Integrity Hc Of Herrin
Inspection history, citations, penalties and survey trends for this long-term care facility in Herrin, Illinois.
- Location
- 1900 North Park Avenue, Herrin, Illinois 62948
- CMS Provider Number
- 146092
- Inspections on file
- 29
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Integrity Hc Of Herrin during CMS and state inspections, most recent first.
A resident dependent on staff for toileting hygiene and with significant cognitive and physical impairments was left in visibly wet pants for several hours, despite being observed by multiple staff members. Staff did not consistently attempt alternative approaches when the resident declined care, and there was no documented policy for incontinence checks. The resident was eventually assisted and found to have redness on the buttocks and groin, indicating prolonged exposure to moisture.
Multiple residents with complex medical and mobility needs did not receive scheduled showers or timely incontinence care due to insufficient staffing, as confirmed by resident and staff interviews, facility records, and direct observation. Staff shortages led to missed or delayed care, with some residents experiencing long waits for assistance and inadequate hygiene.
Several residents with significant care needs experienced delays in call light response and assistance with toileting and bathing due to insufficient CNA staffing. Both residents and staff reported that low staffing levels led to unmet care needs, missed showers, and prolonged wait times for incontinence care.
Multiple residents with significant care needs did not receive timely assistance with ADLs, including bathing and incontinence care, due to insufficient CNA staffing. Residents and staff reported frequent delays, missed scheduled showers, and long wait times for call light responses. Staff interviews confirmed that short staffing made it difficult to meet residents' needs, and documentation of care was inconsistent.
The facility did not maintain an effective bed bug control program, as evidenced by a resident discovering bed bugs, lack of staff education on bed bug management, and absence of systematic monitoring or inspection of rooms after the initial report. Staff were not consistently informed about pest control procedures, and cleaning practices sometimes compromised treatment effectiveness. The facility's policy requiring staff training and regular inspections was not followed, putting all residents at risk.
A resident with severe cognitive impairments was involuntarily discharged to a facility over two hours away without proper notice to her family. The LTC facility failed to provide the opportunity for appeal, did not notify the ombudsman, and lacked necessary documentation, resulting in psychosocial harm to the resident.
A facility failed to implement transmission-based precautions and proper hand hygiene, leading to infection control deficiencies. A resident with COVID-19 was not encouraged to wear a mask or stay in her room, despite being on isolation precautions. Additionally, a CNA did not perform hand hygiene between glove changes during catheter care for another resident, contrary to facility policy.
The facility failed to provide a method for residents to call for assistance while in the shower stalls on both the A and B halls. Observations revealed that neither stall contained a call light or any accessible method for residents to summon help. The administrator confirmed the absence of a call system and the lack of a policy regarding call light presence, potentially affecting all 32 residents.
A dietary staff member removed plates from residents who were still eating, disrupting their dining experience. The staff member was unaware of any policy against this practice, and the facility lacked a policy on dining cleaning procedures.
The facility failed to maintain a clean and sanitary bathroom environment for residents on the B and C Halls. Observations showed a cracked and peeling shower stall floor with mold, gaps near the toilet, and black accumulation with water pooling. The men's bathroom also had dirt and debris accumulation. The administrator acknowledged the need for repair and cleaning, contrary to the facility's maintenance policy.
A resident with a history of abusive behavior physically contacted another resident, resulting in a bruise. Despite the known history, the facility failed to prevent the altercation. An initial investigation found no witnesses, but a later report confirmed the incident, leading to a substantiated abuse finding. The involved residents have cognitive and behavioral issues, highlighting a deficiency in the facility's response.
A resident reported an unwitnessed altercation with another resident, who allegedly hit her in the mouth. Despite the facility's policy requiring immediate reporting of abuse allegations, the incident was not reported to the Administrator until days later. The involved residents have complex medical histories, with one having a severe cognitive deficit and a history of impulsive behaviors.
A resident with severely impaired cognition was discharged from a facility without proper notification to their representative, V13. The Social Service Director attempted to contact V13 but did not document all attempts and only mailed a letter on the day of discharge. V13 was unaware of the transfer until contacted by the new facility, leading to frustration as the new location was much farther from his home. The facility did not follow its policies on discharge notification and failed to notify the ombudsman.
A resident with severe dementia and behavioral issues was discharged to another facility without a completed discharge summary, as required by the facility's policy. The Social Service Director was unaware of the requirement, resulting in the summary being completed months after the discharge. The facility's policy mandates that a discharge summary and post-discharge plan be developed and reviewed with the resident and family at least 24 hours before discharge.
A resident with respiratory issues did not receive prescribed medications on time, leading to a deficiency. Despite a physician's order for immediate administration of Prednisone and Duoneb, the facility delayed treatment without justification, resulting in continued respiratory distress for the resident. Staff were unable to explain the delay, and documentation was lacking.
The facility failed to provide nutritional supplements as ordered and did not follow its weight management policy for two residents. One resident experienced significant weight loss and did not receive a health shake in a consumable form, while another resident under hospice care did not receive extra dessert as prescribed. The facility's policy on weight assessment and intervention was not adhered to, leading to deficiencies in nutritional care.
Two residents with specific dietary orders did not receive the appropriate meals as prescribed by their physicians. One resident with dementia and heart failure was given a crispy rice dessert bar instead of a mechanical soft diet, leading to difficulty chewing. Another resident with dementia and prediabetes also received the same inappropriate dessert, resulting in similar issues. The facility's dietician confirmed the failure to provide the correct diet items.
The facility failed to meet the required room size standards, providing less than 80 square feet per resident in multiple occupancy rooms. Despite the deficiency, residents expressed no concerns about their living space, and the issue was not raised in Resident Council meetings.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
A resident with diagnoses including paranoid schizophrenia, post-traumatic seizures, insomnia, anxiety disorder, essential tremor, and a history of traumatic brain injury was observed to have visibly wet pants for an extended period while sitting in a common area. The resident's Minimum Data Set indicated that he was rarely or never understood and was dependent on staff for toileting hygiene. The care plan noted a risk for impaired skin integrity and a history of refusing incontinence care at times. On the day in question, the resident was first observed with visibly wet pants at 9:15 AM, and this condition persisted until at least 11:50 AM. Multiple staff members, including CNAs, the Activities Assistant, the DON, and the CNA Supervisor, walked by or interacted with the resident during this time but did not address or acknowledge the resident's soiled condition. Some staff asked the resident if he wanted to use the bathroom or take a shower, but the resident either declined or did not respond. Staff interviews later revealed that the resident sometimes refused care, but alternative approaches, such as having a different staff member ask, were not consistently attempted during the observed period. Despite the facility's expectation that residents should be checked for incontinence at least every two hours, there was no documented policy on this practice, and the resident remained in soiled clothing for several hours. When the resident was finally assisted to the shower room, redness was observed on his buttocks and groin. The failure to provide timely incontinence care and maintain the resident's dignity was directly observed and confirmed through staff interviews and record review.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the daily needs of all residents, as evidenced by multiple missed or delayed care events. Several residents with significant medical conditions, including diabetes, hemiplegia, cognitive impairment, and mobility deficits, did not receive scheduled showers or timely incontinence care. Documentation showed that residents dependent on staff for activities of daily living (ADLs) such as bathing and toileting often missed scheduled showers, sometimes going up to six days without bathing, and experienced delays in call light response, resulting in incontinence episodes. Interviews with residents revealed consistent concerns about inadequate staffing, with reports of long wait times for assistance, missed showers, and insufficient help with toileting. Some residents reported waiting up to an hour for staff to respond to call lights, and several stated that they had experienced incontinence episodes due to these delays. Observations by surveyors confirmed instances of poor hygiene, such as greasy hair and foul body odor, and staff interviews corroborated that low staffing levels made it difficult to provide timely care, especially during shifts with only one or two CNAs present. Review of facility records, including timecards and schedules, confirmed that there were multiple shifts with only one or two CNAs available to care for approximately forty residents. Staff members, including CNAs and nurses, reported being unable to complete all scheduled showers or respond to call lights promptly during these periods. The facility's assessment tool did not specify staffing requirements tailored to the facility's needs, further contributing to the deficiency in meeting resident care needs.
Delayed Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for six out of eight residents reviewed for call light response. Multiple residents with significant medical needs, including diabetes, obesity, major depressive disorder, post-traumatic stress disorder, hemiplegia, and incontinence, reported delays in receiving assistance after activating their call lights. These residents were dependent on staff for activities of daily living such as toileting, bathing, and incontinence care, and several reported waiting up to an hour for help or experiencing incontinence episodes while waiting for staff to respond. Interviews with residents revealed consistent concerns about insufficient staffing levels, particularly during certain shifts or on weekends. Residents described situations where only two CNAs were available for the entire facility, leading to delays in care, missed showers, and unmet toileting needs. Some residents were unable to recall the exact wait times but indicated that the delays were significant enough to result in discomfort or incontinence. Staff interviews corroborated the residents' accounts, with CNAs and an LPN acknowledging that staffing shortages made it difficult to answer call lights and provide timely care. Staff described working shifts with only one or two CNAs, sometimes being left alone for extended periods, and being unable to complete scheduled showers or incontinence care. The administrator confirmed that the facility often operated with fewer CNAs than ideal, and that nurses were expected to assist on the floor when possible.
Failure to Provide Timely ADL Assistance Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs), including bathing and incontinence care, for eight residents reviewed for ADL needs. Multiple residents with significant medical conditions such as diabetes, hemiplegia, heart disease, cognitive impairment, and mobility deficits were dependent on staff for essential care. Documentation and interviews revealed that scheduled showers were frequently missed, and residents often experienced delays in receiving incontinence care and assistance with toileting. Care plans for several residents lacked specific interventions for bathing or toileting, and scheduled shower lists were not consistently followed. Residents and their family members reported that insufficient staffing led to long wait times for assistance, sometimes up to an hour, resulting in missed showers and incontinent episodes. Several residents stated that there were not enough CNAs on duty, especially during certain shifts, which directly impacted the timeliness and frequency of care provided. Observations included residents with greasy hair and foul body odor, and staff interviews confirmed that short staffing made it difficult to complete scheduled showers and respond to call lights promptly. Staff also reported that on some occasions, only one CNA was available for the entire facility, making it impossible to meet all residents' needs in a timely manner. The facility's own staff, including CNAs and nurses, acknowledged the ongoing staffing shortages and the resulting inability to provide timely ADL care. Some staff described working shifts with only one or two CNAs, which was insufficient to complete all required care tasks, including showers and incontinence care. Documentation of care provided was also inconsistent, with some staff admitting to forgetting to fill out shower sheets. The administrator confirmed that the facility often operated with fewer CNAs than ideal, and that nurses were sometimes required to assist with direct care due to the lack of available CNAs.
Failure to Maintain Effective Bed Bug Control Program
Penalty
Summary
The facility failed to maintain an effective bed bug control program, resulting in the presence of bed bugs and a lack of comprehensive response to the infestation. A resident first discovered a bed bug in her room and reported it to staff, who collected the specimen for confirmation. Despite confirmation of bed bugs by the pest control company, there was no evidence that the facility implemented systematic monitoring or inspection of other rooms following the initial report. Staff interviews revealed that several employees, including housekeeping, CNAs, and LPNs, were not educated on bed bug identification, management, or the facility's policy regarding infestations. Documentation showed that the pest control company treated affected rooms and provided recommendations, such as avoiding the use of wet cleaning methods on treated surfaces and sealing gaps around pipes. However, staff were not consistently informed about which rooms had been treated, leading to inappropriate cleaning practices that could compromise the effectiveness of pest control measures. Additionally, there was no documentation of staff education, ongoing monitoring, or inspection of recommended areas after the initial confirmation of bed bugs. The facility's own policy required staff training, regular inspections, and follow-up monitoring after treatment, but these steps were not followed. The lack of staff education, absence of a clear monitoring protocol, and failure to inspect and seal recommended areas contributed to the ongoing risk of bed bug infestation, potentially affecting all residents in the facility.
Inadequate Communication and Documentation in Resident Discharge
Penalty
Summary
The facility failed to appropriately manage the non-emergent involuntary discharge of a resident, identified as R185, resulting in the resident being transferred to a facility over two hours away without proper notice to her family. R185, who had severe cognitive impairments and a history of wandering, was discharged without a physician's order or adequate communication with her family. The facility did not provide the resident or her family with the opportunity to appeal the discharge, as required by policy. R185's care plan indicated she had no discharge potential due to her cognitive and safety awareness issues, yet she was transferred to another facility with a locked unit. The facility's Social Services Director, V3, attempted to contact R185's son, V13, but failed to document these attempts or successfully communicate the discharge plan. V13 was unaware of the transfer until contacted by the new facility, leading to distress and a lack of opportunity to appeal the decision. The facility did not follow its own policies regarding involuntary discharges, failing to notify the ombudsman or complete necessary documentation. The administrator, V1, acknowledged the oversight in not treating the discharge as involuntary and failing to ensure V13 was informed. The lack of communication and documentation resulted in R185 being moved without her family's knowledge, causing psychosocial harm due to the sudden change in environment.
Infection Control Deficiencies in Transmission-Based Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement transmission-based precautions and proper hand hygiene, leading to deficiencies in infection control for two residents. Resident R85, who was admitted with chronic obstructive pulmonary disease, Alzheimer's disease, dementia, and bipolar disorder, tested positive for COVID-19 while hospitalized. Upon returning to the facility, R85 was placed on transmission-based precautions. However, observations revealed that R85 was allowed to ambulate and eat in the dining room without wearing a mask or being encouraged to stay in her room, despite being on isolation precautions. Staff did not intervene to enforce these precautions, even when R85 interacted closely with peers. Additionally, the facility failed to ensure proper hand hygiene during catheter care for Resident R3, who was admitted with urinary retention and acute cystitis. A certified nursing assistant provided catheter care but did not perform hand hygiene between glove changes, which is against the facility's hand hygiene policy. The Director of Nurses acknowledged the expectation for hand hygiene to be performed between glove changes, but this was not adhered to during the observed care. These deficiencies highlight lapses in the facility's infection prevention and control program, as staff did not follow established protocols for transmission-based precautions and hand hygiene. The facility's policies, which align with guidelines from health authorities, were not effectively implemented, leading to potential risks of infection transmission among residents.
Absence of Call System in Shower Stalls
Penalty
Summary
The facility failed to provide a method for residents to call for assistance while in the shower stalls located in both the A and B halls. During observations conducted on September 18, 2024, it was noted that neither shower stall contained a call light or any accessible method for residents to summon help. This deficiency was confirmed through interviews with the facility's administrator, who acknowledged the absence of a call system in the shower stalls and admitted that there was no existing policy regarding the presence of call lights in these areas. The lack of a call system in the shower stalls has the potential to affect all 32 residents residing at the facility.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified and respectful dining experience for residents, as observed during a survey. On September 18, 2024, a dietary staff member, identified as V10, was seen removing plates from residents who were still eating, which disrupted their dining experience. At one table, V10 removed a resident's plate while three others were still eating, prompting one resident to stop eating and leave the table. At another table, V10 attempted to remove a resident's plate and glass, despite the resident indicating they were not finished. The staff member was not aware of any policy against this practice and stated that she would remove plates as soon as she perceived a resident to be finished, regardless of others still eating at the table. The facility administrator confirmed the absence of a policy on dining cleaning procedures.
Unsanitary Bathroom Conditions for Residents
Penalty
Summary
The facility failed to maintain a clean and sanitary bathroom environment for 14 residents residing on the B and C Halls. Observations revealed significant issues in the shower room on the B hall, including a cracked and peeling shower stall floor with mold present between the wall and floor. Additionally, there was a 2.5-inch gap between the wall and floor near the toilet, and a black accumulation with water pooling in front of the toilet. The men's bathroom on the B hall also had an accumulation of dirt and debris, resulting in a black substance forming in front of the toilet. These conditions were confirmed by the facility administrator, who acknowledged the need for repair and cleaning. The facility's maintenance policy requires maintaining the building in good repair and free from hazards, which was not adhered to in this instance.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent physical abuse of a resident by another resident with a known history of abusive behavior. The incident involved a resident, identified as R85, who entered the room of another resident, R16, and made physical contact, resulting in a slight bruise to R16's upper lip. This incident was reported by staff, and both residents were assessed for injuries, with first aid provided to R16. Despite the known history of R85's behaviors, the facility did not effectively prevent the altercation. Another incident was reported involving the same residents, R16 and R85, in the dining room, where R85 allegedly made contact with R16. This incident was initially unwitnessed and unreported to the administration until days later. R16 reported the incident, and a witness, R7, later confirmed seeing R85 hit R16. The facility's initial investigation did not find any witnesses, but upon reopening the investigation, the allegation of abuse was substantiated. R16 has a history of schizoaffective disorder, major depressive disorder, bipolar disorder, and anxiety disorder, with a BIMS score indicating cognitive intactness. R85, with a severe cognitive deficit, has a history of impulsive behaviors, including physical aggression. The facility's abuse prevention policy requires separation and evaluation of residents involved in such incidents, but the delayed reporting and investigation highlight a deficiency in the facility's response to resident-to-resident altercations.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility staff failed to report an allegation of resident-to-resident physical abuse to the Administrator immediately, involving a resident identified as R16. The incident occurred on 9/13/24, when R16 reported that another resident, R85, made contact with her in the dining room. Although the altercation was unwitnessed and no injuries were noted, R16 later stated that R85 had previously given her a bloody lip and attempted to take a towel and her walker, hitting her in the arm and mouth. Despite these claims, the nurse on duty did not report the incident to the Administrator until 9/16/24, when the Administrator discovered the incident while reviewing notes. R16's medical history includes schizoaffective disorder, major depressive disorder, bipolar disorder, and anxiety disorder, with a BIMS score indicating cognitive intactness. R85, on the other hand, has a severe cognitive deficit with a history of impulsive and physical behaviors, including hitting and inappropriate touching. The facility's Abuse Prevention Program-Policy requires employees to report any allegations of abuse immediately to the Administrator, which was not adhered to in this case, leading to a delay in the investigation of the incident.
Failure to Notify Resident's Representative of Discharge
Penalty
Summary
The facility failed to provide a resident, identified as R185, or their representative, with a written notice of discharge including appeal rights. R185, who had a severely impaired cognition as indicated by a BIMS score of 00, was discharged from the facility without proper notification to their son, V13, who was the resident's Power of Attorney (POA). The facility's Social Service Director, V3, attempted to contact V13 but was unsuccessful and did not document all attempts. V3 mailed a letter to V13 on the day of discharge, but V13 reported not receiving any prior notification or paperwork regarding the discharge. The facility initiated R185's discharge to another facility with a locked memory care unit. V13 was not informed of the transfer until contacted by the new facility to verify medications. V13 expressed anger and frustration, stating that he was not aware of the discharge and that the new facility was significantly farther from his home. The facility's administrator, V1, acknowledged that they did not complete a notice of involuntary transfer form or notify the ombudsman, and there was no documentation of attempts to contact V13 or other family members listed in R185's contact list. The facility's policies on transfer or discharge were not followed, as they did not provide the required documents to the resident or representative, nor did they review the final post-discharge plan with the resident and family at least 24 hours before discharge. The facility lacked a policy regarding involuntary facility-initiated non-emergent discharges, and V1 admitted that V3, who was still learning the Social Service Director role, might not have known to contact other family members. The failure to notify V13 prevented him from exercising his right to appeal the discharge.
Failure to Provide Discharge Summary for Resident Transfer
Penalty
Summary
The facility failed to provide a discharge summary for a resident, identified as R185, who was reviewed for discharge. R185 was admitted with multiple diagnoses, including severe dementia and cognitive communication deficit, and had a history of wandering and behavioral issues. The resident was dependent on assistance for daily activities and was considered to have no discharge potential due to poor safety awareness and cognition. Despite this, R185 was discharged to another facility without a completed discharge summary, as required by the facility's policy. The Social Service Director, identified as V3, admitted that the discharge summary was not completed until several months after the discharge occurred. V3 was unaware of the requirement to complete a discharge summary when transferring a resident to another facility. The facility's policy mandates that a discharge summary and post-discharge plan be developed and reviewed with the resident and family at least 24 hours before discharge, and a copy should be provided to the resident and receiving facility. This policy was not followed in the case of R185, leading to the deficiency noted in the report.
Failure to Administer Medications as Ordered for Respiratory Concerns
Penalty
Summary
The facility failed to follow physician's orders for a resident with respiratory concerns, leading to a deficiency. The resident, who had a history of chronic obstructive pulmonary disease, asthma, dementia, and anxiety disorder, reported feeling unwell with symptoms of shortness of breath and constant coughing. The physician ordered a chest x-ray, Prednisone, and Duoneb to be administered on the same day. However, the medications were not started until two days later, and the Duoneb was not administered at all by the time of the survey. Despite the physician's expectation for immediate administration, the facility delayed the treatment without documented justification. The resident continued to experience respiratory distress, including labored breathing and difficulty in conversation, as observed by the surveyor. The Director of Nursing and other staff members were unable to provide an explanation for the delay in medication administration, and there was a lack of documentation regarding assessments and interventions in the resident's electronic health record.
Failure to Provide Nutritional Supplements and Adhere to Weight Management Policy
Penalty
Summary
The facility failed to provide nutritional supplements as ordered and did not adhere to its weight management policy for two residents. Resident 27, who has severe cognitive impairment and other medical conditions, experienced a significant weight loss of 15.7% since admission. Despite a recommendation from the registered dietician to provide a health shake with meals, the resident was observed attempting to drink a frozen health shake, indicating it was not prepared for consumption. Additionally, there was a lack of documentation and notification regarding the resident's weight loss, and the resident was not weighed according to the facility's policy. Resident 15, who is under hospice care with a terminal diagnosis, did not receive the prescribed extra dessert with lunch on multiple occasions. The resident's weight records contained an incorrect entry, which affected the weight monitoring and notification process. The registered dietician was not informed of the resident's significant weight loss, and the resident did not receive the dietary supplements as ordered. The facility's policy requires immediate notification of the dietician in case of significant weight changes, which was not followed. The facility's policy on weight assessment and intervention outlines specific procedures for monitoring and addressing weight changes, including weekly weigh-ins for new admissions and immediate notification of the dietician for significant weight changes. However, these procedures were not followed for the residents in question, leading to deficiencies in their nutritional care. The lack of adherence to the policy and failure to provide ordered supplements contributed to the identified deficiencies.
Failure to Provide Prescribed Diets
Penalty
Summary
The facility failed to provide diets as ordered for two residents, R18 and R24, who were reviewed for nutrition. R18, diagnosed with dementia and diastolic heart failure, had a physician's order for a regular diet with mechanical soft texture, thin liquid consistency, and specific dietary items such as cut meats, super cereal, and health shakes. However, during an observation, R18 was given a crispy rice dessert bar, which was not suitable for her mechanical soft diet, leading her to struggle with chewing and ultimately not consuming the dessert. Similarly, R24, diagnosed with dementia, Alzheimer's disease, and prediabetes, had a physician's order for a NAS diet with mechanical soft texture and thin liquids. R24 was also observed receiving the crispy rice dessert bar, which was not appropriate for the ordered diet, resulting in difficulty chewing and a reaction that included clearing his throat and leaving the table. The facility's diet spreadsheet and policy on therapeutic diets indicated that mechanically altered diets should include items consistent with the specific diet texture. However, the registered dietician, V17, confirmed that the residents did not receive the diet items as ordered, which should have included desserts suitable for a mechanical soft diet. This discrepancy between the ordered diets and the actual food provided to the residents highlights the facility's failure to adhere to prescribed dietary orders, as observed and documented during the survey.
Deficiency in Room Size Standards
Penalty
Summary
The facility failed to provide the required 80 square feet of floor space per resident in multiple occupancy rooms, affecting eight residents. During a survey, the administrator and surveyor measured several rooms and found that the space per resident was below the required standard. For instance, one room measured 153.13 square feet, providing only 76.56 square feet per person, while another room measured 145.83 square feet, offering just 72.92 square feet per person. These measurements were consistent across all rooms assessed, indicating a systemic issue with room sizes. Despite the deficiency in room size, the residents involved, who were alert and oriented, expressed no concerns about their living space. The facility's administrator confirmed that all rooms, except for two used as offices, were double occupancy. The facility's Bed Management Tool corroborated the residency of the affected individuals in the measured rooms. Additionally, a review of six months of Resident Council meeting minutes revealed no reported concerns regarding room sizes.
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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