Ignite Medical Mchenry
Inspection history, citations, penalties and survey trends for this long-term care facility in Mchenry, Illinois.
- Location
- 550 Ridgeview Drive, Mchenry, Illinois 60050
- CMS Provider Number
- 146195
- Inspections on file
- 33
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Ignite Medical Mchenry during CMS and state inspections, most recent first.
A cognitively intact post–joint replacement resident with an order for PRN oxycodone-acetaminophen every 4 hours reported requesting pain medication from a CNA during shift change but did not see a nurse for approximately 1.5 hours, during which her pain escalated to 7/10. The LPN who eventually assessed her stated they had not been informed of the earlier request, and documentation showed a 6.5-hour gap between PRN doses despite the every-4-hours order. The DON confirmed that CNAs are expected to notify nurses of pain complaints and that the care plan required immediate response to any pain complaint, but this did not occur.
A resident with multiple respiratory and cardiac conditions did not receive prescribed doses of Incruse Ellipta inhaler for several days after admission. Staff interviews revealed confusion about medication availability and administration, with the inhaler remaining unopened and only two doses given during a six-day stay, despite physician orders for daily use.
A resident with diabetes and other medical conditions did not receive three prescribed doses of Insulin Glulisine, despite elevated blood sugar levels that required insulin per physician orders. Staff interviews revealed that the insulin was not available and that there was a lack of immediate communication with the provider to obtain new orders, resulting in a significant medication error.
A resident who is incontinent and fully dependent on staff for ADLs was found in bed with saturated linens and a strong, foul odor, indicating they had not been changed in accordance with the facility's policy of providing incontinence care every two hours or as needed. CNAs present were unaware of when the resident was last changed, and the assigned CNA reported the last change was several hours prior, contrary to established protocols.
A resident with ADHD, traumatic brain injury, and dementia had her psychiatric medication discontinued without notification to her, her family, or her psychiatrist. The medication was stopped based on a physician's note, and the facility administrator confirmed there was no documentation of required notifications.
Two residents using CPAP machines did not have physician orders for their use, despite documentation of CPAP dependence and nightly use. Staff relied on family members for setup and did not consistently assist with application or ensure orders were in place, and the facility's policy did not address the requirement for physician orders for respiratory treatments.
A resident was administered psychotropic medications, including quetiapine, escitalopram, and trazodone, without obtaining proper consent from the resident or responsible parties prior to administration. Consent forms were either unsigned or signed after the medications had already been given, contrary to facility policy and staff expectations.
A resident with significant mobility and health issues, identified as high fall risk, experienced two falls. After each incident, the care plan was not updated to include new or individualized fall prevention interventions, despite facility policy requiring such updates.
The facility failed to follow physician orders for pressure ulcer care for two residents. One resident's sacral dressing was not changed as scheduled, and another resident's wound care orders were not properly documented or followed. Both residents were cognitively intact and had care plans addressing their pressure injuries, but the facility's inconsistent adherence to treatment protocols led to deficiencies.
A resident's midline catheter dressing was not changed according to standard practice, resulting in a saturated dressing with dried blood. The facility's policy requires dressing changes every seven days or as needed, but staff were unaware of the catheter's insertion date and the need for a change. The resident's physician orders lacked specific instructions for dressing care, leading to the oversight.
A facility failed to provide adequate ADL assistance for a resident with multiple health issues, including chronic kidney disease and heart failure. The resident required assistance for personal hygiene and bed mobility. A CNA found the resident's incontinence brief saturated with urine and the blanket underneath soiled. Despite this, the CNA left the resident on the soiled blanket, contrary to the facility's policies on ADL care and linen management.
The facility failed to provide adequate pressure ulcer care and prevention for two residents, resulting in deficiencies. One resident had a stage four pressure injury with a saturated dressing that was not changed as needed, and her heels were unprotected. Another resident had a painful open area without a dressing, and her heels were also unprotected. The facility's wound care protocols were not followed, leading to inadequate management of pressure injuries.
The facility failed to properly use PPE and perform hand hygiene for residents on enhanced barrier precautions. A CNA did not change gloves or wear a gown while providing care to three residents with conditions requiring such precautions, including MRSA and ESBL resistance. The DON confirmed the need for proper glove and gown use, as outlined in the facility's infection control policy.
The facility failed to properly store and label refrigerated foods and did not ensure staff wore hairnets correctly, affecting all residents. A surveyor found raw chicken and sliced ham improperly covered and a pork loin without a label. Additionally, a dietary aide was observed with hair outside the hairnet while working in the kitchen, contrary to facility policy.
A resident with a stage II pressure injury did not receive timely treatment upon readmission to the facility. The wound was identified, but no treatment was applied or documented until two days later, contrary to the facility's wound care policy. The lapse occurred because the nurse did not contact the wound care nurse or the resident's provider for treatment orders.
A resident with dysphagia and other medical conditions was left unsupervised while eating, despite requiring one-to-one feeding assistance. The resident was observed coughing and using a suction tube independently, highlighting a lack of adherence to posted swallow precautions and facility policy.
The facility failed to monitor two residents during medication administration. One resident had medications left at her bedside, leading to pills being dropped and not taken. Another resident had a cup of pills left on her refrigerator without proper authorization. The facility's policy requires nurses to observe residents taking medications, which was not adhered to in these cases.
The facility failed to maintain proper isolation precautions for two residents, leading to potential cross-contamination. One resident on contact isolation for ESBL did not have appropriate signage or PPE for six days, and staff inconsistently used PPE. Another resident on contact isolation for C-diff had a nurse enter without wearing required PPE. The facility's infection control policy was not followed in both cases.
Failure to Provide Timely PRN Pain Medication Following Resident Request
Penalty
Summary
The deficiency involves the facility’s failure to provide timely administration of PRN pain medication to a cognitively intact female resident admitted after joint replacement surgery with a left artificial hip joint. Upon admission, the resident had an order for Oxycodone-Acetaminophen 10-325 mg to be given every 4 hours as needed for pain, and her initial care plan directed staff to respond immediately to any complaint of pain. On the evening in question, the resident reported that around 7:00 PM she told a CNA she needed pain medication and was informed it was shift change and it might be a little while before the nurse came. The resident stated that she did not see anyone until approximately 8:30 PM, at which time she reported her pain as 7/10 and appeared grimacing and agitated. The resident’s family member, who was on the phone with the resident at about 8:30 PM, corroborated that the resident said she had requested pain medication at 7:00 PM and had not seen anyone since. The LPN who entered the room around 8:30 PM stated they were not informed in report or by a CNA that the resident had requested pain medication earlier and indicated they would have administered it sooner if they had known. Documentation showed the resident received Oxycodone just before 2:00 PM and then not again until 8:30 PM, a 6.5-hour interval, despite the order allowing dosing every 4 hours as needed. The DON stated that a resident’s pain level is what they say it is and that CNAs are expected to notify the nurse when a resident requests pain medication so the nurse can act, underscoring that this communication did not occur as required by the resident’s care plan and the facility’s pain management policy.
Failure to Administer Medication per Physician's Orders
Penalty
Summary
The facility failed to ensure that medications were administered to a resident according to physician's orders. A resident with multiple diagnoses, including interstitial pulmonary disease, COPD, chronic respiratory failure, congestive heart failure, and pulmonary hypertension, was admitted to the facility and had a physician's order for Incruse Ellipta inhalation to be given once daily for COPD. Review of the medication administration record showed that the resident did not receive the prescribed inhaler from 11/28 to 12/1, resulting in four missed doses. Interviews with the resident's significant other and nursing staff confirmed that the medication was not administered as ordered, with the inhaler remaining unopened for several days after admission. Staff interviews revealed confusion regarding the availability and administration of the medication. The resident's significant other reported being told by nursing staff that the inhaler was not available due to a need for prior authorization, and that the medication was not on the nurse's schedule to administer. Nursing staff acknowledged that only two doses had been used during the resident's six-day stay, and the DON stated that medications should be available upon admission and that nurses are expected to communicate when medications are not available. The facility's policy requires all medications to be administered as ordered by a healthcare professional.
Significant Medication Error Due to Missed Insulin Doses
Penalty
Summary
A resident with diagnoses including type 2 diabetes, cerebral infarction, dementia without behaviors, and atrial fibrillation was admitted to the facility with physician's orders for Insulin Glulisine to be administered three times daily per sliding scale. On one day, the resident did not receive any of the prescribed insulin doses, despite having elevated blood sugar readings between 240-365 that would have required insulin administration according to the physician's orders. The medication administration record confirmed that three doses were missed. Interviews with staff revealed that medications for new admissions typically arrive the next morning, and if a medication such as insulin is not available, the provider and pharmacy should be notified immediately. The LPN stated that the resident's insulin was not given due to insurance issues and that the provider should have been contacted for new orders. The DON indicated that prior authorization for medications is usually addressed before admission and was unaware of any such requirement for this resident. Facility policy requires that all medications be administered as ordered and that staff should check for misplaced medications and contact the pharmacy if a medication is unavailable. The failure to administer insulin and to communicate promptly with the physician constituted a significant medication error.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A resident who is incontinent of urine and dependent on staff for activities of daily living, including toileting and hygiene, was found lying in bed with a strong, foul odor present in the room. Upon observation, the resident's brief, pad, and sheet were saturated with dark, foul-smelling urine, with the saturation reaching through to the mattress. Certified Nursing Assistants (CNAs) present at the time of observation stated they had not changed or assisted in changing the resident earlier that day and were unaware of when the resident was last changed. The CNA assigned to the resident reported that the last change occurred at approximately 7:30 AM, despite facility policy and the Director of Nursing stating that incontinent residents are to be changed every two hours and as frequently as needed. The resident's care plan confirms total dependence on staff for toileting and hygiene, and the facility's incontinence care policy requires residents to be kept dry, comfortable, and odor-free.
Failure to Notify of Psychiatric Medication Discontinuation
Penalty
Summary
The facility failed to notify a resident, the resident's physician, and a family member when the resident's psychiatric medication was discontinued. The resident, who has a history of ADHD, traumatic brain injury, and dementia, was found to have her lisdexamfetamine stopped based on a physician's progress note, which indicated the medication should be discontinued. The resident's husband reported not being informed of this change and only learned about it after contacting the psychiatrist, who stated the treatment should not have been stopped. The facility administrator confirmed there was no documentation showing that the resident or family was notified of the medication change.
Failure to Obtain Physician Orders for CPAP Use
Penalty
Summary
The facility failed to ensure that two residents using CPAP (Continuous Positive Airway Pressure) machines had appropriate physician orders for their use. One resident reported that their family set up the CPAP machine and that the facility only assisted by providing distilled water, with no physician order present for the device. The respiratory therapy staff confirmed that they do not manage residents' personal CPAP machines and that nursing staff are responsible for obtaining physician orders, which should include the prescribed settings. However, review of the resident's records showed no physician order for the CPAP machine. Another resident's spouse stated that they brought the CPAP machine to the facility and instructed a CNA on its use, but observed that the machine was not used as intended and that staff did not assist with its application at night. The resident's records, including hospital discharge instructions and nurse practitioner notes, indicated CPAP dependence and nightly use, but there was no physician order for the CPAP during the resident's stay. The facility's respiratory supplies policy did not address the need for a physician order for respiratory treatments.
Failure to Obtain Consent Prior to Administering Psychotropic Medications
Penalty
Summary
The facility failed to obtain proper consent prior to administering psychotropic medications, including anti-psychotic, anti-anxiety, and anti-depressant drugs, to a resident. Review of the resident's records showed that medications such as quetiapine, escitalopram, and trazodone were administered before signed or verbal consent was obtained from the resident or their responsible parties. Consent forms for these medications were either unsigned or signed after the medications had already been given. Family members and the resident were unaware of having provided consent prior to administration, and facility documentation did not show evidence of verbal consent being obtained. The resident in question had recently returned from a hospital stay and was prescribed escitalopram and trazodone upon discharge, but not quetiapine. Despite this, the facility administered quetiapine without prior consent. The facility's own policy requires that psychotropic medications be initiated only after informed consent is obtained from the resident or their representative. Interviews with staff confirmed that consent should be obtained before administering such medications, regardless of prior hospital use.
Failure to Update Fall Interventions After Resident Falls
Penalty
Summary
A resident with multiple medical conditions, including muscle weakness, unsteadiness, reduced mobility, cellulitis, end stage renal disease, and a need for assistance with personal care, was admitted to the facility and identified as a high fall risk based on an initial Fall Risk Evaluation. Despite this high risk, the resident experienced two falls: one unwitnessed fall in her room and a second witnessed fall while transferring into bed. Following both incidents, the resident's Fall Risk Care Plan, which initially included only standard admitting interventions, was not updated to reflect the new falls or to add individualized interventions. The facility's Fall Prevention policy requires that safety interventions be added to the care plan for residents at risk for falls and that interventions be individualized. However, no changes or additions were made to the care plan after either fall, as confirmed by record review and staff interview.
Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper pressure ulcer care for two residents, leading to deficiencies in following physician orders for pressure injuries. For one resident, identified as R2, the wound care nurse was observed changing a sacral dressing that was dated four days prior, with stool present on the dressing. The resident reported that the dressings had only been changed a few times since his admission, and the wound care nurse confirmed that he had been on vacation for two weeks, leaving the responsibility to floor nurses. The treatment administration record (TAR) showed missed dressing changes on several dates, indicating a lack of adherence to the prescribed schedule. Another resident, identified as R1, reported that his sacral dressing had not been changed in over a week. The physician's order for R1's wound care, which included specific instructions for cleansing and dressing changes, was not reflected in the TAR. The wound care nurse confirmed that the orders were not entered as directed by the wound care doctor, who was new to the facility. The TAR showed inconsistencies in the documentation of dressing changes, with several shifts not signed off as completed. Both residents were cognitively intact and had care plans that included interventions for their pressure injuries. The facility's skin policy and procedure emphasized the need for appropriate treatment and services to promote healing and prevent further skin integrity issues. However, the lack of adherence to physician orders and inconsistent documentation of wound care interventions contributed to the deficiencies observed during the survey.
Failure to Change Midline Catheter Dressing as Required
Penalty
Summary
The facility failed to ensure that a resident's midline catheter dressing was changed according to standard practice. On January 13, 2025, a resident was observed with a midline catheter in the right arm, with a gauze dressing that was visibly saturated with dried blood and dated January 9, 2025. The resident mentioned that the catheter was inserted at the hospital before being discharged to the facility for antibiotic treatment. The facility's policy requires that midline dressings be changed every seven days or as needed if the dressing is loose or soiled to prevent infection. Interviews with the facility's nursing staff revealed a lack of awareness regarding the resident's catheter insertion date and the need for a dressing change. A registered nurse confirmed the dressing was overdue for a change and noted the presence of oozing at the site. The Director of Nursing stated that the facility's policy includes checking the site for infection signs and changing the dressing as needed. However, the resident's physician orders did not include specific instructions for dressing changes, contributing to the oversight.
Failure to Provide Adequate ADL Assistance and Linen Management
Penalty
Summary
The facility failed to provide adequate ADL assistance for a resident who required it, as observed during a survey. A resident, admitted with multiple diagnoses including chronic kidney disease, diabetes mellitus, and heart failure, was noted to have an ADL self-care performance deficit and limited physical mobility. The resident's care plan indicated the need for one staff member for personal hygiene and dressing, and two staff members for bed mobility and toileting. On a specific day, a CNA provided incontinence care and found the resident's incontinence brief saturated with dark urine, with urine also noted on the blanket underneath. Despite acknowledging the resident as a 'heavy wetter' and the resident expressing discomfort from being in bed too long, the CNA laid the resident back onto the soiled blanket and left the room without replacing it. This action was contrary to the facility's ADL policy and Linen Management Infection Control policy, which require care according to individualized care plans and proper handling of soiled linens.
Deficient Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to implement appropriate pressure ulcer care and prevention measures for two residents, R2 and R4, leading to deficiencies in their care. R2 was admitted with a stage four pressure injury to her sacrum and was at high risk for developing further pressure injuries. Despite having a care plan in place, R2's dressing was not changed as needed, resulting in a saturated and malodorous dressing. Observations revealed that R2's heels were not protected as required, and the wound care nurse acknowledged that the dressing should have been changed when it became soiled. R4, who had a history of pressure injuries, was also found to have inadequate care. Her care plan indicated a need for specific dressing changes to her right ischial tuberosity, but on observation, there was no dressing in place, and she complained of pain. The wound care nurse was unaware of the missing dressing and emphasized the importance of dressing changes to prevent wound deterioration. R4's heels were also unprotected, contrary to the facility's protocols. The facility's wound care program policy outlines the necessity for regular skin assessments and the implementation of risk reduction measures, such as heel protectors and repositioning. However, these protocols were not followed for R2 and R4, resulting in deficiencies in their care. The facility's failure to adhere to its own policies and procedures contributed to the inadequate management of pressure injuries for these residents.
Inadequate Use of PPE and Hand Hygiene in Infection Control
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the use of personal protective equipment (PPE) and hand hygiene, for residents on enhanced barrier precautions. Three residents, identified as R2, R3, and R4, were involved in these deficiencies. R2, who was on contact isolation for MRSA in a wound, was observed receiving incontinence care from a CNA who did not change gloves or perform hand hygiene after touching various surfaces and the resident's body. Similarly, R4, who had pressure injuries and was under enhanced barrier precautions, received care from the same CNA who failed to change gloves or wear a gown while performing incontinence care and subsequently touching the resident's face. R3, diagnosed with ESBL resistance and requiring enhanced barrier precautions, also received inadequate care from the CNA, who did not change gloves, perform hand hygiene, or wear a gown while providing peri care. The Director of Nursing confirmed that gloves should be changed and hands cleaned after touching dirty items and before touching clean items, and that gowns and gloves should be worn for residents on enhanced barrier precautions. The facility's policy on enhanced barrier precautions emphasizes the use of targeted gown and glove use during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms.
Deficiencies in Food Storage and Hairnet Use
Penalty
Summary
The facility failed to ensure proper storage and labeling of refrigerated foods and did not enforce the use of hairnets in the kitchen, affecting all residents. During a kitchen tour, a surveyor observed a pan of raw chicken thighs marinating in a metal pan with loose saran wrap, exposing the chicken. The pan was labeled with a prepared date of 8/13/24 and a use-by date of 8/19/24, but the chicken was not frozen by the use-by date. Additionally, a tray of sliced ham was found with loose saran wrap, exposing the meat, which was used for the noon meal. A large pork loin was also found without a proper label, only marked with a '16' in marker, indicating it was placed in storage on 8/16. The facility's policies require refrigerated foods to be labeled with discard or use-by dates and to be tightly wrapped to prevent contamination. Furthermore, a dietary aide was observed with her hair outside of the hairnet while working in the food preparation area. The aide moved throughout the kitchen with her hair exposed until the surveyor pointed it out to the dietary manager. The facility's policy mandates that all food and nutrition services employees wear hair restraints to prevent hair from falling into the food. These deficiencies in food storage and personal hygiene practices were identified during the survey, highlighting lapses in adherence to the facility's established policies.
Failure to Implement Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to implement a treatment for a stage II pressure injury for a resident, identified as R49, for two days. R49 was readmitted to the facility after being hospitalized for a lung abscess and diarrhea. Upon readmission, an admission note documented open areas and redness on the sacrum, but no treatment was applied or notifications made. The sacral wound was later assessed as a stage II pressure injury by the Certified Wound Care Nurse, V5, on 8/12/24, two days after the initial identification. The facility's Wound Policy and Procedure requires that any resident with a wound receives treatment and services consistent with their goals of treatment, including notification of any skin impairment identified on admission. However, the nurse who identified the wound did not call the wound care nurse or the resident's provider for treatment orders, nor did they apply or document any treatment. The first documented wound treatment was not completed until 8/14/24, indicating a lapse in the facility's adherence to its wound care policy.
Failure to Supervise Resident with Swallow Precautions
Penalty
Summary
The facility failed to provide adequate supervision for a resident with swallow precautions, leading to a deficiency in ensuring a safe eating environment. The resident, who had diagnoses including Parkinson's disease, pneumonitis due to inhalation of food and vomit, chronic obstructive pulmonary disease, and dysphagia, was observed eating alone in his room despite having a posted requirement for one-to-one feeding assistance. The resident was intermittently coughing while feeding himself and was using a suction tube independently, indicating a lack of supervision and assistance during meals. Staff interviews revealed that the resident had been evaluated by a speech therapist and required assistance with meals due to poor attention and impulsivity, making it unsafe for him to eat alone. Despite this, the resident was left unattended with his breakfast tray, contrary to the facility's policy and the posted swallow precautions. The Director of Nurses and Corporate Nurse acknowledged that staff should have been present at all times for residents requiring one-to-one feeding assistance to prevent potential choking hazards.
Failure to Monitor Medication Administration
Penalty
Summary
The facility failed to properly monitor residents during medication administration, leading to deficiencies in the care of two residents. Resident 1, who has chronic obstructive pulmonary disease, type 2 diabetes mellitus, congestive heart failure, and chronic lymphocytic leukemia, reported that a night nurse left her morning medications at her bedside without ensuring they were taken. This resulted in medications being dropped and not consumed, as evidenced by a pill found on her bed. The facility's policy requires that medications should not be left at the bedside unless there is a physician's order, and the nurse must observe the resident taking the medication. Similarly, Resident 32 was found with a cup containing at least 12 pills left on her refrigerator, which she preferred to take after eating. There were no care plan interventions or physician orders allowing medications to be left at her bedside. The Director of Nursing confirmed that nurses should monitor residents while they take their medications and that medications should not be left unattended. The facility's procedure mandates that staff remain with the resident to ensure medication is swallowed, which was not followed in these instances.
Failure to Maintain Isolation Precautions
Penalty
Summary
The facility failed to maintain proper isolation precautions for two residents, leading to potential cross-contamination. Resident R61, who was on contact isolation for ESBL in her urine, did not have appropriate signage or personal protective equipment (PPE) available outside her room for six days after the order was given. The resident's room lacked a biohazard bin for used PPE, and there was inconsistency among staff in wearing gowns and gloves when entering the room. The facility's policy required immediate implementation of contact isolation precautions, including signage and PPE availability, which was not followed. Similarly, Resident R49, who was on contact isolation for C-diff, had a sign indicating the need for gowns and gloves upon room entry. However, a Certified Wound Care Nurse entered the room without wearing the required PPE and touched the resident's bedding. The facility's infection control policy mandates the use of gowns and gloves to prevent the spread of infections, especially for residents with multi-drug resistant organisms. The Director of Nursing acknowledged the importance of these precautions, which were not adhered to 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.
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