Jennings Terrace
Inspection history, citations, penalties and survey trends for this long-term care facility in Aurora, Illinois.
- Location
- 275 South Lasalle, Aurora, Illinois 60505
- CMS Provider Number
- 146197
- Inspections on file
- 16
- Latest survey
- January 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Jennings Terrace during CMS and state inspections, most recent first.
A facility failed to promptly address a billing grievance raised by a resident's family member, resulting in a deficiency. The family member contacted the facility about billing discrepancies for a period when they were paying out of pocket despite the resident being approved for public aid. Despite involving the Ombudsman, the facility did not provide a timely resolution, violating its grievance policy.
The facility did not perform an assessment to identify potential growth areas for Legionella and other waterborne pathogens, affecting all 46 residents. The Maintenance Director confirmed no assessment or testing had been done in the past three years, despite the facility's policy requiring such measures.
The facility failed to label and date medications properly, leading to expired medications not being discarded. Narcotic medications had broken seals, and suppositories were stored unsanitarily. The DON and a pharmacist confirmed that narcotics should be destroyed if not administered, with a witness present, to prevent diversion. The facility's policy requires medication storage areas to be clean, safe, and sanitary.
The facility failed to prepare green peas to the appropriate pureed consistency for residents on pureed diets. A cook did not test the consistency of the pureed peas, which contained fibrous casings, posing a risk of choking. The Dietary Manager confirmed the inconsistency, and the Registered Dietitian emphasized the need for a smooth, pudding-like consistency. The facility's policy required food to be pureed to meet individual needs.
The facility did not use the McGeer Criteria for monitoring antibiotic use from March to November 2024, affecting nine residents. The Infection Preventionist/ADON stopped using the criteria due to multiple responsibilities, leading to a lack of documentation to assess if residents met standards for antibiotic use.
The facility failed to provide dementia training for CNAs responsible for caring for residents with dementia, affecting 26 residents. The CNA Supervisor and Director of Nursing confirmed the absence of such training, and several CNAs reported not receiving dementia training during their orientation or employment. Despite caring for residents with dementia, CNAs were not equipped with the necessary training to address their specific needs.
A resident with multiple diagnoses, including diabetes and heart failure, had a sacral wound that was not properly assessed or documented by the facility. Despite having a wound care order, the care plan was not updated, and the DON was unaware of the wound. The wound care doctor was not involved, and the facility's policies for skin assessment and documentation were not followed, resulting in a deficiency.
The facility's arbitration agreement was found deficient as it lacked required language stating that residents or their representatives are not required to sign the agreement as a condition for admission or continued care. Additionally, it did not inform them of their right to rescind the agreement within 30 days. The Community Relations Coordinator confirmed the omission, affecting all 46 residents.
A resident was injured while being transported in a wheelchair without foot pedals, resulting in a fall and head laceration. Staff interviews confirmed that it is the transporter's responsibility to ensure residents' feet are either held up or placed on foot pedals. The facility's policy lacked specific safety measures for wheelchair transportation.
The facility failed to ensure proper kitchen sanitization and correct storage and disposal of food items, leading to potential risks of foodborne illnesses. Sanitizing buckets and the three-compartment sink tested at zero ppm for sanitizer concentration, and multiple food items were improperly labeled, stored, or expired.
The facility failed to ensure lint was removed from the dryers, posing a fire hazard. Significant lint accumulation was observed in three dryers, with one dryer having a one-inch layer of lint and the other two having piles of lint about 10 inches high and wide. The laundry staff cleans the dryers once a day without keeping a log, and the facility lacks a policy on lint removal. The Maintenance Director acknowledged the fire hazard and the absence of maintenance logs.
A facility failed to investigate and report a potential abuse allegation involving a resident with Alzheimer's disease and dementia. Another resident reported observing an agency CNA pushing the affected resident into a dining room table. The administrator did not conduct a thorough investigation or report the incident to the State Survey Agency, only requesting the CNA not return to the facility.
A resident with moderately impaired cognition and a need for moderate assistance with personal hygiene was observed with unwanted facial hair, which was not addressed by staff despite the resident's request. The ADON confirmed that CNAs were responsible for such care, and the facility's policy required assistance for residents unable to perform ADLs independently.
The facility failed to secure hazardous chemicals, leaving a bleach bottle and an odor eliminator in shared bathrooms of residents with impaired mental status. Housekeeping staff admitted to the oversight, and the DON confirmed the chemicals should have been locked away for safety.
The facility failed to ensure sanitary storage and containment of respiratory equipment for a resident with COPD. The resident's oxygen tubing and nasal cannula were observed on the floor on two occasions, contrary to the facility's policy requiring storage in a plastic bag when not in use.
A facility failed to administer the correct dose of insulin to a resident with Type 2 Diabetes Mellitus. An agency RN left 2 units of insulin in the pen, resulting in the resident not receiving the full prescribed dose of 50 units. The ADON confirmed that the nurse should have administered the full dose as per the doctor's order.
The facility failed to isolate a COVID-positive resident from her COVID-negative roommate, despite having available beds for relocation. The COVID-negative resident later tested positive and was on antiviral medication. The facility's policy and CDC guidelines were not followed, leading to a deficiency in infection control practices.
A resident was found repeatedly yelling for help because his call light was not functioning. Upon testing, the call light only worked intermittently and then failed to turn off. The DON confirmed the call light was sticky and not functioning properly, despite the facility's policy requiring timely response and maintenance of call lights.
Failure to Address Billing Grievance Promptly
Penalty
Summary
The facility failed to address a billing grievance raised by a resident's family member, resulting in a deficiency. The resident, identified as R1, was admitted and later discharged from the facility. R1's family member, V5, raised concerns about billing discrepancies for the period when the family was paying out of pocket despite R1 being approved for public aid. V5 contacted the facility's Administrator and Business Office Manager (BOM) on September 20, 2024, regarding the credit due to R1's family. However, V5 felt that the facility did not respond promptly to the grievance, leading him to seek assistance from the Ombudsman, V3. The Ombudsman, V3, attempted to mediate the issue by contacting the facility on December 13, 2024, but was unsuccessful in obtaining a resolution. The facility stopped responding to V3 on December 26, 2024. The BOM, V2, acknowledged that V5 had contacted her in October 2024 but admitted to ceasing communication after V3's involvement. The facility confirmed the amount due to R1's family on January 1, 2025, but failed to communicate this to V5 and V3. The facility's grievance policy mandates prompt resolution of grievances, which was not adhered to in this case, as evidenced by the 130-day delay in addressing V5's billing grievance.
Failure to Conduct Legionella Assessment
Penalty
Summary
The facility failed to conduct an assessment to identify potential growth areas for Legionella and other opportunistic waterborne pathogens, affecting all 46 residents. The Maintenance Director, who has been with the facility for three years, confirmed that no such assessment had been performed during his tenure. He also stated that the facility had not engaged a company to conduct the necessary assessment, nor had any testing for Legionella been carried out. The facility's policy on Infection Prevention & Control for Legionnaires Disease, dated November 1, 2018, outlines the procedure for maintaining a water management program. This includes identifying building water systems that require Legionella control measures and assessing the risk posed by hazardous conditions in those systems. However, the facility did not have an assessment or a building flow diagram as recommended by the CDC toolkit, indicating a lapse in following their own policy and procedures.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly label and date medications once opened, which is crucial for determining their expiration dates. This deficiency was observed in several instances, including Latanoprost ophthalmic solutions for two residents that were opened but not discarded after their expiration dates. Additionally, two inhalers were found opened without being dated, contrary to pharmacy recommendations that require discarding them six weeks after opening. Furthermore, expired medications were not removed, as evidenced by a vial of Tuberculin Purified Protein that was kept beyond its recommended disposal date. The facility also failed to maintain the integrity of narcotic medications, as several blister packs had broken seals that were taped over, which is against the facility's controlled medication policy. Suppository medications were stored in unsanitary conditions, with boxes drenched in water from a leaking refrigerator. The Director of Nursing and a Registered Pharmacist confirmed that narcotic medications should be destroyed if not administered, with a witness present, to prevent potential diversion. The facility's policy mandates that medication storage areas be kept clean, safe, and sanitary, which was not adhered to in these instances.
Failure to Ensure Proper Pureed Food Consistency
Penalty
Summary
The facility failed to prepare green peas to the appropriate pureed consistency for residents on pureed diets, affecting five residents in the sample. During an observation in the facility kitchen, a cook, identified as V5, was seen preparing pureed green peas for these residents. V5 used a food processor to puree the peas but did not test the consistency of the final product. Upon tasting, it was found that the mixture contained fibrous casings from the pea pods, which were not chewable and posed a risk of getting stuck in the throat when swallowed. The Dietary Manager, V4, confirmed the inconsistency of the pureed peas, agreeing that the product should have been smooth and pudding-like without fibrous casings. The facility's diet list confirmed that the affected residents were on pureed diets, and the Registered Dietitian, V7, reiterated that the expected consistency should be smooth and free of chunks or fibrous material. The facility's policy and procedure for pureed diets, dated 2010, stated that food should be provided in a form designed to meet individual needs, with pureed diets served as ordered by the physician. The policy also specified that whole food should be pureed to a semi-solid, pudding-like consistency.
Failure to Utilize McGeer Criteria for Antibiotic Stewardship
Penalty
Summary
The facility failed to utilize the McGeer Criteria for monitoring antibiotic use from March 2024 through November 19, 2024, as per their policy. This deficiency affected nine residents who were reviewed for antibiotic stewardship. The Infection Preventionist/Assistant Director of Nursing (V3) admitted to ceasing the use of the McGeer Criteria in March 2024, despite the facility's protocol requiring its use to evaluate and communicate clinical signs and symptoms when a resident is suspected of having an infection. The facility's infection tracking binder showed documentation of the McGeer Criteria for January and February 2024, but none for the subsequent months. V3 acknowledged that due to multiple responsibilities, infection control had been neglected, resulting in the absence of necessary documentation to determine if residents met the standards for antibiotic utilization.
Lack of Dementia Training for CNAs
Penalty
Summary
The facility failed to provide dementia training for Certified Nurse Assistants (CNAs) responsible for caring for residents with dementia. This deficiency affected 26 residents identified by the facility as having a dementia diagnosis. Interviews and record reviews revealed that the CNA Supervisor, who is responsible for conducting annual evaluations and in-services for CNAs, did not provide dementia training and could not recall attending such training. The Director of Nursing, who started working at the facility in April 2024, confirmed that no dementia training had been conducted since her tenure began. An in-service binder review failed to produce any documentation of dementia training, and the Community Relations Coordinator, who was believed to conduct such training, stated that she did not provide dementia training for the staff. Several CNAs, including those who had been working at the facility for varying lengths of time, reported that they had not received dementia training during their orientation or at any point during their employment. Despite caring for residents with dementia, these CNAs were not equipped with the necessary training to address the specific needs of these residents. The lack of dementia training was a significant oversight, as the facility had a substantial number of residents diagnosed with dementia, yet there was no evidence of structured training to ensure CNAs were adequately prepared to provide appropriate care.
Deficiency in Wound Care Assessment and Documentation
Penalty
Summary
The facility failed to properly assess and document a resident's wound care, specifically for a resident identified as R5. R5, a cognitively intact female with multiple diagnoses including osteoarthritis, congestive heart failure, and type 2 diabetes, was admitted to the facility with a sacral wound. Despite the presence of a wound care order dated October 23, 2024, which included specific instructions for cleansing and dressing the wound, the facility did not update R5's care plan to reflect the wound. The care plan had not been revised since August 23, 2023, and did not include interventions for the sacral wound. Observations and interviews revealed that R5 had been experiencing pain and had an open wound on her sacrum for several months. The Director of Nursing (DON) was unaware of the wound and could not provide any assessment or documentation for it. The wound care doctor had not been informed or involved in R5's care, and R5's name was not listed in the wound care system for October or November 2024. The facility's policies required comprehensive skin assessments and documentation, which were not followed in this case, leading to a deficiency in wound care management.
Deficient Arbitration Agreement Lacks Required Language
Penalty
Summary
The facility's arbitration agreement was found to be deficient as it lacked the required language indicating that residents or their representatives are not obligated to sign the arbitration agreement as a condition for admission or continued care. Additionally, the agreement did not inform residents or their representatives of their right to rescind the agreement within 30 calendar days of signing. This deficiency was identified during a review of the facility's admission packet, which included the arbitration agreement under the section titled 'Miscellaneous Provisions N. Mediation/Arbitration.' The Community Relations Coordinator, identified as V8, confirmed during an interview that the arbitration agreement did not contain the necessary language. V8 explained that she typically reviews the contract with residents or their representatives, either in person or over the phone, but acknowledged the omission upon re-reading the agreement. The facility's failure to include this critical information affects all 46 residents residing at the facility, as indicated by the facility's application for Medicare and Medicaid.
Failure to Safely Transfer Resident Using Wheelchair
Penalty
Summary
The facility failed to safely transfer a resident using a wheelchair, resulting in an accident. On 5/13/24, a resident was being transported from her room to the dining room by an Activity Aide. The resident's wheelchair did not have foot pedals, and the Activity Aide instructed the resident to hold her feet up. However, the resident's foot got caught in the front wheel of the wheelchair, causing her to topple over and fall to the ground, hitting her head and sustaining a laceration. The Maintenance Director confirmed that there was no issue with the wheelchair's wheels or brakes. The resident was sent to the emergency room and returned to the facility the same day without needing sutures or having any fractures. The resident's fall risk assessment indicated she was at high risk for falls, and her MDS showed no cognitive impairment. Interviews with various staff members, including a CNA, LPN, and the Director of Nursing, revealed that it is the responsibility of the transporter to ensure that residents' feet are either held up or placed on foot pedals to prevent accidents. The facility's policy on assistive devices and equipment, revised in July 2017, did not include specific safety measures for transporting residents in wheelchairs. The Administrator confirmed that the resident was bleeding from her forehead when she arrived at the scene, and 911 was called to transport the resident to the hospital. The incident highlights a gap in the facility's policy and staff training regarding the safe transportation of residents in wheelchairs.
Improper Kitchen Sanitization and Food Storage
Penalty
Summary
The facility failed to ensure proper sanitization of the kitchen and correct storage and disposal of food items, which could prevent the transmission of foodborne illnesses. During a quality assurance check, it was observed that the sanitizing buckets and the three-compartment sink tested at zero parts per million (ppm) for sanitizer concentration. The Dietary Manager acknowledged that staff were not regularly checking or documenting the sanitizer levels, which should be done several times during meal preparation and at least three times a day for the sink. This lapse in procedure could lead to ineffective sanitization and potential cross-contamination and foodborne illnesses among residents. During a kitchen tour, several issues were noted with food storage. Multiple opened food items in the dry storage area lacked proper labeling, including open dates and use-by dates. Some items were expired, and others were not stored according to manufacturer instructions, such as lime juice that should have been refrigerated. In the walk-in cooler, moldy green peppers and improperly stored Canadian bacon were found. The reach-in cooler contained opened mayonnaise and cream cheese without proper labeling. The walk-in freezer had a large bag of garlic bread with illegible writing, and the reach-in freezer contained expired apple muffin batter. The facility's policies on food storage and sanitization were not followed. The policies required that foods stored in bins be labeled with the item and date unpacked, and that open products be tightly covered to protect against contamination. The sanitizing solution policy required testing each time the sanitization buckets were changed. The Dietary Manager admitted that these procedures were not being followed, leading to potential risks of foodborne illnesses due to improper food handling and storage practices.
Failure to Remove Lint from Dryers Poses Fire Hazard
Penalty
Summary
The facility failed to ensure lint was removed from the facility's dryers, posing a fire hazard. On 01/17/24 at 3:48 PM, it was observed that the facility's three dryers had significant lint accumulation. Dryer 1 had approximately a one-inch layer of lint on the bottom and on all four sides of the lint basket, while dryers 2 and 3 had lint approximately one inch thick on the top of the lint screens and a pile under both screens about 10 inches high and 10 inches wide. Both dryers 2 and 3 were running with clothes in them at the time of observation. The laundry staff member (V16) stated that she cleans the dryers once a day at the end of her shift and does not keep a log of when the lint is cleaned. She mentioned that she handles about 20 to 30 loads a day. The Maintenance Director (V12) acknowledged that running the dryers with such lint accumulation would be a fire hazard and admitted that the facility does not have a policy on removing lint from the dryers. Additionally, the facility does not maintain a log for dryer maintenance. The dryer manuals provided by the facility emphasized the importance of keeping lint screens clean to prevent fire hazards, suggesting cleaning every third or fourth load.
Failure to Investigate and Report Potential Abuse
Penalty
Summary
The facility failed to respond appropriately to a potential abuse allegation involving a resident with multiple diagnoses, including Alzheimer's disease and dementia. The incident was reported by another resident who observed an agency CNA pushing the affected resident into a dining room table. Despite being informed of the concern, the facility's administrator did not conduct a thorough investigation or report the allegation to the State Survey Agency. Instead, the administrator only contacted the staffing agency to request that the CNA not return to the facility. The facility's documentation showed that the grievance was not resolved and was still in process at the time of the survey. The facility's policy on abuse and neglect requires the identification and investigation of possible incidents or allegations, but this protocol was not followed. The administrator admitted to only performing a quick verbal follow-up and did not consider the concern as abuse, which led to the failure in addressing the potential abuse allegation properly.
Failure to Assist Resident with Grooming and Hygiene
Penalty
Summary
The facility failed to ensure residents receive assistance for grooming and hygiene care, specifically for one resident who was observed with several white hairs on her upper lip and chin. The resident expressed dissatisfaction with the hair and mentioned that someone was supposed to remove it but never did. The resident's MDS indicated moderately impaired cognition and a need for moderate assistance with personal hygiene, while her care plan required extensive assistance from one staff member for personal hygiene. The Assistant Director of Nursing confirmed that CNAs were responsible for assisting residents with ADL care and acknowledged that the resident should not have hair on her chin or upper lip. The facility's policy stated that residents unable to carry out ADLs independently should receive necessary services to maintain good grooming and personal hygiene.
Failure to Secure Hazardous Chemicals
Penalty
Summary
The facility failed to secure hazardous chemicals, which were found in shared bathrooms of residents with impaired mental status. Specifically, a 32 oz spray bottle of bleach was found in the shared bathroom of two residents, one of whom had a severely impaired mental status and the other with diagnoses including dementia, schizoaffective disorder bipolar type, neurocognitive disorder, and major depressive disorder. The housekeeping staff admitted to leaving the bleach bottle in the bathroom after cleaning it. Additionally, a 32 oz spray bottle of odor eliminator was found in another shared bathroom of two residents, one with schizoaffective disorder, major depressive disorder, and far-sightedness, and the other with dementia with agitation, mild cognitive impairment, and age-related cognitive decline. The housekeeping staff acknowledged that the bottle should have been locked away for safety reasons. The Director of Nurses confirmed that the chemicals should not have been left in the residents' rooms due to safety concerns, especially for residents with altered mental status who could potentially harm themselves or others. The facility's Chemical Use Policy mandates that all chemicals must be under the control of housekeeping staff, either in a locked housekeeping cart or behind locked doors. The failure to adhere to this policy resulted in hazardous chemicals being accessible to residents, posing a significant safety risk.
Failure to Ensure Sanitary Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure sanitary storage and containment of respiratory equipment for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD). On two separate occasions, the resident's oxygen tubing and nasal cannula were observed on the floor when not in use. The resident confirmed that he uses the oxygen. The facility's policy, updated earlier in the month, mandates that oxygen tubing should be stored in a plastic bag when not in use for infection control reasons. The Assistant Director of Nursing confirmed that the equipment should not be on the floor.
Failure to Administer Correct Insulin Dose
Penalty
Summary
The facility failed to administer the correct dose of insulin medication to a resident. During a medication pass, an agency RN administered 50 units of Lantus insulin to a resident with Type 2 Diabetes Mellitus. However, after the administration, it was observed that 2 units of insulin remained in the pen, indicating that the resident did not receive the full prescribed dose. The resident's electronic medical records confirmed the diagnosis and the physician's order for 50 units of insulin. The Assistant Director of Nursing acknowledged that the nurse should have administered the full dose as per the doctor's order. The facility's policy on administering medications states that medications must be administered in accordance with the orders.
Failure to Isolate COVID-Positive Resident from COVID-Negative Roommate
Penalty
Summary
The facility failed to isolate a COVID-positive resident from her COVID-negative roommate, leading to a deficiency in infection control. On 01/17/24, the Director of Nursing (DON) stated that one resident was positive for COVID and another was under observation, both sharing the same room. Despite the facility's policy to isolate COVID-positive residents and relocate their COVID-negative roommates, the two residents were kept together based on the physician's instructions. The Assistant Director of Nursing (ADON) confirmed that there were seven open beds available to relocate the COVID-negative resident, but this was not done. The COVID-negative resident expressed concerns about not being offered another room and not knowing how she was being protected from COVID. Nurse documentation later indicated that the COVID-negative resident tested positive and was on antiviral medication, although initial tests were negative. The facility's policy, dated 4/27/20, mandates that any resident suspected or confirmed to have COVID-19 should be moved to a private room, and only residents of the same gender and infection status may be cohorted. The ADON/IC Nurse stated that no facility-wide testing was conducted because the two residents did not leave their room, and there were no exposure risks. However, the facility policy and CDC guidelines recommend isolating symptomatic or exposed residents from confirmed COVID-positive residents until testing confirms their status. The failure to follow these guidelines and policies led to the deficiency in infection control practices at the facility.
Non-Functional Call Light
Penalty
Summary
The facility failed to ensure a resident had a functional call light available. A male resident was observed repeatedly yelling for help from his room, stating that no one was answering his call light. Upon testing, it was found that the call light was not activated and only worked intermittently after being re-plugged by a CNA. The call light then failed to turn off. The Director of Nurses confirmed that the call light was sticky and not functioning properly, and stated that staff are expected to check call lights at the beginning of every shift. The facility's call light policy mandates that call lights be answered in a timely manner and maintained by the facility.
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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