The dietary manager confirmed the error, noting that new kitchen staff were responsible, and the resident's diet card did not fully match the physician's order.
A resident admitted with multiple chronic conditions experienced a fall, required hospitalization and surgery, and returned to the facility with new care needs. Despite these significant changes, the facility did not complete the required Significant Change in Condition Comprehensive Assessment/MDS, as confirmed by the MDS Coordinator.
A resident with multiple risk factors for falls, including recent fall history, mobility impairment, and use of high-risk medications, was inaccurately assessed as low risk and did not have a comprehensive care plan or fall prevention interventions in place prior to experiencing a fall that resulted in a wrist fracture requiring surgery. Staff were unaware of the resident's fall risk and necessary precautions, and the care plan was not completed until weeks after admission.
Two residents with severe cognitive impairment were physically harmed by peers with known behavioral issues. In one case, a resident was pushed and sustained a head injury after wandering into another's room; in another, a resident was forcefully grabbed by her roommate, causing fear and distress. Staff did not consistently recognize or document these incidents as abuse, and there were gaps in monitoring and assessment.
A resident with bowel and bladder incontinence was found in a urine-saturated bed after the CNA failed to provide timely care. The CNA, unfamiliar with the assigned floor, did not return to assist the resident after an initial refusal of care. The facility's policy requires checks every two hours, which was not followed, leading to the deficiency.
A facility failed to provide immediate post-fall care to a resident on anticoagulant therapy, delaying treatment for a subdural hematoma. The resident was found on the floor after an unwitnessed fall, but staff did not notify the physician or send him to the hospital until the next day. Additionally, another resident sustained a nasal fracture due to improper turning and positioning by a single CNA, despite requiring two-person assistance.
A resident with a history of aggression in an LTC facility was involved in multiple incidents of abuse, including hitting and shoving other residents, resulting in injuries. The facility failed to identify, investigate, or report these incidents as abuse, despite witness statements and video evidence. The resident's psychiatric history and aggressive behavior were not adequately managed, leading to an Immediate Jeopardy situation.
The facility failed to address dietary grievances raised in resident council meetings, affecting all 160 residents. Concerns included disorganization in the kitchen, insufficient dining room staff, meal discrepancies, and lack of a full-time dietary manager. Despite these issues being documented from October 2023 to April 2024, grievance forms lacked investigation and corrective action details. Interviews with the Activity Director and Resident Council President revealed ongoing inaction and poor communication from the facility.
The facility failed to store dry foods properly and ensure kitchen staff adhered to hygiene policies, affecting 160 residents. Bins in the dry storage room were undated, dirty, and inadequately covered. A cook was observed with improperly restrained hair, violating the facility's hygiene policy.
The facility failed to implement proper infection control measures during a COVID-19 outbreak, with staff not wearing appropriate PPE and not assessing residents for COVID-19 symptoms. Residents with symptoms were not isolated, and there was inadequate documentation and follow-up testing. Additionally, improper PPE use and cross-contamination occurred during wound care, and residents with infections were not placed in appropriate isolation.
The facility failed to provide an ongoing program of activities for residents on the second floor of building four, affecting their physical, mental, and psychosocial well-being. Since COVID-19 restrictions began, residents have been unable to participate in activities or leave their unit, leading to feelings of isolation and boredom. The Activity Director cited a broken air conditioning system and admitted to forgetting about the residents on that floor, resulting in a lack of engagement and stimulation.
A resident experienced diarrhea during the night and was unable to get assistance from staff, resulting in a soiled blanket and floor. Despite notifying staff, the resident was observed lying on the soiled blanket throughout the day until a CNA was informed and took action to address the situation.
A facility failed to conduct a Level 2 PASARR for a resident diagnosed with Disorganized Schizophrenia and Schizoaffective Disorder-Depressive Type. The resident's Level 1 PASARR form inaccurately indicated no major mental illnesses, and the Social Service Coordinator acknowledged the oversight. This failure to perform the necessary screening upon admission constitutes a deficiency.
A facility failed to update a resident's care plan to reflect the removal of a tracheostomy. The care plan, dated June 2024, still indicated the presence of a tracheostomy, despite a physician's order from August 2024 noting its removal. The MDS/Care Plan Coordinator admitted the care plan should have been revised.
The facility failed to provide prescribed range of motion (ROM) programs for two residents with limited mobility. One resident, with a history of cerebral vascular accident, did not receive active ROM exercises as ordered for 19 out of 29 days. Another resident, with contractures and requiring total assistance, did not receive passive ROM as ordered for 9 out of 30 days. Both residents reported that the exercises were not conducted by staff.
A facility failed to secure a resident's indwelling urinary catheter drainage bag in a dignity enclosure bag, as required by their policy. The resident had a catheter due to hydronephrosis, and the drainage bag was observed attached to the wheelchair and touching the ground without a privacy covering. The DON confirmed the bag should have been covered and off the floor.
During a routine medication pass, two RNs were observed storing and administering medications improperly by using pre-prepared clear medication cups instead of original containers, contrary to the facility's policy. This involved multiple residents and indicated a failure to maintain safe and secure medication storage.
A facility failed to document hospice services in a resident's medical record, impacting coordinated care. The resident's care plan initially lacked hospice documentation and later omitted specific hospice responsibilities. Hospice documentation was not accessible to the interdisciplinary team, with staff unable to locate hospice records. The hospice RN noted that visit notes were likely taken to medical records, and the Careplan Coordinator did not include hospice-specific interventions in the care plan.
The facility failed to implement its abuse prevention program, resulting in incidents involving three residents. A resident was startled by another, leading to a fall and head injury, but no safety measures were implemented. This allowed further aggression, resulting in another resident being physically assaulted. Despite a history of aggressive behavior, the resident was not monitored until after the second incident.
A facility failed to investigate a potential abuse incident where one resident allegedly pushed another, causing a fall and head injury. Despite witness accounts and reports, the incident was treated as a fall rather than abuse, violating the facility's Abuse Prevention Program.
A resident with a history of aggression in an LTC facility physically assaulted other residents, leading to injuries and hospital evaluations. Despite known behaviors, the facility failed to monitor or intervene adequately, resulting in incidents of abuse. The facility's administration and nursing staff demonstrated a lack of coordination and communication, failing to report and investigate abuse allegations properly.
The facility failed to implement its abuse prevention program, resulting in incidents involving three residents. Despite witnessing aggressive behavior from a resident, the facility did not take immediate action to increase monitoring or implement safety measures, leading to repeated occurrences of aggression. Staff interviews confirmed that interventions were only put in place after multiple incidents, highlighting a failure to protect residents adequately.
The facility failed to investigate a potential abuse incident where one resident allegedly pushed another, causing a fall and head injury. Despite witness accounts and reports to the DON, the incident was treated only as a fall, not as abuse. The Administrator was absent, and the DON dismissed the abuse claims, leading to a deficiency in the facility's abuse prevention program.
A resident was found unresponsive without a pulse or respirations, and an RN failed to initiate CPR immediately, contrary to facility policy. The RN left the resident to make phone calls instead of starting CPR, resulting in a delay until other staff began resuscitation efforts. This incident exposed a lack of training on the facility's CPR policy, placing other residents at risk.
The facility did not develop a system to evaluate residents' capacity to consent to sexual activity, resulting in two severely cognitively impaired residents engaging in a sexual act without confirmed consent. Both residents were assessed as severely cognitively impaired according to MDS/BIMS assessments. The incident was discovered by a CNA, raising concerns about the residents' understanding and ability to communicate decisions regarding sexual activity. The facility's policy on assessing capacity to consent was not utilized, highlighting a procedural gap in protecting residents from potential harm.
The facility failed to prevent resident-to-resident physical abuse when one resident slapped another during a verbal altercation. The incident was reported, and the residents were separated. The facility's policy prohibits abuse, but it was not effectively enforced in this case.
Failure to Implement Care-Planned Fall Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall-prevention interventions for a cognitively impaired, high fall-risk female resident, resulting in a serious fall with injury. The resident’s fall risk assessment identified her as HIGH risk for falls, and her care plan, initiated on 2/1/24, documented that she was at risk for falls related to weakness, impaired gait and balance, and required assistance for bed mobility and transfers. Care-planned interventions included cues in the room to ask and wait for assistance, non-skid strips at bedside and in front of the toilet, a low bed, call light within reach, and floor mats to the right side of the bed. However, on observation of the resident’s memory care room after the fall, there were no posted signs instructing her to call and wait for help, no fall mats, and no non-skid strips at the bedside or in the bathroom. On the morning of the incident, staff found the resident on the floor next to her bed with severe right arm pain, and she was sent to the hospital where she was diagnosed with a comminuted right humerus fracture requiring surgical intervention. Multiple staff interviews showed inconsistent understanding of the resident’s fall risk status and transfer needs. An agency LPN and one CNA reported that the resident was a fall risk, had a history of self-transferring, and required one-person assistance with transfers, while another former CNA and another CNA believed the resident was independent and safe to self-transfer and did not recognize her as a fall risk. These CNAs stated they did not check, or did not think to check, the electronic health record for the resident’s fall risk status and transfer requirements. The DON and Administrator both stated that the resident was confused, had a history of falls and self-transferring, required staff assistance with transfers and supervision for safety, and that fall interventions should follow the resident when she transfers to a different room. Despite this, the care-planned fall interventions were not in place at the time of the fall.
Failure to Identify and Offload Pressure Ulcers and Implement Pressure-Relieving Devices
Penalty
Summary
The deficiency involves the facility’s failure to identify and manage a pressure injury in a timely manner for a resident at risk for pressure ulcers, and failure to implement appropriate pressure-relieving interventions for two residents with pressure ulcers. One resident was admitted with multiple diagnoses including hemiplegia/hemiparesis, arthritis, chronic kidney disease, Parkinson’s disease, depression, and a history of a pressure ulcer of the left buttock. A facility assessment documented severe cognitive deficits, dependence on staff for most care, and risk for developing pressure ulcers. A Weekly Wound Evaluation dated 1/15/26 showed an in-house acquired stage 3 pressure injury to the sacrum measuring 5 cm by 1.5 cm with depth unable to be determined. The care plan identified actual impairment to skin integrity of the sacrum and risk for skin breakdown, with directions to assess for and provide appropriate pressure-relieving devices and to assess for changes in skin condition each shift. Surveyors observed that this resident, who was bedbound, did not consistently have heel protector boots in place despite being at risk for pressure ulcers. In the morning, the resident was lying in bed with her heels directly on the air mattress while her tan inflatable heel protector boots were found under the edge of the dresser near the bed. Later that day, during wound care, the resident was observed wearing blue heel protector boots, and the wound care nurse stated there was no physician order for heel protectors but she felt the resident should wear them due to her condition and had placed them for that reason. The wound care nurse also reported that the sacral wound was first identified when a CNA reported a wound on the resident’s bottom while getting her up for the day. The treatment nurse stated it was her understanding that nurses should be documenting weekly skin checks to detect developing wounds and implement additional preventive measures, and she did not believe the resident wore heel protectors. The DON stated she would have expected early identification of wounds and the use of a low air loss mattress and heel protector boots or heel offloading for a bedbound resident. For a second resident with an unstageable pressure injury to the coccyx/sacrum, surveyors observed that the resident was on an air mattress that was set to “firm” rather than adjusted to the resident’s weight, and the resident’s wheelchair pressure-relief cushion was flattened, torn, and leaking foam. The wound care nurse confirmed the cushion was worn and stated it was for pressure relief, and upon checking the mattress, acknowledged it was set too high and should be set to the resident’s weight. The resident appeared confused when asked about mattress firmness. Documentation for this resident showed an unstageable pressure injury with moderate serosanguinous drainage and strong odor, with the wound location changed from right buttock to sacrum due to exacerbation, and a low air loss mattress ordered. The care plan documented admission with a pressure ulcer of the right buttock related to immobility but did not include pressure ulcer preventive measures or pressure-relieving devices. The facility’s preventative skin care policy required use of Braden scores and weekly skin assessments to determine specific preventive needs, including offloading devices such as “Heels Up” or therapeutic boots for residents at high risk, and immediate reporting of any skin alterations to the charge nurse for assessment and follow-up.
Failure to Maintain Safe Environment and Supervision Resulting in Repeat Resident Falls
Penalty
Summary
The facility failed to maintain a safe environment, provide adequate supervision, and implement necessary assistive interventions for three residents reviewed for falls. Each of these residents was identified as high risk for falls due to severe cognitive impairment and dependence on staff for activities of daily living, including toileting. Despite documented histories of falls and related injuries, care plans for these residents were not initiated or updated in a timely manner, and essential interventions such as toileting schedules and transfer status were not communicated to staff or included in the electronic Kardex. Staff interviews revealed a lack of awareness regarding residents' care needs and interventions, with several CNAs and nurses stating they did not know where to find updated information or were unaware of specific care plans in place for fall prevention. One resident was admitted following a fall that resulted in a subdural hematoma and subarachnoid hemorrhage, yet did not have fall interventions included in the care plan upon admission. This resident experienced multiple subsequent falls within the facility, including one resulting in a head laceration and another subdural hematoma, with documentation gaps regarding toileting and transfer assistance. Staff reported confusion about the resident's care needs, and the care plan was not updated to reflect necessary interventions until well after the incidents occurred. Another resident, also severely cognitively impaired and on anticoagulant therapy, experienced unwitnessed falls, including one where the resident slipped in urine and another resulting in a laceration requiring sutures. The fall care plan for this resident was not created until after the initial fall, and the Kardex did not reflect fall interventions. A third resident, with repeated falls documented over several months, did not have toileting tasks or new safety interventions added to the care plan or Kardex until long after multiple incidents. Staff interviews indicated that interventions such as placing the resident in a recliner to prevent sliding from a wheelchair were not documented in the care plan. The MDS nurse acknowledged delays in updating care plans due to workload and staffing issues, and the DON stated she was not aware that care plans were not being updated. Throughout the report, there is consistent evidence of inadequate communication, lack of timely care plan updates, and insufficient staff training regarding fall prevention and resident care needs.
Failure to Honor Resident Visitation Rights
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of his choosing, specifically by not allowing the resident's significant other to visit. The Social Services Director stated that the significant other was not permitted to visit and that this decision was made by the facility and the police, with the resident's guardians also involved in the decision-making process. The receptionist confirmed that all receptionists were instructed not to allow the significant other to visit, to ask her to leave if she arrived, and to involve the police if necessary. The electronic check-in system was programmed to deny her access. The significant other continued to call the facility frequently to request visitation. The administrator reported that he was unaware of the situation until questioned by surveyors and stated that, unless there was an order of protection, visitation should not be restricted. The resident's admission record identified the significant other as his partner, and the facility was unable to provide any legal documentation prohibiting her visits. The facility's visitation policy supports residents' rights to receive visitors, and the resident's care plan did not address any need for restricted or limited visitation.
Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
A deficiency occurred when a resident who was prescribed a therapeutic diet by their physician did not receive the correct meal as ordered. During a meal observation, the resident was served one corndog, pasta salad, watermelon, and cottage cheese, despite having a physician order for a cardiac, low concentrated sweets diet with half portion carbohydrates, double proteins, and no pork. The resident's diet card indicated a regular diet with low concentrated sweets, no pork, and double protein, but only one corndog was provided instead of the required double protein portion. The dietary manager confirmed that the resident should have received two corndogs to meet the double protein requirement and attributed the error to new kitchen staff. The facility's policy requires therapeutic diets to be prepared and served as ordered by the attending physician, with trays clearly identified by color-coded cards reflecting the diet order.
Failure to Complete Significant Change Assessment After Resident Fall and Hospitalization
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. The resident was admitted with multiple diagnoses, including polyosteoarthritis, restless leg syndrome, essential hypertension, anemia, osteoporosis, depression, a history of falls, spinal stenosis, and orthopedic aftercare following a contusion of the right hip. After admission, the resident sustained a fall, was transferred to the hospital, underwent surgical treatment for a left wrist fracture, and returned to the facility with a left-hand brace, sling, non-weight bearing status for the left upper extremity, and pain medication. Despite these significant changes in condition, the medical record did not include a completed Significant Change in Condition Comprehensive Assessment/Minimum Data Set (MDS). The Care Plan and MDS Coordinator confirmed that the required assessment had not been completed.
Failure to Assess Fall Risk and Implement Timely Interventions Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to correctly assess a resident's fall risk, develop a comprehensive care plan, and implement timely fall prevention interventions. The resident was admitted with multiple diagnoses, including polyosteoarthritis, osteoporosis, depression, hypotension, and a recent history of falls. Despite these risk factors, the fall risk assessment inaccurately documented the resident as low risk, stating independence with ambulation and continence, which contradicted the Minimum Data Set (MDS) and comprehensive assessment findings. The care plan did not include fall prevention interventions until after the resident experienced a fall. The resident attempted to self-transfer to the bathroom during the night, resulting in an unwitnessed fall and a left wrist fracture that required surgical repair. Prior to the fall, the care plan lacked specific goals and interventions for several identified needs, including fall prevention, range of motion, self-care deficits, and management of other medical conditions. The resident was receiving medications such as diuretics and opioids, which are known risk factors for falls, and required assistance with transfers and activities of daily living, but these needs were not adequately addressed in the care plan. Interviews with staff revealed a lack of awareness regarding the resident's fall risk and the interventions in place prior to the incident. The care plan and MDS coordinator confirmed that the comprehensive care plan was not completed until several weeks after admission, and the Director of Nursing was unaware of this delay. The failure to accurately assess risk, develop a timely and comprehensive care plan, and implement appropriate interventions directly contributed to the resident's fall and injury.
Failure to Prevent and Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to prevent and protect cognitively impaired residents from physical abuse, resulting in two separate incidents involving four residents. In the first incident, a resident with severe cognitive impairment and a history of wandering entered another resident's room. The second resident, also severely cognitively impaired and with a documented history of agitation and aggression, pushed the wandering resident out of the room, causing the latter to fall and sustain a head injury. Staff did not witness the actual push, but a physical therapy assistant observed the aftermath, including the resident being shoved from the doorway and hitting his head. Documentation revealed that the injured resident had a history of Alzheimer's disease, dementia, and was at high risk for wandering, while the other resident had a history of behavioral disturbances and aggression. There was inconsistent staff awareness and documentation regarding the injury and the aggressive resident's history, and the incident was not substantiated as abuse by the facility administration due to both residents' cognitive impairments. In the second incident, two female residents with severe cognitive impairment and dementia were involved in a physical altercation. One resident was observed by staff grabbing her roommate by the hair and wrists, causing the roommate to feel angry and scared. The aggressor had a documented history of behavioral disturbances, including physical altercations and defensive behaviors when peers entered her space. Staff intervened promptly, separated the residents, and placed the aggressor on one-to-one supervision until she was transferred to the hospital for evaluation. The roommate was subsequently moved to another room and later to another unit at the request of her family. Both residents were assessed for injuries, and none were found, but the emotional impact on the victim was documented. In both cases, the facility's policies required prompt reporting, investigation, and protection of residents from abuse, including abuse by other residents. However, the facility did not identify or substantiate either incident as abuse, citing the residents' cognitive impairments and lack of willful intent. The documentation and staff interviews revealed gaps in monitoring, assessment, and recognition of aggressive behaviors and injuries, as well as inconsistent application of the facility's abuse prevention policies.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, leading to a deficiency. The resident, who was always incontinent of bowel and bladder, was found by her daughter lying in a urine-saturated bed. The resident's care plan required checks every two hours and as needed for incontinence, but this was not adhered to. The Certified Nursing Assistant (CNA) assigned to the resident's care on the day of the incident stated that she had attempted to change the resident earlier in the morning, but the resident refused assistance. The CNA did not return to provide care until after the resident's daughter raised concerns, resulting in the resident remaining in a urine-soaked state for an extended period. The CNA expressed that she was not familiar with the floor she was assigned to and had requested not to be scheduled there without proper orientation. The Director of Nurses confirmed that the facility's policy is to provide incontinence care every two hours and as needed, and that the CNA should have informed the nursing staff when the resident refused care. The incident highlights a breakdown in communication and adherence to care protocols, resulting in the resident's prolonged exposure to urine.
Failure to Provide Immediate Post-Fall Care and Safe Positioning
Penalty
Summary
The facility failed to provide immediate post-fall care to a resident receiving anticoagulant therapy, resulting in delayed treatment of a subdural hematoma. The resident, who was on Coumadin and Aspirin for chronic atrial fibrillation, was found on the floor mat next to his bed after an unwitnessed fall. Despite the resident's complaints of head pain and nausea, the staff did not notify the physician or send the resident to the hospital until the following day, leading to a significant delay in treatment. The incident report indicates that the resident was found on the floor during routine care, and initial assessments showed no evident injuries. However, the resident later complained of a severe headache and nausea, prompting a visit to the emergency department where a CT scan revealed a large subdural hemorrhage. The facility's policy required neuro checks and physician notification for falls involving head injuries, but these protocols were not followed, and the resident's condition worsened due to the delay in care. Additionally, the facility failed to safely turn and position another resident, resulting in a nasal fracture. This resident, who required substantial assistance for bed mobility, was being turned by a single CNA when she fell off the bed. The facility's policy required two-person assistance for such tasks, but this was not adhered to, leading to the resident's injury. Both incidents highlight significant lapses in following established protocols for fall prevention and post-fall management.
Failure to Prevent Resident Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, particularly involving a resident with a known history of aggression, identified as R500. This resident was involved in multiple incidents of aggression, including verbally yelling and physically hitting another resident, R134, and shoving residents R84 and R103 to the ground. These incidents resulted in significant injuries, including a bleeding laceration and hospitalization for R84, and hip and knee pain for R103. Despite these occurrences, the facility did not adequately identify, investigate, or report these incidents as potential abuse, which led to an Immediate Jeopardy situation. The facility's policies on abuse prevention and reporting were not effectively implemented. The policy required immediate reporting and investigation of any incidents or allegations of abuse, but this was not followed. The Director of Nursing and the Administrator failed to recognize and report the incidents involving R500 as abuse, despite witness statements and video surveillance suggesting otherwise. The facility's failure to act on these incidents allowed R500 to continue interacting with other residents, posing a risk to their safety. R500 had a documented history of psychiatric issues, including Schizoaffective Disorder, Bipolar Disorder, and Dementia, with behaviors such as verbal and physical aggression, hallucinations, and delusions. Despite this, the facility did not take adequate measures to manage R500's behavior or protect other residents. The lack of appropriate supervision and intervention allowed R500 to engage in aggressive behavior, resulting in harm to other residents and a failure to maintain a safe environment.
Removal Plan
- Investigation of both incidents were completed and reported to state survey agency and physician for R84, R103, and R500.
- R84 was transferred to the hospital for evaluation.
- R103 was transferred to the hospital for evaluation. No injuries were noted and R103 returned to the facility with no new orders.
- R500 was placed on one-to-one supervision.
- R500 care plan was updated to include one-to-one supervision and again updated to include one-to-one supervision until the resident is deemed safe by psychiatry and/or nursing assessment.
- R500 care plan was updated to include behavior monitoring every shift.
- R84, R103, and R500 care plans have been updated to include one-to-one time with Social Services as needed to vent feelings.
- Administrator in-serviced by Risk Management Consultant regarding Abuse Prevention Policy.
- In-servicing training by Administrator/designee on Abuse Prevention Policy with all staff was initiated.
- In-servicing training by Administrator/designee on Abuse Prevention Policy with all staff will continue, and any remaining employees must be trained prior to reporting for work for their next scheduled shift. Employees will not be allowed to work until they have completed the in-service.
- QAA team members were in-serviced on the facility's Abuse Prevention Program policy and procedure by the Administrator.
- Social Services Director and/or designee will audit Trauma Screening assessments and Screening Assessments for Indicators of Aggressive and/or Harmful Behavior for all residents with the potential to be affected by this alleged deficiency to ensure those assessments are current. Social Services Director/designee will ensure interventions are care planned for any residents assessed to be at risk.
- QAA team will review the Trauma Screening assessments and Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors during quarterly QA meetings with medical director and address any concerns.
- QAA team will review the Trauma Screening assessments and Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors during Morning QA meetings daily for a period on all new admits to assure compliance.
- The facility will follow state and federal guidelines regarding Abuse Reporting by requiring reporting of all reports of abuse to be reported to the facility QA Committee for follow up and review.
- In-service training by Administrator/designee on Abuse Prevention Policy with all staff will continue monthly for a period, then quarterly for a period by the DON or Administrator.
- Administrator will enforce the interventions of plan of removal of immediacy and assurance of continued compliance.
Unresolved Dietary Grievances in Resident Council Meetings
Penalty
Summary
The facility failed to effectively resolve grievances voiced in resident council meetings, affecting all 160 residents. The Resident Council Meeting Minutes and General Feedback/Grievance Forms from October 2023 to April 2024 document repeated concerns about the dietary services, including disorganization in the kitchen, insufficient staff in the dining room, discrepancies between meal tickets and served meals, and the absence of a full-time dietary manager. Despite these documented concerns, the sections for steps taken to investigate and corrective actions on the grievance forms were consistently left blank, indicating a lack of response or resolution from the facility. Interviews with the Activity Director and the Resident Council President further highlight the facility's inaction. The Activity Director stated that grievances are supposed to be addressed by the relevant department heads, but the forms lacked written responses. The Resident Council President expressed frustration, noting that issues raised in meetings are not addressed, and feedback from the facility is minimal and ineffective. This ongoing lack of action and communication from the facility has left residents' concerns unresolved, contributing to the deficiency.
Deficiencies in Food Storage and Staff Hygiene
Penalty
Summary
The facility failed to adhere to its policies regarding the storage of dry foods and the personal hygiene of kitchen staff, which could potentially affect all 160 residents. During an inspection of the dry storage room, it was observed that four clear bins labeled as oatmeal, flour, thickener, and bread crumbs were not dated as required by the facility's policy. The Dietary Manager confirmed the absence of dates on the bins, which should have been present. Additionally, the bins appeared cloudy and dirty, and the lids had a significant gap, which the Dietary Manager acknowledged as inadequate for proper coverage. Furthermore, a cook was observed with a hairnet improperly worn, allowing her long hair to remain unrestrained. This was in violation of the facility's Employee Health and Personal Hygiene policy, which mandates that hair restraints be worn at all times. The cook did not initially respond to inquiries about her hairnet usage but adjusted it to cover her hair when questioned. These observations indicate a lapse in maintaining professional standards for food storage and personal hygiene in the kitchen.
Inadequate Infection Control and PPE Use During COVID-19 Outbreak
Penalty
Summary
The facility failed to properly implement infection prevention and control measures during a COVID-19 outbreak, as evidenced by multiple instances of staff not wearing appropriate personal protective equipment (PPE). Staff members, including registered nurses and certified nurse aides, were observed not wearing masks or wearing them improperly in areas with known COVID-19 cases. This non-compliance with PPE protocols was noted despite the facility's policy requiring the use of N95 masks in certain areas and surgical masks in others. Additionally, staff failed to don PPE during the care of residents in contact isolation for COVID-19, leading to potential exposure and spread of the virus. The facility also did not adequately assess and respond to residents showing symptoms of COVID-19. Several residents reported symptoms such as coughing and weakness, yet there was a lack of documentation and follow-up testing for COVID-19. In some cases, residents with symptoms were not placed in isolation, and their symptoms were not communicated to the infection preventionist or physician. This oversight in monitoring and responding to potential COVID-19 cases further compromised infection control efforts. Furthermore, the facility did not maintain proper infection control practices during wound care. Staff were observed not using gloves or gowns appropriately, and there were instances of cross-contamination during wound care procedures. For example, a wound care nurse did not change gloves or perform hand hygiene after touching a resident's wound and then handling other items. Additionally, residents with known infections, such as MRSA, were not placed in appropriate isolation, increasing the risk of spreading infections within the facility.
Failure to Provide Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the physical, mental, and psychosocial well-being of residents on the second floor of building four. This deficiency was observed through interviews and record reviews, revealing that since August 23, 2024, no group activities were conducted for the 35 residents residing on that floor. Residents expressed their dissatisfaction, stating that they were unable to participate in activities or leave their unit due to COVID-19 restrictions. The lack of activities led to residents feeling isolated and bored, with some expressing a desire for simple activities like Bingo. The Activity Director acknowledged the issue, citing a non-functional air conditioning system in the activity room as a reason for not conducting activities. The Activity Director also admitted to forgetting about the residents on the second floor, who were not allowed to leave their unit. This oversight resulted in a lack of engagement and stimulation for the residents, as no alternative arrangements were made to provide activities on their floor.
Failure to Maintain Resident Dignity and Cleanliness
Penalty
Summary
The facility failed to ensure that staff treated a resident with dignity and respect, as evidenced by an incident involving a resident who experienced diarrhea during the night. The resident reported that no one answered her call light, forcing her to clean herself up, which resulted in a mess on her bed. The resident pointed out the soiled blanket to the staff, indicating it needed to be washed. Observations made later in the day confirmed the presence of a brown stool smear on the blanket and multiple spots of stool on the floor next to the resident's bed. Despite these conditions, the resident was observed lying on the soiled blanket at different times throughout the day, with the brown spots still present on the floor. It was only after a Certified Nurse Aid was notified of the situation that action was taken to remove the soiled blanket and arrange for the floor to be cleaned.
Failure to Conduct Level 2 PASARR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to conduct a Level 2 Pre-Admission Screening and Resident Review (PASARR) for a resident identified as R73, who was part of a sample of 124 residents reviewed. The facility's policy requires coordination with the PASARR program and mandates a Level 2 review for residents with serious mental disorders or intellectual disabilities upon a significant change in status. Despite this, R73, who was diagnosed with Disorganized Schizophrenia and Schizoaffective Disorder-Depressive Type, did not receive the necessary Level 2 PASARR upon admission. R73's medical records indicated diagnoses of Major Depressive Disorder, Alcohol Abuse, Disorganized Schizophrenia, and Schizoaffective Disorder-Depressive Type. However, the Level 1 PASARR form, dated 9/11/2018, incorrectly stated that the resident did not have any major mental illnesses. This discrepancy was acknowledged by the Social Service Coordinator, who confirmed that a new PASARR should have been conducted upon R73's admission to the facility on 2/10/2021. The failure to perform the required Level 2 PASARR constitutes a deficiency in the facility's compliance with regulatory requirements.
Failure to Update Care Plan for Tracheostomy Removal
Penalty
Summary
The facility failed to update the care plan for a resident, identified as R127, to reflect the removal of a tracheostomy. According to the facility's Comprehensive Person-Centered Care Planning Policy and Procedure, the care plan should be reviewed and revised by an interdisciplinary team after each assessment. However, R127's care plan, dated June 26, 2024, still documented the presence of a tracheostomy, despite a physician's order dated August 20, 2024, indicating that the tracheostomy had been removed and the site required specific wound care. On August 29, 2024, the MDS/Care Plan Coordinator acknowledged the oversight, stating that the care plan should have been updated to discontinue the tracheostomy.
Failure to Provide Prescribed Range of Motion Programs
Penalty
Summary
The facility failed to provide appropriate range of motion (ROM) programming for residents with limitations in ROM, as evidenced by the cases of two residents. Resident 57, who has a history of cerebral vascular accident with hemiplegia or hemiparesis, was supposed to receive active range of motion (AROM) exercises for both upper and lower extremities. However, documentation showed that AROM was not conducted as ordered for 19 out of 29 days. Furthermore, the resident reported that no exercises or ROM activities had been performed. Similarly, Resident 78, who has contractures in both upper and lower extremities and requires total assistance with most activities of daily living, was to participate in a passive range of motion (PROM) program. The documentation indicated that PROM was not conducted as ordered for 9 out of 30 days. The resident confirmed that PROM had not been conducted daily and stated that it had never been done by the staff. These findings highlight the facility's failure to adhere to the prescribed ROM programs for residents with limited mobility.
Failure to Secure Catheter Drainage Bag in Privacy Cover
Penalty
Summary
The facility failed to ensure that a resident's indwelling urinary catheter drainage bag was secured in a dignity enclosure bag, as required by the facility's Foley Catheter Management Policy. The policy mandates that all catheter bags be covered with privacy bags at all times. The deficiency was observed in one of four residents reviewed for urinary catheters. The resident, identified as R55, had a 16fr, Balloon 10ml indwelling catheter due to hydronephrosis. On two separate occasions, the resident's catheter drainage bag was observed attached to the wheelchair and touching the ground without a privacy covering. The Director of Nursing confirmed that the drainage bag should have been covered and kept off the floor.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to store medications in a safe manner for three residents during a routine medication pass. The facility's policy on the storage of medications, dated May 8, 2019, requires that medications be stored in a safe, secure, and orderly manner in the containers in which they are received. However, during observations on August 27 and 28, 2024, it was noted that Registered Nurse V22 administered medications to a resident using a clear medicine cup with writing on the side, which contained multiple medications. V22 admitted to preparing medications in advance, contrary to her usual practice, and was found with additional pre-prepared medication cups in her cart, some containing pills and others serving as reminders for future medication administration. Similarly, on August 28, 2024, Registered Nurse V30 was observed with a clear medication cup containing a resident's morning medications on top of her medication cart. Both nurses confirmed that their medication carts held all medicines for the residents on their respective floors. These actions indicate a failure to adhere to the facility's medication storage policy, as medications were not stored in their original containers and were pre-prepared in advance, potentially compromising the safety and security of medication administration.
Failure to Document Hospice Services in Resident's Medical Record
Penalty
Summary
The facility failed to ensure coordinated care for a resident receiving hospice services by not including documented hospice services in the resident's medical record. This deficiency was identified for one resident out of a sample of 124. The facility's agreement with the hospice provider required that a Plan of Care be developed and shared with the facility, reflecting the participation of the hospice, the facility, and the resident's family. However, the resident's care plan initially lacked documentation of hospice services and later did not specify hospice responsibilities or interventions. Observations and interviews revealed that hospice documentation was not readily accessible to the facility's interdisciplinary team. A Licensed Practical Nurse was unable to locate the hospice binder or any hospice documentation. The hospice Registered Nurse indicated that visit notes and the plan of care were brought to the facility but were likely taken to medical records. The Infection Preventionist questioned the need for staff access to hospice records, and the Careplan Coordinator admitted to not including hospice-specific interventions in the care plan, only noting that the resident was on hospice.
Failure to Implement Abuse Prevention Program
Penalty
Summary
The facility failed to implement its abuse prevention program effectively, resulting in incidents involving three residents. The program requires immediate reporting of any abuse, neglect, or exploitation to the Administrator or DON, followed by an investigation. However, the facility did not adhere to these procedures, as evidenced by the incidents involving residents R84, R103, and R500. The facility's failure to take immediate action and implement safety measures after the first incident led to further occurrences of aggression. Resident R84 was involved in an incident where she was startled by another resident, R500, leading to a fall and head injury. Despite the facility's investigation identifying the root cause as peer agitation, no safety measures were implemented to protect R84 or other residents from R500. This lack of intervention allowed R500 to continue exhibiting aggressive behavior, resulting in another incident involving resident R103, who was physically assaulted by R500, causing her to fall. The facility's video surveillance confirmed that R500 was not receiving increased monitoring or one-to-one supervision after the initial incident. Staff interviews revealed that R500 had a history of increased behaviors and physical aggression, yet no interventions were put in place until after the second incident. The facility's inaction and failure to follow its abuse prevention program contributed to the repeated incidents of aggression and harm to residents.
Failure to Investigate Alleged Resident Abuse
Penalty
Summary
The facility failed to identify and investigate a potential allegation of verbal and physical abuse involving two residents. The incident occurred when one resident allegedly pushed another, causing the latter to fall and sustain a head injury. Despite witness accounts indicating that the fall was aggressive and involved a push, the facility's Director of Nursing (DON) did not investigate the incident as abuse. Instead, it was treated solely as a fall incident. The Administrator was not involved in the initial investigation due to absence, and the DON did not consider the incident as a potential abuse allegation, despite reports and witness statements suggesting otherwise. The facility's Abuse Prevention Program mandates immediate examination and reporting of abuse allegations, but these procedures were not followed. A CNA reported witnessing the push and informed the DON and Assistant Director of Nursing (ADON), but her statement was not accurately reflected in the incident report. Another CNA corroborated the account of the push, but the DON dismissed these claims, instructing staff to stop discussing the incident as abuse. The failure to properly investigate and report the incident as a potential abuse case constitutes a deficiency in the facility's handling of abuse allegations.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, particularly involving a resident with a known history of aggression, identified as R500. This resident, diagnosed with Schizoaffective Disorder, Bipolar Disorder, and Dementia, exhibited behaviors such as hitting, pushing, and verbal aggression. Despite these known behaviors, the facility did not adequately monitor or intervene, leading to incidents where R500 physically assaulted other residents. Specifically, R500 was involved in altercations with residents R134, R84, and R103, resulting in injuries and hospital evaluations for the victims. The facility's policy on abuse prevention mandates immediate reporting and investigation of any abuse allegations. However, the facility failed to identify and investigate potential abuse allegations involving R500. For instance, R500 was reported to have pushed R84, causing a severe head injury, but the incident was initially treated as a fall rather than potential abuse. Similarly, R500's altercation with R134, where R500 slapped R134, was not substantiated as abuse despite witness accounts. These oversights indicate a failure to adhere to the facility's abuse prevention policy and protect residents from further harm. The facility's administration and nursing staff demonstrated a lack of coordination and communication in handling these incidents. The Director of Nursing and the Administrator had differing accounts of the incidents, and there was a failure to report all abuse allegations to the state agency. The facility's video surveillance did not provide conclusive evidence, and staff statements were inconsistent or altered, further complicating the investigation process. These deficiencies resulted in an Immediate Jeopardy situation, affecting the safety and well-being of all residents in the dementia unit.
Failure to Implement Abuse Prevention Program
Penalty
Summary
The facility failed to implement its abuse prevention program effectively, resulting in incidents involving three residents. The program requires immediate reporting of any abuse, neglect, or exploitation to the Administrator or DON, followed by an investigation. However, the facility did not adhere to these procedures, as evidenced by the incidents involving residents R84, R103, and R500. The facility's failure to take immediate action and implement safety measures after the first incident led to further occurrences of aggression. Resident R84 was involved in an incident where she was startled by another resident, R500, leading to a fall and head injury. Despite the facility's investigation identifying the root cause as peer agitation, no safety measures were implemented to protect R84 or other residents from R500. Similarly, Resident R103 experienced physical aggression from R500, resulting in a fall. The facility's video surveillance confirmed that R500 was not receiving increased monitoring or one-to-one supervision after these incidents. Staff interviews revealed that R500 exhibited increased aggressive behaviors, yet no interventions were put in place until after multiple incidents occurred. Witnesses reported that R500 physically assaulted both R84 and R103, but the facility did not implement one-to-one monitoring until after the second incident. This lack of timely intervention and monitoring contributed to the repeated occurrences of aggression, highlighting the facility's failure to protect its residents adequately.
Failure to Investigate Alleged Resident Abuse
Penalty
Summary
The facility failed to identify and investigate a potential allegation of verbal and physical abuse involving two residents. The incident occurred when one resident allegedly pushed another, causing the latter to fall and sustain a head injury. Despite witness accounts indicating that the fall was aggressive and involved a push, the facility's Director of Nursing (DON) did not investigate the incident as abuse. Instead, it was treated solely as a fall incident. The Administrator was not involved in the initial investigation due to absence, and the DON did not consider the incident as a potential abuse allegation, despite reports from staff members suggesting otherwise. Witnesses, including a Certified Nursing Assistant (CNA), reported hearing and seeing the altercation, with one CNA stating that she saw the resident being pushed. This CNA also reported the incident to the Licensed Practical Nurse (LPN), DON, and Assistant Director of Nursing (ADON), but her statement was not accurately reflected in the incident report. The DON dismissed the abuse claims, instructing staff to stop spreading information about the push, as the resident who fell did not explicitly state she was pushed. The facility's failure to properly investigate and document the incident as a potential abuse case constitutes a deficiency in their abuse prevention program.
Failure to Provide Immediate CPR to Resident
Penalty
Summary
The facility failed to provide immediate CPR to a resident who was found unresponsive and without a pulse or respirations. The resident, who had no advance directives or code status documented, was discovered by an RN who left the room to make phone calls instead of initiating CPR. This delay in response was contrary to the facility's policy, which requires staff to remain with the resident and signal for assistance. The RN, upon finding the resident unresponsive, did not follow the protocol of initiating CPR and instead contacted the Director of Nursing (DON) for guidance. The DON instructed the RN to start CPR, but by the time the RN returned to the resident's room, other staff members had already begun CPR. This lapse in immediate action placed other residents with full code status at risk of not receiving timely life-sustaining treatment. The incident highlighted a lack of training and awareness among staff regarding the facility's CPR policy. Interviews revealed that the RN was unsure of the resident's code status and felt the need to consult with the DON before taking action. Additionally, it was noted that the RN and another staff member had not received training on the facility's CPR policy, which contributed to the delay in providing necessary care.
Removal Plan
- In-servicing by members of the Nurse Management team for licensed and certified staff on the facilities Advanced Directives, Cardiopulmonary Resuscitation, POLST Form, and Code Pink-Nurse Emergency Page was initiated.
- In-service by members of the Quality Assurance team for All staff on the facilities Advanced Directives, Cardiopulmonary Resuscitation, POLST Form, and Code Pink-Nurse Emergency Page was initiated.
- DON/MDSC/SS team members completed an audit of all residents' code status orders, POLST Forms and advanced directive care plans. This audit was repeated with no inconsistencies noted. A review of all new admits completed.
- V7 has been removed from the facility's schedule and has not worked since the alleged deficiency.
- All staff who have not received the above-mentioned in-service will be removed from the facility schedules until the in-servicing has been completed with a QAT member.
- In-servicing training by members of the Nurse Manager Quality Assurance Team on Advanced Directives, Cardiopulmonary Resuscitation, POLST Form, and Code Pink-Nurse Emergency Page with all staff will continue monthly for the next 3 months, then quarterly.
- DON/MDSC/SSD will complete an audit of all residents' code status orders, POLST Forms and advanced directive care plans monthly then quarterly and PRN.
- LNHA will enforce the interventions of plan of removal of immediacy.
Failure to Assess Capacity for Consent in Cognitively Impaired Residents
Penalty
Summary
The facility failed to develop a system to assess and evaluate residents for capacity to consent to sexual activity, resulting in two cognitively impaired residents (R1, R2) engaging in a sexual act without confirmed consent. Both R1 and R2 were severely cognitively impaired according to current MDS/BIMS assessments, indicating their inability to give consent. The incident involving R1 and R2 was discovered when a CNA found R1 with his penis in R2's mouth, leading to concerns about the lack of capacity to consent to the sexual act due to their cognitive impairments. Despite the facility having a policy recognizing residents' right to engage in sexual activity with consent, no assessment was conducted to confirm R1 and R2's ability to consent prior to or after the incident. The Immediate Jeopardy was identified on 3/13/24 when the sexual act between R1 and R2 was discovered. The facility's policy on assessing residents' capacity to consent to sexual activity was not utilized due to R1 and R2's cognitive impairments, as confirmed by the Medical Director. The incident raised questions about the residents' understanding of the consequences of their actions and their ability to communicate decisions regarding sexual activity. The lack of assessment and confirmation of consent for R1 and R2 highlights a gap in the facility's procedures to protect residents from potential harm related to sexual activities.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two residents. Resident 2 (R2) and Resident 3 (R3) were roommates from December 12 to December 20, 2023. On December 20, 2023, R2 reported an altercation with R3, where R3 slapped R2 twice across the face after a verbal exchange. R2 had no visible signs of injury, and the incident was reported to the physician and police. R3 was subsequently moved to another room. R2's medical history includes colostomy, end-stage renal disease requiring dialysis, left hemiplegia, and mood disorder, while R3's diagnoses include amnesia and Wernicke's encephalopathy. R3 admitted to slapping R2 during an interview on January 24, 2024, stating that R2 was smoking in their room and became argumentative when confronted. The facility's final investigation confirmed the physical contact between R2 and R3. The Social Service Coordinator noted that R2 often becomes agitated when confronted about smoking or vaping in the facility. The facility's policy prohibits abuse and mistreatment of residents by anyone, including other residents, but this policy was not effectively enforced in this instance.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
