Integrity Hc Of Anna
Inspection history, citations, penalties and survey trends for this long-term care facility in Anna, Illinois.
- Location
- 315 South Brady Mill Road, Anna, Illinois 62906
- CMS Provider Number
- 146006
- Inspections on file
- 24
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 50
Citation history
Health deficiencies cited at Integrity Hc Of Anna during CMS and state inspections, most recent first.
A resident with multiple cardiac conditions, COPD, and limited mobility, who used a wheelchair for ambulation, fell to the floor of a facility van when the driver braked suddenly to avoid an animal. The resident reported striking the dashboard and having the wheelchair land on top of him, and later imaging confirmed rib and clavicle fractures. The van driver (a CNA) stated that the wheelchair and seat belt had been properly secured using four clamps and a seat belt, while another CNA reported that the resident later said he had not been buckled in properly. Facility documentation initially cited a seat belt malfunction as the root cause, and the facility’s Drive Safe Program assigns responsibility to the driver to ensure all passengers are securely seated and using seat belts.
Multiple residents experienced unclean bathroom conditions when commodes and surrounding areas were left with feces or dried stains, and requests for cleaning were not promptly addressed. One resident and a roommate reported being unable to use their shared commode due to its dirty condition and being told by a staff member that cleaning it was not her job, with housekeeping only cleaning it the next morning. Other residents were observed with feces on toilet risers and dried red/brown substances on commode fixtures and walls. CNAs reported that bathrooms are sometimes "horrible" and that housekeeping does not always clean proactively, while the housekeeping supervisor reported no complaints despite a written environmental services quality control policy.
The facility failed to consistently honor resident diet orders and food preferences, including during use of an emergency menu while the kitchen was under renovation. A resident with multiple comorbidities and a moderate cognitive deficit, ordered an NCS diet and documented to prefer Cheerios, was served Fruit Loops instead of a non‑sugar cereal. A resident with diabetes reported repeated peanut butter and jelly sandwiches over several days due to reliance on a shelf‑stable emergency menu with limited variety. Despite resident council feedback that some did not want corned beef, the facility served corned beef hash, leading several cognitively intact residents to refuse the meal, describe lunch as awful, and substitute other foods or personal supplies. The Dietary Manager and Social Services Director acknowledged awareness of these expressed preferences, and facility policy required assessment and communication of individual food preferences.
Surveyors found that hot foods were not maintained at safe temperatures during a noon meal service. A resident with diabetes, morbid obesity, heart failure, and CKD, who was cognitively intact and on a NAS diet with fluid restriction and protein supplements, reported that her corned beef hash was served cold. Dietary staff, serving from roasting pans due to a kitchen remodel, checked food temperatures with a calibrated thermometer and recorded the corned beef hash at 110°F and green beans at 130°F, both below the FDA Food Code requirement of at least 135°F for hot holding TCS foods. The facility could not provide a policy on food temperatures.
A cognitively intact resident with COPD and morbid obesity, using a bariatric bed, repeatedly lacked properly fitting linens for her specialty mattress. Surveyors observed the bed with only a partially tucked flat sheet or a fitted sheet that had come off a mattress corner, and the resident reported that the facility had very few sheets that actually fit her bed and that incorrect or half sheets would not stay in place. CNAs acknowledged there were not enough bariatric-size sheets and that only certain marked sheets fit, while others did not work well. The Housekeeping/Laundry Supervisor confirmed a limited number of correctly sized sheets, noted that previously purchased sheets were the wrong size, and was unsure how many bariatric beds were in use or whether there were enough appropriate linens. The Administrator could not explain the lack of proper sheets, the resident’s care plan did not address linen or mattress needs, and the facility had no supply policy available.
A resident with multiple chronic conditions and moderate cognitive impairment had physician orders and a care plan for an NCS diet with super cereal at breakfast, fortified foods TID, and health shakes TID. During survey observation, the resident’s breakfast tray did not include the ordered fortified super cereal, despite the meal card specifying one serving. The Dietary Manager confirmed that the super cereal (oatmeal) should have been served, and facility policy requires use of a tray identification system to ensure residents receive therapeutic diets and supplements as ordered.
A resident with Parkinson’s disease, COPD, heart disease, adult failure to thrive, anxiety, and a moderate cognitive deficit had a physician order and care plan for an NCS diet with mechanical soft (dental soft) texture and thin liquids, along with fortified foods and health shakes. Despite a meal card specifying dental soft texture and a facility policy requiring adherence to therapeutic diet orders, the resident was served peanut butter cookies at breakfast that were not pre-softened. The resident reported being told by staff to dunk the cookies in milk and demonstrated difficulty eating them, stating they were not soft enough. The dietitian and dietary manager acknowledged that cookies for residents on mechanical soft diets were supposed to be softened before serving, but this was not done in this case.
A resident with diabetes, a chronic right plantar foot ulcer, and multiple comorbidities required extensive ADL assistance and was care planned as non‑weight‑bearing on the right lower extremity with twice‑daily wound treatments. A wound physician repeatedly documented an electronically signed order for a pressure‑relieving boot, but this order was never entered into the medical record, and no boot order appeared on the care plan, physician orders, or treatment records. Staff, including a CNA, PTA, RN, and the wound nurse, reported never or rarely seeing any boot in use, while a family member stated she had brought a specialized boot from home that was not used. The regional clinical director acknowledged the wound physician’s documentation should have been processed as an order, resulting in the resident not receiving the ordered pressure‑relieving boot to offload pressure from the diabetic foot ulcer.
A resident with severe cognitive impairment, total dependence for ADLs, incontinence, and a documented Stage IV pressure ulcer to the buttocks was care planned and assessed as high risk for skin breakdown, with facility policy requiring special support surfaces such as an air loss mattress. Although the wound log listed an air loss mattress as preventative equipment, surveyors twice observed only a standard mattress in use over an extended period following a room change, and staff could not explain why the air mattress had not been moved. Serial wound measurements by the wound physician and an LPN showed a deep, persistent Stage IV ulcer, and the wound physician, regional clinical director, and medical director all stated that an air loss mattress was expected and that lack of such a surface could contribute to wound deterioration, demonstrating the facility’s failure to implement appropriate pressure ulcer prevention and treatment interventions.
Several residents with significant medical needs were not provided with appropriate incontinence briefs, especially at night, leading to embarrassment and discomfort. Staff and resident interviews confirmed frequent shortages of the correct sizes, and facility documentation showed ongoing grievances about the lack of supplies. The facility did not have a specific policy for incontinence care, and staff were instructed not to use briefs at night unless requested by alert residents, without consulting families of those unable to express preferences.
A resident with severe cognitive and physical impairments, including Alzheimer's disease and contractures, experienced multiple falls resulting in facial lacerations requiring sutures. Despite a care plan outlining specific fall prevention interventions such as reclining the wheelchair and prompt repositioning after meals, staff did not consistently implement these measures. Staff interviews revealed uncertainty and inconsistent application of safety protocols, contributing to repeated falls and injuries.
Multiple residents with complex medical needs experienced delays in care, such as long waits for call light responses and infrequent showers, due to insufficient nursing staff. Staff interviews confirmed frequent short-staffing, especially on day shifts, making it difficult to complete all required care. Facility records showed that staffing levels often fell below what was needed for the resident census, and there was no policy or consistent tracking of staffing changes.
Several residents experienced repeated shortages of bed linens and hygiene supplies, leading staff to use towels, bath blankets, or cut-up materials as substitutes. Large holes in room walls, covered with duct tape, were observed and confirmed by maintenance staff, with some residents reporting the damage existed before their admission. Residents with various medical and cognitive conditions expressed discomfort and dissatisfaction with these conditions, while staff acknowledged ongoing issues with laundry and maintenance.
Several residents who were dependent on staff for bathing did not consistently receive scheduled showers, as confirmed by missing documentation and interviews with residents, family, and CNAs. The lack of a facility policy on bathing and frequent staffing shortages contributed to the failure to provide this essential care.
A resident experienced significant weight loss over nine months due to the facility's failure to implement and document nutritional interventions. Despite being at high risk for malnutrition, the resident's care plan was not effectively followed, and there was a lack of communication and documentation regarding dietary recommendations. The facility did not maintain records of supplement administration, and the resident's weight was not consistently monitored, contributing to ongoing weight loss.
The facility failed to transmit assessments for two residents within the required timeframe. A resident with cognitive communication deficit, dementia, anxiety, and weakness had their MDS completed but not transmitted on time. Another resident with cognitive communication deficit, depression, Parkinson's, and diabetes also had their MDS completed but not transmitted timely. The MDS Coordinator was unaware of the transmission process until consulting a supervisor, leading to late submission.
The facility failed to conduct Level II PASRR evaluations for three residents with mental disorders, including unspecified psychosis and PTSD. The Business Office Manager and Administrator did not refer these residents for evaluations, citing misunderstandings about the diagnoses and the absence of a PASRR policy.
The facility failed to ensure sufficient staff were available to meet resident needs, particularly during the night shift. A resident who had returned from dialysis had to wait a long time to be laid down due to insufficient staffing. Multiple residents and staff members expressed concerns about the staffing levels, particularly during the night shift.
The facility failed to immediately report abuse allegations involving an LPN being verbally and physically abusive to residents. CNAs were unaware of the reporting protocol and the Administrator did not provide the public health contact number.
A resident with multiple health conditions had to wait several hours to be laid down after returning from dialysis due to staffing shortages. The facility had only one nurse and one laundry staff member on duty for several hours, leading to a delay in providing necessary assistance.
The facility failed to identify, assess, and treat pressure ulcers for two residents, leading to the development and worsening of pressure ulcers. One resident developed a stage III pressure ulcer on the left buttock due to inconsistent skin checks and lack of treatment, while another resident developed a stage II pressure ulcer on the left buttock due to inadequate care and documentation.
A facility failed to implement necessary interventions for a resident with self-injurious behaviors and did not obtain required behavioral health services. Despite staff observations and reports, appropriate measures were not taken, leading to the resident developing cellulitis from a self-inflicted wound. The facility did not follow the primary physician's recommendation to use mittens, and instead used ineffective alternatives like socks and non-latex gloves.
The facility failed to complete baseline care plans for four residents within 48 hours of their admission. The care plans were undated, unsigned, and missing critical information such as active diagnoses, initial admission goals, and medication reconciliation. The residents had severe conditions, including sepsis, acute respiratory failure, Alzheimer's disease, and sleep apnea.
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in managing their medical conditions and behavioral issues. Delays in care plan initiation, incomplete documentation, and poor communication contributed to inadequate care.
The facility failed to properly assess and monitor the use of physical restraints for three residents. Socks were used as makeshift restraints for one resident without proper assessment. Two other residents used lap buddies and tray tables without proper assessments or physician's orders, and were observed using these restraints outside of mealtimes, contrary to facility policy.
The facility failed to ensure accurate MDS coding for three residents, leading to deficiencies in their assessments. One resident's cognitive status and medication use were inaccurately documented, another resident's mobility device use was misreported, and a third resident's urinary continence was incorrectly coded. The MDS coordinator admitted to not completing the assessments accurately and timely due to workload and inexperience.
A resident with a history of self-injurious behavior was admitted with multiple skin impairments. The facility failed to maintain consistent skin monitoring records and did not adequately address the resident's self-inflicted scratches. Despite recommendations from the primary physician, the facility did not have mittens available and used soft socks instead, which the resident could remove. The lack of timely and appropriate treatment led to the resident developing cellulitis and other complications, resulting in transfer to a higher level of care hospital.
Resident Injury from Improper Securement During Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was safely secured during transport in the facility van, resulting in the resident falling from his wheelchair when the van made a sudden stop. The resident had a history of myocardial infarction, heart failure, hypertension, atrial fibrillation, COPD, and required oxygen, and his care plan documented limited physical mobility and the need for a wheelchair for ambulation. Despite being cognitively intact per the MDS, he was dependent on staff to properly secure his wheelchair and seat belt during transport. On the day of the incident, the van driver reported that a deer ran in front of the van, requiring abrupt braking, after which the resident was found on the floor of the van. Facility documentation initially recorded that the resident was taken to the hospital and returned with no injuries noted, and the fall report identified a malfunction of the seat belt as the root cause. The Administrator later stated that the resident had been in the wheelchair with a seat belt on, which allegedly came unlatched when the van stopped suddenly, causing the fall. The resident himself reported that he hit the dashboard and that the wheelchair landed on top of him, and he stated he did not remember whether he or the wheelchair had been buckled but believed they must not have been secured for the wheelchair to end up on top of him. Staff accounts regarding proper securement were inconsistent. The van driver (a CNA) stated that there are four clamps to lock the wheelchair in place and a seat belt for the resident, and she asserted that she had buckled both the resident and the chair before starting the trip. However, another CNA stated she knew the resident was not buckled in properly on the day of the incident and reported that the resident told her he was not buckled in. Facility policy in the Drive Safe Program states that the driver is responsible to ensure all passengers are securely seated and using seat belts. Following the incident, subsequent clinical documentation and imaging confirmed that the resident sustained an acute non-displaced right lateral 10th rib fracture and an acute distal clavicle fracture related to the fall in the van.
Failure to Maintain Clean and Sanitary Resident Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain clean, safe, and sanitary resident bathrooms, resulting in unclean commodes and bathroom areas for multiple residents. One resident with heart disease, osteoarthritis, muscle weakness, fatigue, and a moderate cognitive deficit reported that while staff clean earlier in the day, the room does not remain clean later. He and his cognitively intact roommate both stated that the shared bathroom commode was so dirty one evening that it could not be used, and when they requested cleaning, an unidentified staff member told them it was not their job. The commode was not cleaned until the housekeeper addressed it the following morning, and the housekeeper later confirmed there had been feces on the inside of the toilet lid area and that she would not have been comfortable using it in that condition. Another cognitively intact resident with diabetes, morbid obesity, heart failure, and chronic kidney disease was observed to have feces stuck to her toilet riser, which remained present later the same day. A resident with dementia, peripheral vascular disease, muscle weakness, and fatigue was found to have a commode with a dried red/brown substance around the fixtures and splattered down the wall. CNAs interviewed acknowledged that resident bathrooms are sometimes “horrible,” that housekeeping does not always take the initiative to clean bathrooms without being asked, and that toilets are often dirty around the bowl. The housekeeping supervisor stated he had not received complaints about cleaning and indicated he would reeducate staff if concerns were brought to him, despite the facility’s written quality control policy requiring identification of deficiencies and ongoing monitoring of environmental services quality.
Failure to Honor Resident Diet Orders and Food Preferences During Regular and Emergency Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to honor resident food preferences and diet specifications, including during a period when the main kitchen was under renovation and an emergency menu was in use. One resident with Parkinson’s disease, COPD, heart disease, adult failure to thrive, anxiety, and a moderate cognitive deficit had physician orders and a care plan for a no concentrated sweets (NCS) diet with mechanical soft/regular texture, thin liquids, super cereal at breakfast, fortified foods three times daily, and health shakes three times daily. Despite this, the resident was observed at breakfast with a tray containing Fruit Loops, orange juice, milk, a mighty shake, coffee, cookies, pears, and a bowl of milk. The resident’s meal card documented a preference for Cheerios, and the Dietary Manager acknowledged that residents with diabetes should receive non‑sugar cereals such as Cheerios or Rice Krispies and that this resident should have been served the preferred cereal. Another resident with a diagnosis of diabetes reported being served peanut butter and jelly sandwiches for the past few days because the kitchen was down, and he was getting tired of them. Surveyors observed the kitchen under renovation, with appliances, cabinets, flooring, and sinks removed, and staff serving meals from tables in the dining room. The facility was using an emergency menu consisting largely of shelf‑stable foods. The written emergency menu for multiple days specified repetitive items such as juice, dry cereal, canned fruit, peanut butter cookies, pudding, reconstituted milk, and peanut butter and jelly sandwiches, indicating limited variety and repeated use of the same items over several days. Resident council documentation showed that residents had been informed of the upcoming kitchen renovation and menu changes, and that some residents expressed they did not want corned beef. The emergency menu nonetheless included corned beef on specified days, and on one such day kitchen staff served corned beef hash, green beans, cookies, and beverages. One resident refused the corned beef hash, telling staff to take it away and was then offered a corn dog or sandwich. Another resident, alert to person, place, and time, stated lunch was awful and reported eating a ham sandwich instead of the corned beef hash. A third resident, also alert, was observed making a deli sandwich from personal food and described lunch as awful and terrible. The Social Services Director confirmed that several residents at resident council had said they did not want corned beef, and the Dietary Manager acknowledged awareness that a few residents did not want corned beef hash but stated they did not ask all residents about their preference, despite a facility policy stating that individual food preferences would be assessed on admission and communicated to the interdisciplinary team.
Failure to Maintain Safe Hot Holding Temperatures for Served Food
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure hot foods were served at safe temperatures in accordance with professional standards and the FDA Food Code. The daily census documented 63 residents in the facility. One cognitively intact resident with diabetes, morbid obesity, heart failure, and chronic kidney disease, who was on a NAS diet with a 2-liter fluid restriction and protein supplements, reported that her corned beef hash at the noon meal was served cold. Her care plan required that her nutritional diet be prepared and served as ordered. When surveyors entered the dining room shortly after this complaint, dietary staff were serving the noon meal from roasting pans because the kitchen was being remodeled. At the time of observation, the cook checked the temperatures of the foods in the roasting pans using a facility thermometer she stated was calibrated and accurate. The thermometer showed the corned beef hash at 110.0°F and the green beans at 130.0°F. The dietary manager stated that the corned beef hash should be 155–165°F and the green beans 145°F. Later, the cook rechecked the temperatures and found the green beans at 168.0°F and the corned beef hash at 129.0°F. The facility was unable to provide a policy related to food temperatures. According to the 2022 FDA Food Code, hot holding temperatures for TCS food must be maintained at 135°F or greater, and the measured temperatures of the corned beef hash and green beans were below this standard at the time of the initial check.
Failure to Provide Properly Fitting Linens for Bariatric Mattress
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences by not maintaining linens that properly fit a bariatric specialty mattress. The resident, who was admitted with COPD and morbid obesity and was cognitively intact with a BIMS score of 15, reported that the facility did not have sheets that fit her bariatric bed. Surveyor observations on multiple occasions showed the resident’s bed either with only a partially tucked flat sheet and no fitted sheet, or with a fitted sheet that had come off the upper corner of the mattress. The resident stated that the facility had only two sets of sheets that fit her mattress, that staff could not always find them, and that when incorrect or half sheets were used, they did not stay on the mattress. Staff interviews confirmed an ongoing shortage of properly sized bariatric sheets. One CNA stated there were not enough sheets for bariatric beds, and another CNA acknowledged that they did not really have enough bariatric-size sheets and that the resident specifically requested sheets with orange stitching because those were the only ones that fit, while the green stretchy sheets did not really work. The Housekeeping/Laundry Supervisor reported finding only three sheets that fit the resident’s bed, stated that previously purchased sheets were the wrong size, and indicated he did not know how many bariatric beds were in the facility and would need to count sheets to determine if there were enough. The Administrator could not explain why the resident did not have properly fitting sheets, and the facility was unable to provide a policy related to supplies. The resident’s care plan did not address linens or mattress needs in any focus area or intervention.
Failure to Provide Ordered Breakfast Nutritional Supplement
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered nutritional supplements as prescribed by the physician for one resident. The resident was admitted with multiple diagnoses including Parkinson’s disease, spondylolysis, repeated falls, COPD, heart disease, adult failure to thrive, anxiety, and a cognitive communication deficit, and had a BIMS score of 09 indicating a moderate cognitive deficit. The physician’s order summary directed that the resident receive an NCS diet with mechanical soft texture, thin liquids, super cereal at breakfast, health shakes TID with meals, and fortified foods TID. The resident’s care plan also identified a nutrition focus area, noting potential nutritional problems and specifying interventions including an NCS diet, super cereal at breakfast, fortified foods TID, and health shakes TID, with an intervention to provide and serve supplements and diet as ordered. On the morning of the survey observation, the resident’s breakfast tray contained fruit loops, orange juice, milk, a mighty shake, coffee, cookies, pears, and a bowl of milk, with no super cereal present. The resident’s meal card for breakfast documented “Fortified Super Cereal – 1 serving” under breakfast supplements, but this item was not on the tray. When interviewed, the Dietary Manager identified the super cereal as oatmeal and confirmed that the resident should have been served oatmeal as a super cereal with breakfast. The facility’s Therapeutic Diets Policy states that therapeutic diets are prescribed by the attending physician and that the Food Services Manager will establish and use a tray identification system to ensure each resident receives the diet as ordered. Despite this policy, the ordered super cereal supplement was not provided with the resident’s breakfast.
Failure to Provide Physician-Ordered Mechanical Soft Diet Consistency
Penalty
Summary
The deficiency involves the facility’s failure to provide food in the physician-ordered mechanical soft (dental soft) consistency for a resident with multiple medical conditions and a moderate cognitive deficit. The resident was admitted with diagnoses including Parkinson’s disease, spondylolysis, repeated falls, COPD, heart disease, adult failure to thrive, anxiety, and a cognitive communication deficit. The resident’s MDS documented a Brief Interview for Mental Status score of 09, indicating a moderate cognitive deficit. The physician’s order summary specified an NCS (no concentrated sweets) diet with mechanical soft texture and thin liquids, along with super cereal at breakfast, health shakes three times daily with meals, and fortified foods three times daily. The current care plan documented a nutrition focus area noting potential nutritional problems and referenced both a mechanical soft texture diet and, in a later intervention entry, a regular texture diet, while also instructing staff to provide and serve the diet and supplements as ordered. On the morning of the survey observation, the resident was observed in his room with a breakfast tray that included fruit loops, orange juice, milk, a mighty shake, coffee, cookies, pears, and a bowl of milk. The resident’s meal card identified the required texture as dental soft (mechanical soft). The resident reported that staff told him to dunk his cookie in the bowl of milk, and he demonstrated dunking a cookie and attempting to bite it, stating that he only had one set of teeth and that the cookies were not soft enough for him to eat. The facility dietitian stated that peanut butter cookies for any resident on a mechanical soft diet should have been softened prior to being served. The dietary manager stated that the peanut butter cookies were supposed to be softened in milk before serving but that a cognitively intact resident could do this themselves. The facility’s Therapeutic Diets Policy required that mechanically altered diets be treated as therapeutic diets and that a tray identification system be used to ensure each resident receives the diet as ordered, but the resident nonetheless received cookies that were not pre-softened to the ordered mechanical soft consistency.
Failure to Implement Ordered Pressure-Relieving Boot for Diabetic Foot Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered interventions to promote safety and healing of a diabetic foot ulcer for one resident. The resident had multiple diagnoses including COPD, acute respiratory failure, type 2 diabetes mellitus, a non‑pressure chronic ulcer of the right plantar foot with fat layer exposed, lymphedema, CHF, and hypothyroidism, and required extensive assistance with ADLs and mobility. The MDS documented a diabetic foot ulcer, and the care plan identified a right plantar foot wound related to diabetes with goals for weekly improvement and interventions including twice‑daily wound treatments, non‑weight‑bearing (NWB) status to the right lower extremity, staff assistance with ADLs, and skin inspections. The facility’s wound log documented a sizable right plantar diabetic ulcer. Wound physician notes on multiple dates documented an order for a pressure‑relieving boot for the resident’s feet, and the regional clinical director acknowledged that these electronically signed notes should have been processed as physician orders. However, review of the care plan, physician orders, and treatment administration records showed no documented order for a pressure‑relieving boot. The wound physician stated he placed the order for a pressure‑relieving boot in his notes as part of his usual practice for foot wounds and that the resident needed to keep pressure off the right foot. The assistant DON/wound nurse, who stated she makes rounds with the wound physician and enters orders based on those rounds, reported she had never seen the resident with a boot and was not aware of the pressure‑relieving boot order in the wound physician’s notes. Staff and family interviews further demonstrated that the ordered pressure‑relieving device was not implemented. A CNA reported the resident was often noncompliant with lying down and elevating his feet, that his foot was always wrapped, and that she had only seen heel protectors a couple of times when he was in bed, but never any kind of boot while he was up in his wheelchair. A family member stated the resident had a long‑standing diabetic foot wound, was NWB on the right foot, and that she brought a specialized boot from home at admission but never saw the resident wearing that or any boot during frequent visits. A PTA recalled the family‑provided pressure‑relieving boot did not fit and was unsure if anyone attempted to obtain a better‑fitting boot. An RN stated she had never seen the resident with a boot and was unaware of any boot order. The facility’s preventative skin care policy allowed for pressure‑relieving devices and required proper fitting of devices, but no pressure‑relieving boot was obtained or consistently used for this resident despite the wound physician’s documented order.
Failure to Maintain Required Pressure-Relieving Mattress for Resident With Stage IV Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement required pressure ulcer prevention and treatment interventions for a resident with a known Stage IV pressure ulcer to the right medial buttocks. The resident had multiple diagnoses including sequelae of cerebral infarction, vascular dementia, muscle weakness, and a documented Stage IV pressure ulcer, and was assessed as severely cognitively impaired, totally dependent for all ADLs, and always incontinent of bowel and bladder. The MDS and care plan identified the resident as at high risk for skin breakdown, with a Braden score of 12, and the care plan called for monitoring factors that could lead to skin alterations and following facility policies and protocols for prevention and treatment of skin breakdown, including evaluation and treatment by a wound physician. The facility’s written Preventative Skin Care policy required special mattresses and/or chair cushions for any resident identified as high risk for skin breakdown. The wound log documented that the resident’s right medial buttock wound, categorized as end-stage skin failure, had an air loss mattress listed as preventative equipment. However, surveyor observations on two separate dates showed that the resident’s bed had a standard mattress in place while the resident had a Stage IV buttock wound and was at high risk for further breakdown. Staff interviews revealed uncertainty about whether the resident had been on an air loss mattress prior to a room change, and the business office records showed the last room move occurred several months earlier. The DON confirmed the resident had been on an air loss mattress before the room change and acknowledged not knowing why the air loss mattress was not moved with the resident, despite believing the resident still needed it. Wound measurements documented by the wound physician over multiple weeks showed ongoing depth and changes in the wound dimensions, and the wound physician stated that he initially categorized the wound as end-of-life and did not change that category, although he acknowledged it should be classified as a Stage IV pressure ulcer. The wound physician, the regional clinical director, and the medical director each stated that a resident with a Stage IV buttock wound should be on an air loss mattress and that lack of such a mattress could contribute to deterioration or impaired healing of the wound. During a wound treatment observation, an LPN measured the wound at a greater depth than previously recorded. The facility’s failure to ensure that the resident remained on an air loss mattress in accordance with the care plan, policy, and clinical expectations led to the worsening of the resident’s Stage IV pressure ulcer to the buttocks.
Failure to Provide Incontinence Products Compromises Resident Dignity
Penalty
Summary
The facility failed to provide appropriate incontinence products to four residents, resulting in a lack of dignity and embarrassment for those affected. Multiple residents with significant medical conditions, including pressure ulcers, diabetes, hemiplegia, and chronic kidney disease, reported that they were not provided with incontinence briefs, particularly at nighttime. Some residents stated that they were forced to wet themselves on bed pads or in their clothing, leading to feelings of embarrassment and discomfort. Residents also reported that staff refused their requests for incontinence briefs at night, and that the facility frequently ran out of the correct sizes, forcing them to use ill-fitting products or go without. Staff interviews confirmed that the facility had a recurring issue with running out of incontinence briefs, especially in larger sizes. Certified Nurse Assistants (CNAs) and supervisors stated that they had to inform the administrator when supplies were low, and sometimes had to use alternative sources or go without briefs for residents. Observations of storage areas revealed limited stock, with some sizes missing entirely. Staff also reported that the administrator instructed them not to use incontinence briefs at night unless specifically requested by alert residents, and that families of non-alert residents were not consulted about their preferences. The administrator cited concerns about skin breakdown as a reason for not using briefs at night, but acknowledged there was no physician order for this practice. Facility documentation, including grievance forms and resident council memoranda, showed ongoing concerns from residents about the lack of appropriate incontinence supplies, particularly larger sizes. The facility's own admission packet and dignity policy stated that incontinence care and supplies were to be provided to all residents as part of routine care. Despite these policies, the facility did not have a specific policy on incontinence care or supplies, and failed to address repeated grievances about the issue. This resulted in residents experiencing embarrassment, discomfort, and a lack of dignity due to inadequate incontinence care.
Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and consistently maintain interventions to prevent future falls for a resident with significant cognitive and physical impairments. The resident had diagnoses including Alzheimer's disease, legal blindness, abnormalities of gait and mobility, and lack of coordination, and was assessed as being at high risk for falls. The care plan included interventions such as promptly laying the resident down after meals, reclining the wheelchair for safety, and ensuring the wheelchair was locked and positioned under the table. Despite these documented interventions, the resident experienced multiple falls, including incidents where the wheelchair was not reclined as required and where staff were unsure about the use of foot pedals. On several occasions, the resident was found on the floor after falling from the wheelchair, sustaining injuries including lacerations to the face that required sutures. Staff interviews revealed inconsistent application of safety interventions, such as not reclining the wheelchair when transporting the resident and uncertainty about the use of foot pedals. The resident's physical condition, including contractures and a tendency to lean forward, further increased the risk of falls, yet interventions were not reliably implemented to address these risks. Facility records and staff statements indicated that the resident was unable to self-propel and was not educatable due to severe cognitive impairment. Despite being identified as high risk and having a care plan in place, the facility did not ensure that interventions were consistently followed, resulting in repeated falls and injuries. The facility's fall management policy required ongoing and consistent implementation of safety precautions for at-risk residents, which was not achieved in this case.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple reports from residents, family members, and staff. Several residents with significant medical conditions, including diabetes, COPD, hemiplegia, and chronic kidney disease, reported delays in response to call lights, infrequent showers, and unmet personal care needs. One resident stated it sometimes took staff 30 minutes or more to answer his call light and that he only received a shower once a week instead of the expected two times. Another resident reported waiting up to an hour for assistance and not consistently receiving scheduled showers. A family member also expressed concerns about a resident not receiving showers as required. Staff interviews corroborated these concerns, with several CNAs stating that the facility was often short-staffed, particularly on the day shift. Staff described difficulties in completing all required resident care, including showers and personal hygiene, due to insufficient staffing. Some staff reported having to cover multiple halls or pass on care tasks to the next shift, and noted that staffing levels had recently decreased from three to two staff members per hall. The Assistant Director of Nursing acknowledged that on certain days, the facility did not meet the calculated required nurse aide hours based on the facility assessment tool. Review of facility schedules and census reports confirmed that on several days, the number of CNAs scheduled was below the level needed to provide adequate care for the 63 residents. The Administrator confirmed that there was no facility policy on staffing, and the Assistant Director of Nursing stated that daily assignment sheets were not updated to reflect when staff left early or did not show up. These actions and inactions resulted in insufficient staffing to meet residents' needs for timely assistance and personal care.
Failure to Maintain Clean, Comfortable, and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for five residents reviewed for environmental conditions. Multiple residents reported frequent issues with the availability of bed linens and bed pads, sometimes waiting until late in the day or being unable to rest due to the lack of clean linens. Staff interviews confirmed that shortages of linens, bed pads, and wash cloths were common, especially when the facility's dryer was not functioning, leading to the use of towels, bath blankets, or even cut-up towels as substitutes for proper bedding and hygiene supplies. Physical observations revealed significant environmental deficiencies in resident rooms, including large holes in the walls above air conditioning units that were covered with duct tape. These holes were present in at least two rooms, and residents stated that the damage existed prior to their occupancy. The Maintenance Director measured the holes, confirming their size, and acknowledged a backlog of maintenance requests. Staff also reported that termites were present in certain areas, and that the wall damage was extensive enough for a hand to go through in one instance. Residents affected by these deficiencies had various medical conditions, including hemiplegia, cognitive impairment, depression, and incontinence. Some residents with intact cognition expressed discomfort and dissatisfaction with the lack of proper linens and the use of makeshift substitutes, particularly when dealing with incontinence. Facility policies reviewed emphasized the responsibility of department directors to report maintenance needs and the importance of resident dignity, but these were not consistently upheld in practice.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that residents who required assistance with activities of daily living, specifically bathing or showers, consistently received this care as scheduled. Four residents with varying degrees of cognitive and physical impairment were identified as not receiving showers according to the facility's established schedule. Documentation and interviews revealed that showers were missed on multiple occasions for these residents, with gaps in the shower review sheets indicating that the care was not provided as required. Residents affected included individuals with significant medical histories such as diabetes, chronic obstructive pulmonary disease, pressure ulcers, hemiplegia, and severe cognitive impairment. These residents were documented as dependent or requiring substantial assistance for bathing. Interviews with the residents, a family member, and multiple CNAs confirmed that showers were often missed, and the lack of consistent care was attributed to frequent staffing shortages. Residents and family members expressed concerns about the infrequency of showers, and staff reported difficulty in completing all required showers due to insufficient staffing levels. The facility did not have a policy on bathing or showers, as confirmed by the administrator. The assistant director of nursing was unable to provide additional documentation to show that showers were completed on the missing dates, indicating that the care was likely not provided. The lack of documentation and staff statements further supported the finding that the facility failed to provide necessary assistance with bathing for residents who were unable to perform this activity independently.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately identify, evaluate, and intervene in the case of a resident, R42, who experienced significant weight loss over a period of nine months. R42 was admitted with diagnoses including mild protein-calorie malnutrition and moderate cognitive impairment. Despite these conditions, the facility did not provide any nutritional approaches as noted in the Minimum Data Set (MDS) and failed to document any nutritional assessments. The resident's care plan, initiated in June 2023, included interventions such as providing a diet as ordered and monitoring for signs of malnutrition, but these were not effectively implemented. Throughout the period from January to September 2024, R42's weight decreased significantly from 175 lbs to 131 lbs, indicating a substantial weight loss that was not adequately addressed by the facility. The Registered Dietitian (RD) noted the resident's high risk due to weight loss and made several dietary recommendations, including the addition of health shakes and consideration of an appetite stimulant. However, there was a lack of documentation and follow-up on whether these interventions were implemented. The RD did not see the resident in April, May, and August 2024 due to a lack of weight records, and there was no documentation of progress notes by the RD for these months. The facility's failure to monitor and document the resident's weight and nutritional intake, as well as the lack of communication and follow-up on dietary recommendations, contributed to the ongoing weight loss. The facility did not maintain records of when supplements were given, and there was no evidence that the resident received the recommended health shakes or appetite stimulant until late September 2024. Additionally, the facility did not document the resident's food preferences, which could have informed more effective nutritional interventions. The interdisciplinary team meetings did not adequately address the resident's weight loss, and the facility's procedures for weight assessment and intervention were not followed, leading to a deficiency in the resident's care.
Failure to Transmit Resident Assessments Timely
Penalty
Summary
The facility failed to ensure timely transmission of assessments for two residents, resulting in a deficiency. Resident 12, diagnosed with cognitive communication deficit, dementia, anxiety, and weakness, had a quarterly Minimum Data Set (MDS) completed on 8/22/24. Resident 31, diagnosed with cognitive communication deficit, depression, Parkinson's, and diabetes, had a quarterly MDS completed on 8/21/24. However, both assessments were not transmitted to the State within the required 7-day period. The MDS Coordinator, V3, admitted to not knowing how to transmit the assessments until consulting with a supervisor on 9/25/24. Consequently, both residents' assessments were transmitted and accepted on 9/25/24, well past the deadline.
Failure to Conduct Level II PASRR Evaluations for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for three residents with diagnosed mental disorders. Resident R37 was admitted with a diagnosis of unspecified psychosis, but the Business Office Manager, V4, did not refer R37 for a Level II PASRR evaluation, believing that the dementia diagnosis overruled the unspecified psychosis diagnosis. Similarly, Resident R46, who was admitted with a diagnosis of post-traumatic stress disorder (PTSD), was not referred for a Level II PASRR evaluation. V4 stated that she was unaware that PTSD would be considered a serious mental illness. Resident R47 was admitted with diagnoses including unspecified psychosis, cognitive communication deficit, and dementia, but a Level II PASRR was not completed. The Administrator, V1, confirmed that the evaluation was not conducted due to the presence of a dementia diagnosis. Additionally, V1 stated that the facility does not have a PASRR policy and instead follows the regulation, which contributed to the oversight in conducting the necessary evaluations for these residents.
Insufficient Staffing During Night Shift
Penalty
Summary
The facility failed to ensure sufficient staff were available to meet resident needs, particularly during the night shift. On one occasion, a resident who had returned from dialysis had to wait a long time to be laid down due to insufficient staffing. The resident, who has moderately impaired cognition and is dependent on staff for transfers and other activities of daily living, was not put to bed until after 10:00 PM, despite being dropped off at the facility at 6:23 PM. This delay was due to the absence of sufficient staff, as one certified nurse assistant (CNA) called off and another refused to clock in without additional support. Interviews with various staff members, including the Director of Nursing (DON) and the Care Plan Coordinator (CPC), confirmed that on the night in question, the facility had only one nurse and one laundry staff member until additional staff arrived later in the evening. The CPC arrived at around 9:00 PM, and another CNA came in at around 10:00 PM. The DON acknowledged that this was an unusual situation and that the facility typically has more staff on the night shift, but also noted that the staff who do work often do not provide quality care. Multiple residents and staff members expressed concerns about the staffing levels, particularly during the night shift. Residents reported that they often felt there were not enough staff to meet their needs, and staff members confirmed that the night shift is frequently understaffed. The facility's Resident Listing Report documented that there were 56 residents living in the facility at the time of the incident.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to immediately report allegations of abuse to the Administrator for four residents. Certified Nurse Assistants (CNAs) reported that a Licensed Practical Nurse (LPN) was verbally abusive to residents, including yelling and making derogatory comments. Additionally, there were reports of physical abuse, such as pushing and slapping residents. The CNAs were unaware of the abuse reporting protocol and did not know who the abuse coordinator was. They also mentioned that the Administrator did not provide them with the contact number for public health to report the abuse. The residents involved had severe cognitive impairments and required varying levels of assistance with daily activities. The Administrator was unaware of the abuse allegations until informed by the surveyor. The facility's Abuse Prevention Training Program requires immediate reporting of any suspected abuse to the Administrator or a designated individual in their absence. However, this protocol was not followed, leading to a delay in addressing the abuse allegations.
Failure to Provide Timely Assistance with Transfers
Penalty
Summary
The facility failed to ensure timely assistance for a resident who required help with transfers into bed. The resident, who has diagnoses including Type 2 diabetes mellitus, hypertension, chronic kidney disease stage 4, and arthritis, reported having to wait a long time to be laid down after returning from dialysis. The resident, who has moderately impaired cognition and is dependent on staff for transfers, stated that the delay occurred because there were not enough staff available to assist him. On the specific date in question, the resident was dropped off at the facility at 6:23 PM but was not put to bed until after 10:00 PM due to staffing shortages. The facility's staffing issues were confirmed through interviews with various staff members. On the night in question, the facility had only one nurse and one laundry staff member on duty from 7:00 PM until 9:00 PM, when additional staff arrived. One certified nurse assistant (CNA) called off, and another CNA refused to clock in because she did not want to work alone. The Care Plan Coordinator Nurse arrived at 9:00 PM, and another CNA came in at 10:00 PM. The Director of Nursing and the Administrator were aware of the staffing shortage and confirmed that the resident was not put to bed until after 10:00 PM due to the lack of available staff. The facility typically has 1-2 nurses and 2-6 CNAs scheduled for the night shift, but on this occasion, they were significantly understaffed. The Director of Nursing acknowledged that this was an unusual situation and that they usually have enough staff on the night shift. However, the staff that were present did not provide the necessary quality of care, leading to the delay in assisting the resident with his transfer into bed. The facility does not have a specific policy for activities of daily living, relying instead on standards of practice.
Failure to Identify and Treat Pressure Ulcers
Penalty
Summary
The facility failed to identify, assess, and implement treatment and interventions for pressure ulcers for two residents. One resident (R1) was admitted with a small scabbed area on her left buttock, which was not measured or treated upon admission. Despite being at high risk for skin breakdown, weekly skin checks were not consistently completed, and the resident developed a stage III pressure ulcer on her left buttock. The facility also failed to document and follow up on the resident's left heel wound treatment as ordered, leading to further complications and a referral to a wound clinic only after significant deterioration. Another resident (R2) was admitted with multiple diagnoses and required substantial assistance with daily activities. Despite being at low risk for skin breakdown according to the Braden assessment, the resident developed a stage II pressure ulcer on the left buttock. The resident reported not being turned enough and experienced pain from prolonged sitting without a pressure-relieving cushion. The facility's documentation and care plan did not adequately address the resident's skin integrity issues, and the resident's complaints of pain and discomfort were not promptly addressed. The facility's policies on decubitus/pressure area care and preventative skin care were not followed, leading to inadequate assessment, documentation, and treatment of pressure ulcers. The failure to adhere to these policies resulted in the development and worsening of pressure ulcers in both residents, highlighting significant lapses in care and oversight by the facility's staff and administration.
Failure to Implement Interventions for Self-Injurious Behaviors
Penalty
Summary
The facility failed to implement necessary interventions for a resident with self-injurious behaviors and did not obtain the required behavioral health services. The resident, who had a history of Bipolar Disorder and Intellectual Disabilities, was admitted to the facility without proper documentation of her self-injurious behaviors. Despite multiple staff members observing the resident's repetitive scratching and reporting it to the nursing staff, appropriate measures were not taken to address the behavior effectively. The resident's care plan did not document her self-injurious behaviors, and the facility did not have mittens available, which were previously used to prevent the resident from scratching herself. The resident's primary physician, who had been involved in her care for years, confirmed her history of self-injurious behavior and recommended the use of mittens. However, the facility did not follow through with this recommendation, and instead, staff used socks and non-latex gloves, which were ineffective in preventing the resident from scratching herself. The facility's Director of Nursing and other staff members were unaware of the resident's chronic self-injurious behaviors and did not take appropriate steps to obtain a physician's order for mittens or other suitable interventions. As a result of the facility's failure to implement proper interventions and obtain necessary behavioral health services, the resident developed cellulitis from a self-inflicted wound on her chest. The facility's policies on behavioral assessment, intervention, and monitoring were not followed, leading to inadequate care and oversight of the resident's condition. The lack of communication and proper documentation contributed to the resident's deteriorating health and eventual hospitalization for cellulitis and other complications.
Failure to Complete Baseline Care Plans for Residents
Penalty
Summary
The facility failed to complete baseline care plans for four residents (R1, R2, R4, R6) within 48 hours of their admission. For R1, the baseline care plan was undated and unsigned, with several critical areas left blank, including the name of the resident's representative, advanced directives, active diagnoses, initial admission goals, and medication reconciliation. R1 was admitted with serious conditions such as sepsis, urinary tract infection, and bipolar disorder, and was discharged after being sent to a local hospital emergency room. R2's baseline care plan was also undated and unsigned, with missing information such as the name of the resident's representative, active diagnoses, initial admission goals, and medication reconciliation. R2 was admitted with multiple severe conditions, including acute respiratory failure, cardiac arrest, and atrial fibrillation. The care plan failed to document essential details like black box medications and the resident's diabetic status. Similarly, R4 and R6 had incomplete baseline care plans that were undated and unsigned. R4's care plan lacked information on advanced directives, active diagnoses, initial admission goals, and medication reconciliation, despite the resident having conditions like Alzheimer's disease and urinary tract infection. R6's care plan was missing details on active diagnoses, initial admission goals, and medication reconciliation, even though the resident had conditions such as rhabdomyolysis and sleep apnea. The facility's administrator confirmed that they follow RAI guidelines but do not have specific policies for care plans, and the Regional Director of Clinical Reimbursement acknowledged issues with timely completion of care plans.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in their care. For instance, a resident with a history of self-injurious behavior and multiple medical conditions did not have a comprehensive care plan initiated until nearly a month after admission. This delay resulted in inadequate management of her skin issues and behavioral problems, as staff were not fully informed or prepared to address her needs. Communication lapses were evident, as the resident's physician was not informed about the lack of mittens to prevent scratching, and the guardian was not invited to care plan meetings. Another resident, at risk for pressure ulcers, had no interventions listed in her care plan related to skin integrity, despite having pressure-reducing devices in place. This oversight indicates a failure to document and implement necessary preventive measures. Similarly, a male resident with severe cognitive impairment and an indwelling catheter had incomplete care plans with no interventions for his limited mobility, catheter care, or psychotropic medication use. A fourth resident with multiple diagnoses, including sleep apnea and shortness of breath, had no care plan addressing these conditions or the use of oxygen. The facility's Regional Director of Clinical Reimbursement acknowledged issues with timely completion of care plans and noted that the staff responsible for care plans was overburdened and often worked on the floor. The facility's policy on behavioral assessment and care planning was not adequately followed, contributing to these deficiencies.
Improper Use of Physical Restraints
Penalty
Summary
The facility failed to properly assess and monitor the use of physical restraints for three residents. For Resident 1, the facility did not conduct a restraint assessment before placing socks over her hands to prevent self-scratching. Multiple staff members confirmed that socks were used as a makeshift restraint without proper assessment or documentation. The primary physician was not informed that mittens were unavailable, and the Director of Nursing admitted that no assessment was conducted for the use of socks as restraints. Resident 4 was using a lap buddy and a tray table on a geri-chair without proper assessment and consent. The lap buddy was used to aid in positioning due to the resident's history of falls and cognitive impairment. However, the assessment and consent for the lap buddy were obtained after its use had already begun. Similarly, the tray table was used during mealtimes without a physician's order, and the resident was observed using it outside of mealtimes, contrary to the facility's policy. Resident 5 was also using a tray table on a geri-chair during mealtimes without a proper physician's order. The tray table was intended to increase independence with consumption and serve as a boundary identifier. However, the resident was observed using the tray table outside of mealtimes, and the facility's Director of Nursing confirmed that it should have been removed after meals. The facility's policies on abuse prevention and behavioral assessment were not followed, leading to the improper use of physical restraints for these residents.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) coding for three residents, leading to deficiencies in their assessments. For Resident 1, the MDS documented a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitive intactness, which was contradicted by staff interviews and observations. Additionally, the MDS inaccurately reported that Resident 1 did not receive any high-risk medications, despite being prescribed Clonazepam and Eliquis. The resident's guardian was also not involved in the care plan development, contrary to what was documented in the MDS. Resident 2's MDS inaccurately documented that no mobility devices were used in the past seven days and that the resident was dependent on admission for various mobility activities. However, observations and the resident's own statements confirmed that she had been using a wheelchair before admission and continued to do so. The baseline care plan also documented the use of a wheelchair, further contradicting the MDS. For Resident 4, the MDS inaccurately coded urinary continence, failing to account for the resident's use of an indwelling catheter. Observations confirmed the presence of a urinary drainage bag attached to the resident's chair. The MDS coordinator admitted to not completing the assessments accurately and timely due to an extensive workload and being new to the role. These inaccuracies in MDS coding led to deficiencies in the residents' assessments and care plans.
Failure to Assess and Treat Self-Inflicted Injury
Penalty
Summary
The facility failed to assess and seek timely treatment for a self-inflicted injury for a resident (R1) who was admitted with a history of self-injurious behavior, including scratching, picking, and occasionally biting. Upon admission, R1 had multiple skin impairments, including a circumferential sore on the left forearm and a stage III pressure ulcer on the left heel. Despite these conditions, the facility did not maintain consistent weekly skin monitoring records, missing documentation for the week of 2/28/2024. Additionally, the facility did not adequately address R1's self-inflicted scratches, which were reported by multiple CNAs but not effectively managed by the nursing staff or the primary physician (V13). The facility's failure to provide timely and appropriate treatment for R1's self-inflicted injuries led to the development of cellulitis and other complications, ultimately resulting in R1's transfer to a higher level of care hospital. R1's care plan included interventions for skin care, but these were not consistently implemented. For instance, the use of mittens to prevent scratching was recommended by the primary physician (V13), but the facility did not have mittens available and instead used soft socks, which R1 was able to remove. The facility's LPN (V12) reported the issue to the primary physician, who did not follow up after the initial phone call. The facility's standing orders for abrasions were not effectively utilized, and there was a lack of documentation for treatment orders prior to 3/19/2024. This lack of timely and appropriate intervention contributed to the worsening of R1's condition. The facility's policies for decubitus care and change in a resident's condition or status were not followed. The policies required notifying the physician for treatment orders upon identification of skin breakdown and documenting the type, frequency, and site of treatment. However, the facility failed to adhere to these procedures, resulting in inadequate care for R1's self-inflicted injuries. The facility's inaction and lack of timely treatment led to R1 developing cellulitis and other complications, necessitating transfer to a higher level of care hospital.
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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