La Bella At Clifton
Inspection history, citations, penalties and survey trends for this long-term care facility in Clifton, Illinois.
- Location
- 1190 E 2900 North Road, Clifton, Illinois 60927
- CMS Provider Number
- 146085
- Inspections on file
- 41
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at La Bella At Clifton during CMS and state inspections, most recent first.
A resident with significant physical disabilities and intact cognition was subjected to physical and verbal abuse by a family member during a visit, when the family member demanded a bank card and grabbed the resident by the shirt collar and neck. The incident was reported by the resident to staff, assessed by an LPN, and confirmed through interviews, revealing a failure to protect the resident from abuse as required by facility policy.
A cognitively impaired resident exited the facility unnoticed despite known elopement risk and monitoring interventions. Another resident with a history of falls did not receive a timely neurology consult after a witnessed fall with injury, and a third resident's fall from bed was not thoroughly investigated, with missing staff interviews and documentation. These deficiencies reflect lapses in supervision, follow-through on care plans, and incident investigation.
A resident with severe cognitive impairment was not accurately assessed for wandering on the MDS, as behavior tracking and nursing notes documented wandering incidents that were not reflected in the assessment. The MDS Coordinator confirmed the omission after reviewing the records.
Surveyors found that the facility did not employ a clinically qualified Director of Food and Nutrition Services, as the full-time Dietary Manager lacked required certification or equivalent training. This deficiency was confirmed by both the Dietary Manager and the Administrator, despite the facility's own assessment indicating the need for a qualified nutrition professional. Seventy-four residents were affected by this failure.
A resident who began smoking after admission was not identified as a smoker in their care plan, despite being listed as an independent smoker requiring supervision and being observed smoking under staff supervision. The care plan did not address the resident's smoking status or necessary interventions, contrary to facility policy requiring comprehensive, person-centered care plans.
Three residents were involved in incidents where one resident, known to be physically aggressive and severely cognitively impaired, kicked and pushed other residents, resulting in pain and injury. Staff and family members confirmed these events, and documentation showed a pattern of escalating aggression that was not effectively managed, leading to harm among residents.
The facility did not implement effective interventions to prevent abuse, resulting in multiple incidents where a resident with a history of aggression physically assaulted two other residents. Staff and family confirmed the aggressive behavior, and documentation showed that care plan interventions were largely unsuccessful, with more protective measures not attempted prior to the incidents.
A resident with cognitive impairment and a history of aggressive behavior struck another cognitively intact resident in the neck in the dining room, causing pain and ongoing emotional distress. The incident was witnessed by a CNA, and multiple staff confirmed the victim's continued fear and avoidance of the aggressor. The facility failed to prevent the abuse or protect the resident from further psychosocial harm.
Two residents were involved in a physical altercation in the dining room, resulting in one resident experiencing pain and emotional distress. Although the incident was witnessed by a CNA and known to several staff members, it was not reported to the administrator or state survey agency as required. The event was not documented in medical records or investigated according to facility policy, constituting a failure to follow abuse reporting protocols.
The facility failed to follow its policy requiring two staff for mechanical lift transfers, resulting in a resident falling when transferred by a single CNA using a broken wheelchair. Additionally, two residents with severe cognitive impairment experienced falls that were not documented in their medical records, and no post-fall investigations or interventions were implemented. Staff did not attempt alternative care approaches, and the DON confirmed the lack of documentation and investigation.
A resident with a history of abuse experienced increased anxiety and distress after being struck by another resident, which triggered memories of past trauma. The facility did not include specific details about the resident's abuse history or associated triggers in the care plan, nor did it implement individualized trauma-informed interventions. Staff and family were aware of the resident's background, but this information was not consistently documented or communicated, resulting in inadequate psychosocial support.
A resident with severe dementia and a history of aggressive and resistive behaviors did not have a care plan updated to reflect specific incidents or include personalized nonpharmacological interventions. Staff used generic behavior tracking and did not implement or document individualized approaches, despite repeated episodes of aggression, resistance to care, and falls. The facility's dementia care protocol requiring individualized planning and communication was not followed.
Two residents experienced medication administration errors when an LPN failed to shake an Albuterol inhaler before use, did not check blood pressure before giving Clonidine as ordered, and administered rapid-acting insulin before a meal was available, all contrary to physician orders and manufacturer instructions.
A resident experienced a fall after being transferred into a broken, forward-tilted wheelchair that had not been reported for repair. Multiple CNAs noted the wheelchair's unsafe condition had persisted for some time, but the Maintenance Director was not notified and no work order was logged, contrary to facility policy requiring prompt reporting and prioritization of such repairs.
The facility failed to implement a care plan to prevent resident intrusion, resulting in aggression between two residents. An interdisciplinary team had decided to place a sign to guide a wandering resident back to their room, but the sign was not placed, leading to an incident where both residents fell. Instead, a locking doorknob cover was installed, requiring further action to resolve the care plan issue.
The facility's abuse prevention policy failed to include a definition of abuse facilitated by technology, such as video recording residents in compromising situations. This oversight was confirmed during an interview and record review, revealing that the most recent policy revision did not address this issue, potentially affecting all seventy residents in the facility.
The facility failed to provide sufficient CNA staffing, affecting resident care. Observations and interviews revealed that the facility often operated with fewer CNAs than required, leading to delays in call light responses and inadequate care. Residents reported waiting times of up to an hour for assistance with incontinence care. The facility's staffing was based on census numbers rather than resident acuity, contributing to the inadequate staffing levels.
The facility experienced delays in meal service due to insufficient dietary staffing, affecting several residents. The Dietary Manager had to cover cooking duties due to a shortage of staff, with only two aides assisting, leading to meals being served significantly later than scheduled. The morning cook frequently arrived late or was absent, causing breakfast and lunch to be delayed by up to an hour on multiple occasions. This deficiency had the potential to impact all 71 residents in the facility.
The facility failed to maintain adequate food supply and log substitutions, affecting residents' dietary services. Residents reported frequent shortages of food items, and cooks confirmed serving smaller portions or different foods due to insufficient supplies. The substitution log was not consistently maintained, and the dietary manager and dietitian were unaware of the extent of the shortages.
The facility failed to maintain a clean environment due to insufficient housekeeping staff, affecting several residents. Housekeepers did not sweep floors before mopping, and toilets were not cleaned daily unless visibly dirty. Residents reported that their rooms were not cleaned daily, and when they were, the cleaning was not thorough. The housekeeping schedule confirmed that only one housekeeper was scheduled on multiple days, corroborating the residents' and staff's statements.
The facility failed to honor resident food preferences and provide substitutes, affecting six residents. Observations showed yogurt was not served as specified on meal tickets, and substitutes like egg salad were not readily available. Residents expressed dissatisfaction with the food served, and staff confirmed meal preferences were not consistently followed.
The facility failed to provide scheduled showers for three residents who required staff assistance due to various medical conditions. Despite being scheduled for two showers per week, the residents reported receiving showers less frequently, with documentation supporting their claims. The DON acknowledged the issue, noting that proper documentation was not maintained.
The facility failed to prevent the transmission of C-Diff infections due to inadequate disinfection of shared shower rooms, improper hand hygiene, and PPE use. Staff were observed not following infection control protocols, and there was a lack of follow-up on lab testing for residents with symptoms. These deficiencies contributed to the spread of C-Diff among residents.
A resident with a J-tube infection and multi-drug resistant organism experienced a significant delay in receiving prescribed IV antibiotics due to communication issues between the facility, physician, and pharmacy. The antibiotics were administered 10 days after the order, affecting the resident's treatment plan.
A resident was administered Quetiapine Fumarate without informed consent, contrary to the facility's policy requiring consent for new psychotropic medications. The medication was given for several weeks before consent was documented, with discrepancies in the documentation process. This highlights a lapse in adhering to informed consent procedures.
Two residents in a LTC facility did not receive adequate showering services as per the facility's policy. One resident, with mobility issues, received only one shower in a month, while another, with incontinence and a painful wound, received three showers in the same period. Both residents expressed a desire for more frequent showers, and the lack of documentation was confirmed by the Assistant Director of Nursing.
A resident with terminal COPD and respiratory failure received 40 mg of Hydromorphone instead of the prescribed 4 mg due to a concentration change that was not communicated effectively. The LPN administered the incorrect dose, leading to the resident receiving Narcan and being sent to the hospital. The error was discovered when the LPN noticed a change in the medication's color and confirmed the concentration discrepancy. The resident later passed away in the hospital, with the cause of death documented as respiratory failure and COPD exacerbation.
A resident with severe cognitive impairments fell and sustained injuries due to an unsecured toilet seat riser. The facility failed to maintain and monitor the adaptive device, leading to the fall and subsequent injuries, including a fractured finger and a laceration requiring sutures. Interviews revealed that regular checks on the toilet seat risers were not conducted.
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, affecting all 69 residents. The Dietary Manager, observed supervising meal preparations, admitted to not being a certified dietary manager or having equivalent training. The facility's assessment tool indicated the need for a qualified nutrition professional, which was not met.
The facility failed to assess, obtain consent, and care plan the use of side rails for four residents. Observations revealed that residents were using side rails without documented assessments or consents, and the last assessments were outdated. The DON confirmed an issue with the EMR system prompting assessments annually instead of quarterly.
The facility failed to maintain and document influenza and pneumococcal vaccination information and offer pneumococcal vaccines to four residents. The medical records of these residents lacked documentation of vaccination status and offers, contrary to the facility's policy.
The facility failed to assess side rails for entrapment risk for four residents, despite their policy requiring regular inspections and assessments. Staff confirmed that no formal measurements were conducted to ensure the safety of the side rails, potentially leading to entrapment hazards.
The facility failed to accurately complete the comprehensive assessments for two residents. One resident's MDS inaccurately documented IV medication administration, while another resident's MDS incorrectly indicated hospice services instead of palliative care. The Director of Nursing confirmed these inaccuracies.
The facility failed to implement physician orders for lab results and withholding medication, and did not properly assess, measure, and treat diabetic wounds for a resident with multiple health conditions. The resident's wounds were inconsistently documented and treated, and lab orders were not completed as required. The DON cited staffing issues and the wound physician's canceled visits as contributing factors.
The facility failed to complete timely wound assessments, follow physician orders for wound treatments, and monitor dressings for two residents with pressure ulcers. One resident's wound assessment was delayed by six days, and the prescribed dressing was not applied correctly. Another resident's wound assessment form was left blank, and incorrect treatments were administered due to outdated orders in the system.
The facility failed to properly date and maintain respiratory equipment for two residents, leading to deficiencies in respiratory care. One resident's oxygen tubing and humidification bottle were not dated, and another resident's nebulizer equipment was found uncovered and improperly stored.
The facility failed to identify and care plan specific targeted behaviors and nonpharmacological interventions, and complete psychotropic medication assessments for a resident with severe cognitive impairment. The resident's care plan and behavior tracking were generic, and PRN psychotropic medications were administered without documenting specific behaviors or nonpharmacological interventions attempted beforehand. Interviews with CNAs and the DON confirmed these deficiencies.
The facility failed to administer insulin according to the manufacturer's instructions and facility policy, resulting in a 9.09% medication error rate. Three residents received rapid-acting insulin without proper priming and without timely access to food, increasing the risk of hypoglycemia. The Director of Nursing confirmed the lapses in procedure.
The facility failed to ensure IV medications were accurately labeled for two residents, leading to discrepancies between physician orders and IV bag labels. The Registered Nurse confirmed that outdated labels were used, resulting in incorrect dosages of additives being administered.
Failure to Protect Resident from Physical and Verbal Abuse by Family Member
Penalty
Summary
A resident with multiple complex medical conditions, including hemiplegia, muscle weakness, and an above-knee amputation, reported being verbally and physically abused by a family member during a visit. The resident, who was cognitively intact and wheelchair-bound, stated that the stepdaughter demanded a bank card and, upon refusal, grabbed the resident by the shirt collar and neck while outside the facility. The incident was relayed to staff shortly after it occurred, and the resident was assessed for injuries, with none noted at the time. The facility's abuse prevention policy explicitly includes protection from abuse by family members. Despite this, the resident was able to be placed in a situation where physical abuse occurred on facility property. Multiple staff interviews confirmed that the resident reported the incident to an activities staff member, who then notified an LPN. The LPN assessed the resident and confirmed the account of being grabbed by the collarbone and neck during the demand for the bank card. The event was also reported to the facility administrator, who was informed that the family member had already left the premises. The administrator initiated an investigation and notified local law enforcement. The resident's account was consistent across interviews with staff and law enforcement, describing the physical abuse and the demand for the bank card. The facility failed to prevent the abuse from occurring, as required by its own policies and federal regulations.
Failure to Prevent Elopement, Implement Post-Fall Interventions, and Investigate Falls
Penalty
Summary
A severely cognitively impaired resident with a known history of wandering and elopement risk exited the facility unnoticed. The resident had previously demonstrated behaviors such as pacing, exit-seeking, and verbalizing intent to leave, and was identified as an elopement risk upon admission. Despite these known risks and documented interventions such as monitoring for tailgating, use of an audible monitoring system, and a departure alert device, the resident was able to leave the facility without staff awareness. Staff interviews confirmed that the resident was last seen in their room and was later found outside by a CNA who was returning from a break with another resident. There was no staff present with the resident at the time of elopement, and the incident was only discovered after the resident was observed outside, indicating a lapse in supervision and monitoring. Another resident, identified as high risk for falls due to a history of dizziness, hypotension, and previous falls, experienced a witnessed fall at the nurse's station, resulting in head injury and vomiting. The care plan for this resident included a neurology referral as a post-fall intervention, but as of the time of review, there was no documentation that a neurology appointment had been scheduled. Staff interviews confirmed that the resident had a pattern of sudden spells leading to falls, and that post-fall interventions were not fully implemented as documented in the care plan. A third resident with severe cognitive impairment and a history of falls reported falling out of bed and sustaining a skin tear and swelling to the left elbow. The facility's investigation into this incident was incomplete, lacking staff interviews or statements regarding the fall or injury. The care plan included interventions such as a prompted toileting program and a scoop mattress, but there was no documentation of when the resident was last toileted on the day of the fall. The lack of thorough investigation and documentation limited the facility's ability to identify the circumstances of the fall and implement appropriate interventions.
Inaccurate MDS Assessment for Wandering Behavior
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) accurately reflected the resident's wandering behavior. The MDS for a resident with severe cognitive impairment did not document any wandering during the look-back period, despite behavior tracking records showing that the resident exhibited wandering on two separate days and a nursing note indicating the resident entered another resident's room and disturbed them. The MDS Coordinator confirmed that the MDS did not capture these behaviors and acknowledged the discrepancy after reviewing the behavior tracking and nursing notes.
Lack of Qualified Director for Food and Nutrition Services
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, as required. During observations on two consecutive days, the individual actively supervising dietary operations was identified as the full-time Dietary Manager but did not possess certification as a Dietary Manager or have equivalent training. This was confirmed by both the Dietary Manager and the facility Administrator. The facility's own assessment tool indicated the need for a dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services, yet this requirement was not met. At the time of the survey, 74 residents resided in the facility.
Failure to Include Smoking Status in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan that included a resident's smoking status. Although the facility's policy requires that care plans address all resident needs with measurable objectives and timetables, one resident was not identified as a smoker in their care plan, despite being listed as an independent smoker requiring supervision on the facility's Smoker List and photo sheet. The resident was observed smoking outside the facility on multiple occasions under staff supervision, and Safe Smoking Evaluations indicated the resident was a safe smoker who required no assistance and that a care plan should be developed. The resident was admitted as a non-smoker but began smoking about a month after admission. However, the care plan dated prior to the update did not reflect the resident's smoking status or related interventions, despite documentation and observations confirming the resident's smoking activity and need for supervision and use of a smoking apron. This omission resulted in the care plan not addressing all of the resident's current needs as required by facility policy.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving three residents. One cognitively intact resident reported being kicked in the knee by another resident, who was also observed blocking and cursing at her in the dining room. This incident was corroborated by a dietary aide and the resident's family member, who was notified by the facility. Another resident, who is severely cognitively impaired, sustained a right knee skin tear after being pushed to the ground by the same aggressive resident. This event was witnessed by a CNA and documented in the resident's progress notes, with the injured resident expressing pain during wound care. The aggressive resident, who is also severely cognitively impaired, had a documented history of physical aggression toward both residents and staff, with care plans and progress notes indicating unsuccessful attempts at redirection. On the day of the incidents, this resident was removed from the dining room after exhibiting aggressive behavior and was later sent to the emergency room for evaluation. Staff interviews confirmed ongoing challenges in managing this resident's aggression, and psychiatric notes indicated an increase in such behaviors prior to the incidents.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement effective interventions to prevent abuse among residents, specifically involving three residents with a history of aggressive or abusive behavior. On one occasion, an altercation occurred in the dining room where one resident blocked and kicked another, resulting in pain and distress. Staff and family interviews confirmed that the aggressive resident had a pattern of bothering and physically assaulting others. Documentation showed that the resident who was assaulted was cognitively intact, while the aggressor was severely cognitively impaired and had a documented history of aggression toward both residents and staff. Another incident involved the same aggressive resident pushing a severely cognitively impaired resident to the ground, causing a skin tear. Staff observed the aggressive behavior and noted that the resident was difficult to manage, often cursing and being physically aggressive. Despite the care plan identifying the risk of aggression and the need for interventions to protect others, records indicated that interventions were largely unsuccessful, and more effective measures such as moving the resident or providing 1:1 observation were not implemented prior to the incidents. The facility's policy required the administrator to determine protective actions upon receiving abuse allegations, but the documented actions were insufficient to prevent repeated altercations.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. One resident, who is cognitively intact and dependent on staff for transfers, reported being struck on the back of the neck by another resident with severe cognitive impairment and a documented history of aggressive behaviors. The incident occurred in the main dining room and was witnessed by a CNA, who confirmed that the aggressor became upset when unable to pass and then hit the other resident. The victim experienced neck pain for several days and expressed ongoing fear and emotional distress related to the incident, including crying and avoidance of the aggressor. Multiple staff interviews corroborated the incident and the ongoing impact on the victim, who now becomes visibly upset and refuses to participate in activities when the aggressor is present. The aggressor has a documented pattern of physical and verbal outbursts, including aggression toward others on multiple days, and has previously hit staff. The facility's abuse prevention policy states that residents have the right to be free from abuse, including the willful infliction of injury resulting in physical harm, pain, or mental anguish. Despite this, the facility did not prevent the incident or adequately protect the resident from further psychosocial harm.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to timely report an allegation of resident-to-resident physical abuse to both the administrator and the state survey agency for two residents. One resident, who is cognitively intact and requires substantial assistance for transfers, reported that another resident with severe cognitive impairment and a history of aggressive behaviors struck her in the back of the neck while in the dining room. This incident caused the resident neck pain for several days and triggered emotional distress due to past trauma. The incident was witnessed by a CNA, who reported it to an LPN, but not directly to the administrator as required by facility policy. Multiple staff members, including the CNA, LPN, Activity Director, and Maintenance Director, were aware of the altercation or its aftermath, and it was discussed in a morning meeting that the two residents should be kept apart. However, there was no documentation of the incident in either resident's medical records, no abuse investigative file was created, and the incident was not reported to the state survey agency. The administrator, upon being informed, determined the event was accidental and did not consider it abuse, thus did not initiate the required reporting process. The facility's policy requires all possible incidents of abuse to be identified, investigated, and reported within federally mandated time frames. Despite this, the incident involving physical contact and resulting distress was not properly documented, investigated, or reported as an abuse allegation, representing a failure to follow established protocols for abuse prevention and reporting.
Failure to Ensure Safe Transfers and Fall Management
Penalty
Summary
The facility failed to ensure safe mechanical lift transfers and proper fall management for two residents with severe cognitive impairment. In one instance, a resident was transferred by a single CNA using a mechanical lift, contrary to facility policy requiring two staff members. During the transfer, the resident detached the sling from the lift and was subsequently lowered to a reclining wheelchair that was broken and leaning forward, causing the resident to slide out. The CNA admitted to performing the transfer alone due to staff being busy, and the Director of Nursing confirmed that two-person assistance is required for all mechanical lift transfers. Additionally, the facility did not document falls in the medical records, investigate the incidents, or implement post-fall interventions for two residents. One resident experienced two falls that were not recorded in the medical record, and there was no evidence of a root cause investigation or development of post-fall interventions. Staff interviews revealed that alternative approaches or interventions were not attempted during care, and the Director of Nursing acknowledged the lack of documentation and investigation for these incidents.
Failure to Identify Triggers and Implement Trauma-Informed Care for Resident with History of Abuse
Penalty
Summary
The facility failed to identify triggers, develop a care plan, and implement appropriate interventions and services for a resident with a past history of abuse, affecting three residents reviewed for abuse. One resident, who is cognitively intact but has multiple diagnoses including paraplegia, anxiety disorder, cerebral palsy, intellectual disability, and major depressive disorder, reported being physically struck by another resident. This incident triggered memories of past abuse by the resident's mother, leading to increased anxiety, fear, and emotional distress. The resident expressed fear and nervousness whenever encountering the other resident involved in the altercation, and staff confirmed the resident's emotional reactions and avoidance behaviors. Despite the facility's policy on trauma-informed care, which requires screening for trauma, identification of triggers, and individualized care planning, the resident's care plan did not include specific details about the history of abuse, associated triggers, or tailored interventions. The care plan only included a general intervention to keep the resident away from others who might trigger behaviors, without addressing the underlying trauma or providing detailed strategies to mitigate re-traumatization. The social service assessment acknowledged a history of abuse and trauma but lacked further detail, and the psychiatric provider was unaware of the resident's abuse history due to lack of documentation and communication from staff. Interviews with staff and family revealed that the resident's history of abuse and specific triggers were known to some staff and family members but were not consistently documented or communicated among the care team. The psychiatric provider stated that if made aware of the abuse history, additional interventions such as psychotherapy and medication adjustments could have been considered. The resident had not received psychotherapy services in the past six months, and the new LCSW had not yet seen the resident. The lack of comprehensive assessment, care planning, and implementation of trauma-informed interventions resulted in the resident experiencing ongoing distress and inadequate psychosocial support.
Failure to Individualize Dementia Care Plan and Interventions
Penalty
Summary
The facility failed to develop and implement a resident-centered care plan for a resident diagnosed with dementia who exhibited aggressive and resistive behaviors. Despite documented incidents of physical aggression, such as hitting another resident and staff, as well as verbal outbursts and resistance to care, the care plan was not updated to reflect these specific behaviors or to include personalized nonpharmacological interventions. The behavior monitoring and intervention report used was generic and did not identify targeted behaviors or individualized approaches for the resident. Multiple staff interviews confirmed that the resident was consistently combative, resistive to care, and had difficulty understanding verbal cues due to dementia. Staff reported using the same general interventions for all residents, without tailoring strategies to the resident's unique needs or updating the care plan after significant incidents, such as physical altercations and falls. Staff also acknowledged that alternative approaches, such as using visual cues or involving staff members with whom the resident responded better, were not attempted during episodes of resistance. Documentation reviewed showed repeated instances of the resident refusing care, exhibiting physical and verbal aggression, and experiencing falls during care attempts. The facility's own dementia care protocol required individualized care planning and communication of resident needs, but these steps were not followed. The lack of specific, updated interventions and failure to address the resident's behaviors in the care plan contributed to ongoing incidents affecting both the resident and others in the facility.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and manufacturer instructions for two residents. In one instance, a nurse administered Albuterol inhaler to a resident without shaking the inhaler beforehand, despite the medication label and manufacturer's instructions clearly stating that the inhaler should be shaken prior to use. The nurse later confirmed she was unaware of this requirement. In another case, a nurse administered Clonidine to a resident without first checking the resident's blood pressure, even though the physician's order and medication card specified to hold the medication if the systolic blood pressure was less than 120. The nurse also administered rapid-acting Insulin Lispro to the same resident before the meal tray had been delivered, contrary to manufacturer instructions that the insulin should be given within 15 minutes prior to or immediately after a meal. The nurse acknowledged not following these instructions, and the Director of Nursing confirmed the correct timing for insulin administration.
Failure to Maintain Safe Wheelchair Condition Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a wheelchair was maintained in safe operating condition for one resident. According to nursing notes, the resident experienced a witnessed fall after being lowered to the floor from a lift, with a CNA reporting that the resident had unclamped the sling and was then lowered without head injury. Later, a CNA stated that when the resident was transferred into his reclining chair, the wheelchair was broken and tilted forward, causing the resident to slide out. Multiple CNAs confirmed that the wheelchair had been broken and in a forward-tilted position for some time prior to the incident, and that it was eventually switched out due to discomfort and safety concerns. The Maintenance Director reported that repairs are tracked through a logbook, but there was no record of the broken wheelchair, and he was never notified of the issue. Facility policy requires maintenance work orders to be filled out and forwarded to the Maintenance Director, with emergency requests prioritized, but this process was not followed in this case.
Failure to Implement Care Plan Leads to Resident Aggression
Penalty
Summary
The facility failed to implement a care plan to prevent resident intrusion of privacy, which resulted in aggression between two residents. On 3/21/25, an incident occurred when one resident wandered into another resident's room, leading to both residents falling to the floor. Prior to this incident, on 3/20/25, the wandering resident had mistakenly entered the adjoining room, causing distress to the other resident. An interdisciplinary team reviewed the situation and decided to place a sign in the bathroom to guide the wandering resident back to their own room. However, by 3/25/25, the sign had not been placed as planned, and another incident occurred. The Director of Nursing confirmed that the team had agreed on the sign placement, but it was not implemented, leading to the subsequent incident. Instead, a locking doorknob cover was installed on the bathroom door to prevent access to the other resident's room, requiring the resident to leave the door open when using the bathroom. The President of Clinical Operations instructed the Director of Nursing to resolve the care plan issue by implementing both the sign and the doorknob cover.
Deficiency in Abuse Prevention Policy Regarding Technology
Penalty
Summary
The facility failed to update its abuse prevention policy to include a definition of abuse facilitated or enabled by the use of technology. This oversight was identified during an interview and record review, where it was confirmed that the most recent revision of the policy, dated August 2024, did not address the prohibition of abuse through technological means, such as video recording residents in compromising situations. This deficiency has the potential to impact all seventy residents residing in the facility, as the current policy does not adequately protect them from abuse facilitated by technology.
Inadequate CNA Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing of Certified Nursing Assistants (CNAs) to meet the needs of its residents, affecting five out of seven residents reviewed for staffing. Observations and interviews revealed that the facility often operated with fewer CNAs than required, leading to delays in call light responses and inadequate care. Residents reported waiting times of up to an hour for assistance with incontinence care, particularly when CNAs were on lunch breaks or when the facility was short-staffed. The facility's assessment indicated a need for six CNAs on day and evening shifts and three on night shifts. However, records showed that the facility frequently operated with fewer CNAs than needed, with only five CNAs on several occasions. Interviews with CNAs confirmed that working with fewer staff led to rushed care, skipped tasks such as applying lotion after showers, and delayed responses to call lights. The facility's staffing was based on census numbers rather than the acuity needs of residents, which further contributed to the inadequate staffing levels. The Director of Nursing and other staff acknowledged the staffing issues, noting that the facility's staffing calculations did not account for resident acuity. The facility's assessment had not been updated since August 2024, and the staffing ladder used by the scheduler was based on census rather than the specific needs of residents. This deficiency in staffing had the potential to affect all 71 residents in the facility, as many required substantial assistance for daily activities, including transfers that necessitated two-person assistance.
Insufficient Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to provide sufficient dietary support personnel, resulting in delayed meal service for several residents. On a specific day, the Dietary Manager had to work as the dayshift cook due to staffing shortages, with only two dietary aides assisting. This led to delays in meal delivery, with some residents receiving their meals significantly later than the scheduled times. The facility's records indicate that the morning cook, who was responsible for preparing meals, frequently arrived late or did not show up, exacerbating the issue. This resulted in breakfast and lunch being served up to an hour late on multiple occasions. Residents reported receiving their meals late, with breakfast sometimes not served until 9:00 AM, despite the scheduled time being 7:00 AM. The facility's dietary schedules and timecards confirmed the cook's tardiness and absence, contributing to the delays. Staff members corroborated these accounts, noting that the dietary department was short-staffed, and the Dietary Manager had to cover various roles, including cooking and dishwashing, due to the lack of personnel. This deficiency in staffing and timeliness of meal service had the potential to affect all 71 residents in the facility.
Failure to Maintain Food Supply and Log Substitutions
Penalty
Summary
The facility failed to maintain adequate food ordering and supply, resulting in the inability to follow the planned menus and log substitutes. This deficiency affected three of the seven residents reviewed for dietary services and had the potential to impact all 71 residents in the facility. Residents reported that the facility frequently ran out of food items such as milk, orange juice, dinner rolls, and yogurt. The facility's food order invoices showed a gap in ordering beef patties, leading to a shortage of hamburgers for a month. Cooks confirmed that they often had to serve smaller portions or substitute different foods due to insufficient supplies, and the substitution log was not consistently maintained. The dietary manager and registered dietitian were unaware of the extent of the food shortages and the lack of proper logging for substitutions. The dietitian, who visits the facility once a week, stated that substitutions should be logged for review and approval to ensure nutritional needs are met. The facility's orientation documents for kitchen staff emphasized the importance of following menus and recipes, with any changes requiring the dietitian's approval. However, the last recorded entry in the substitution log was several months prior, indicating a lapse in protocol adherence.
Insufficient Housekeeping Staff Leads to Inadequate Cleaning
Penalty
Summary
The facility failed to maintain a clean and homelike environment due to insufficient housekeeping staff, affecting five out of seven residents reviewed. Observations revealed that housekeepers did not sweep floors before mopping, and toilets were not cleaned daily unless visibly dirty. Housekeepers admitted to skipping steps in the cleaning process to save time, especially when only one housekeeper was scheduled, which was a frequent occurrence, particularly on weekends. This resulted in only two of the four halls being cleaned each day, with the remaining halls cleaned the following day. Residents reported that their rooms were not cleaned daily, and when they were, the cleaning was not thorough. Specific complaints included unswept floors, uncleaned toilets, and debris left in rooms. The facility's housekeeping schedule confirmed that only one housekeeper was scheduled on multiple days, corroborating the residents' and staff's statements. The housekeeping supervisor acknowledged the staffing issues and confirmed that the cleaning procedures were not being followed as required.
Failure to Honor Resident Food Preferences and Provide Substitutes
Penalty
Summary
The facility failed to provide food that accommodates resident preferences and ensure substitutes were available, affecting six out of seven residents reviewed for dietary services. Observations revealed that the facility was without yogurt for three days, and peanut butter and toast were served as substitutes. However, yogurt was not included on the meal trays of residents who had it specified on their meal tickets. Additionally, there was no prepared egg salad readily available, and residents did not preselect meals, leading to dissatisfaction with the food served. Several residents expressed concerns about not receiving their preferred food items as documented on their meal tickets. One resident with severe cognitive impairment did not receive yogurt as specified, while others, who were cognitively intact, reported not receiving yogurt or being served items they disliked, such as broccoli. The facility's dietary staff acknowledged the issues, confirming that meal preferences should be followed and that the always available menu items were not consistently provided. The facility's documentation indicated that resident preferences should be honored, but this was not consistently executed, leading to the deficiency.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers for three residents who were dependent on staff assistance for bathing. Resident 2, who was admitted with medical conditions such as Atrial Fibrillation and mobility issues, was scheduled to receive showers twice a week but reported only receiving one or two showers in the previous month. The resident expressed that staff would inform them of a shower day but would not return to assist, leading the resident to wash at the sink, which was insufficient for full cleanliness. The facility's records corroborated the resident's account, showing only one documented shower in December. Similarly, Resident 3, with diagnoses including Acute Respiratory Failure and Morbid Obesity, was also scheduled for two showers per week but reported receiving only one shower weekly. The resident was dependent on staff for showering due to limited mobility and fatigue. Resident 4, who had a sternum fracture and other mobility impairments, was also scheduled for two showers per week but reported receiving showers less frequently, sometimes only once every other week. The Director of Nursing acknowledged the failure to provide the scheduled showers and noted that documentation should reflect when showers are given or refused, which was not consistently done.
Infection Control Deficiencies in C-Diff Outbreak
Penalty
Summary
The facility failed to prevent the transmission of Clostridium difficile (C-Diff) infections, as evidenced by multiple deficiencies in infection control practices. The facility did not ensure proper disinfection of shared shower rooms, which were used by residents from different halls. Observations revealed that shower rooms were not being cleaned thoroughly between uses, and shared products were not stored properly. Additionally, the facility was using bleach wipes instead of the recommended bleach solution for cleaning, which was not in accordance with the infection control guidelines provided by an infection control consultant. The facility also failed to adhere to proper hand hygiene and personal protective equipment (PPE) protocols. Staff members were observed entering and exiting isolation rooms without performing hand hygiene or wearing appropriate PPE, despite the presence of contact isolation signs. This included instances where a registered nurse and a certified nursing assistant did not perform hand hygiene after removing PPE, and a housekeeper entered an isolation room without any PPE and did not perform hand hygiene after handling waste. Furthermore, the facility did not adequately follow up on laboratory testing for residents with gastrointestinal symptoms. Several residents had orders for stool testing for C-Diff, but the facility failed to document the results or follow up with the laboratory. In some cases, samples were not tested, and the facility did not provide information on the status of these tests. This lack of follow-up and documentation contributed to the facility's inability to effectively manage and control the outbreak of C-Diff infections.
Delayed Administration of Antibiotics for J-tube Infection
Penalty
Summary
The facility failed to timely administer a resident's prescribed oral and intravenous antibiotics for an infected jejunostomy tube, resulting in a significant medication error. The resident, diagnosed with Extended Spectrum Beta Lactamase (ESBL) Resistance and a gastrostomy infection resistant to Vancomycin-related antibiotics, was supposed to receive Colistimethate Sodium intravenously every 12 hours for 21 days starting on August 17, 2024. However, the first dose of IV antibiotics was administered 10 days later, on August 18, 2024. This delay was due to a series of communication issues between the facility, the physician, and the pharmacy, including the need for prior authorization and clarification of the antibiotic order. The resident's medical records indicate multiple orders for wound cultures and antibiotics, including Zyvox and Polymyxin B Sulfate, to address the infection. Despite these orders, there were significant delays in obtaining and administering the necessary medications. The resident's condition required contact isolation precautions due to the presence of a multi-drug resistant organism at the J-tube site. The Assistant Director of Nursing confirmed the delay was caused by back-and-forth communication with the doctor and pharmacy, while the Director of Nursing noted that prior authorization requirements contributed to the delay in starting the antibiotics.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent before administering an antipsychotic medication to a resident, identified as R5, who was reviewed for chemical restraints. The facility's Behavioral Health Services Program policy requires obtaining consent for any new psychotropic medications prior to administration. However, R5's records show that Quetiapine Fumarate was ordered and administered starting on June 17, 2024, without prior consent. The Medication Administration Record indicates that the first dose was given on June 19, 2024, and a total of 39 doses were administered over 20 days before consent was documented. The consent for the psychotropic medication was eventually obtained via telephone from R5's Power of Attorney on July 9, 2024, which was after the medication had already been administered for several weeks. Additionally, a Psychotropic Medication Observation form dated June 22, 2024, was provided by the Director of Nursing, indicating that consent was supposedly obtained from the POA on that date. However, this form lacked specific details, such as the name of the person who gave consent, and there was no corresponding Nurse's Note to verify the consent process. This oversight highlights a significant lapse in following the facility's policy for informed consent prior to administering psychotropic medications.
Failure to Provide Adequate Showering Services
Penalty
Summary
The facility failed to provide adequate showering services to two residents, R2 and R3, who were dependent on staff for assistance with activities of daily living, including bathing. R2, who has diagnoses of unsteadiness on feet, unspecified abnormalities of gait and mobility, and weakness, was documented as receiving only one shower over a month-long period, despite being totally dependent on staff for bathing. R2 expressed that she does not always receive her showers, and the Assistant Director of Nursing confirmed the lack of additional shower documentation for R2. Similarly, R3, who has diagnoses including incontinence and deconditioned muscles due to immobility, was documented as receiving showers only three times over a similar period. R3 expressed a desire for more frequent showers, particularly to aid in the healing of a painful wound, but was unaware of her scheduled shower days. The Assistant Director of Nursing confirmed the absence of further shower documentation for R3 within the last 30 days. The facility's policy requires at least one shower per week, or more frequently if preferred by the resident, which was not adhered to in these cases.
Significant Medication Error with Opioid Administration
Penalty
Summary
The facility failed to ensure that a resident's opioid pain medication was administered as prescribed, leading to a significant medication error. A resident with terminal diagnoses of Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure was given 40 mg of Hydromorphone instead of the prescribed 4 mg. This error occurred because the Licensed Practical Nurse (LPN) administered 4 ml of a new, higher concentration Hydromorphone (10 mg/ml) instead of the previous concentration (1 mg/ml), without verifying the updated concentration on the medication bottle or the Electronic Medication Administration Record. The error was discovered when the LPN noticed a change in the medication's color and confirmed the concentration discrepancy after administering the dose. The resident was subsequently given Narcan, an opioid reversal medication, and transported to the emergency room for evaluation. The Director of Nursing confirmed the medication error and noted that the hospice had increased the concentration of Hydromorphone, but the night nurse was unaware of this change. The resident was stable at the time of the incident but later passed away in the hospital. The hospice nurse had written a new order for the increased concentration, but it was not documented who received the order at the facility. The hospice pharmacist noted that there was no alert on the bottle indicating the concentration change, and it was up to the person preparing the medication to place such an alert. The overdose did not immediately result in the resident's death, as the resident was alert and oriented at the hospital following the incident. The death certificate later documented the cause of death as Acute Hypoxic Respiratory Failure, COPD Exacerbation, and Pneumonia.
Failure to Secure Adaptive Device Leads to Resident Fall
Penalty
Summary
The facility failed to maintain and monitor adaptive devices, specifically a toilet seat riser, to ensure proper functioning, which resulted in a fall for a resident (R53). R53, who has severe cognitive impairments and is at risk for falls, experienced a fall when the unsecured toilet seat riser slid off the toilet while R53 was sitting and/or transferring onto it. This incident caused R53 to fall, leading to a fractured finger and a laceration that required three sutures. The incident was documented in R53's progress notes and hospital records, which confirmed the injuries sustained during the fall. Interviews with the Director of Nursing and the Maintenance Director revealed that the toilet seat riser was not properly secured, which allowed it to move and caused the fall. The Maintenance Director admitted that regular checks on the toilet seat risers were not conducted to ensure they were secure. The facility's Fall Prevention Program, which includes measures to assess fall risks and implement appropriate interventions, was not adequately followed in this case, as malfunctioning equipment was not immediately reported for repair or removed from service.
Failure to Employ Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 69 residents residing in the facility. On 5/20/24 at 8:23am, the Dietary Manager was observed actively supervising dietary operations in the facility kitchen during resident meal preparations. The Dietary Manager reported being the full-time manager of the facility food service but admitted to not being a clinically qualified Certified Dietary Manager or having the equivalent training. The Resident Census and Conditions of Residents report dated 5/19/24 documented that 69 residents reside in the facility. Additionally, the Facility Assessment Tool dated 12/13/2022 indicated the need for a dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services, which was not met.
Failure to Assess and Document Side Rail Use
Penalty
Summary
The facility failed to properly assess, obtain consent, and care plan the use of side rails for four residents. Observations revealed that residents were using side rails without documented assessments or consents. For instance, one resident with severe cognitive impairment was observed using a side rail to assist with turning and transfers, but their care plan did not document side rail use, and the last assessment was dated nearly a year prior. Another resident with severe cognitive impairment was found using side rails on an air mattress, but their care plan also lacked documentation of side rail use, and the last assessment was similarly outdated. Additionally, a resident who was cognitively intact stated that side rails were used to prevent falls and assist with turning in bed, yet there were no documented assessments or consents in their electronic medical record (EMR). Another resident with severe cognitive impairment used side rails to get in and out of bed, but their care plan did not document side rail use, and the last assessment was outdated. The Director of Nursing confirmed that side rail assessments were not completed quarterly as required and that there was an issue with the EMR system prompting assessments annually instead of quarterly.
Failure to Maintain and Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to maintain resident influenza and pneumococcal vaccination information and offer pneumococcal vaccines for four of five residents reviewed for immunizations. The facility's policy dated August 2023 requires education on influenza and pneumococcal vaccines to be given to residents and their representatives upon admission, with documentation of vaccination status and refusals in the resident's medical record. However, the facility did not adhere to this policy for residents R31, R7, R14, and R54, as their medical records lacked documentation of vaccination status and offers for the pneumococcal vaccine. Resident R31's medical record did not document influenza and pneumococcal vaccine information, and there was no evidence that R31 was offered the pneumococcal vaccine after admission. Similarly, R7's record did not document pneumococcal vaccine history or refusal, despite the MDS indicating the vaccine was offered and declined. R14's record also lacked documentation of pneumococcal vaccination history and offer. For R54, the MDS indicated ineligibility for the pneumococcal vaccine, but the medical record did not document any vaccination history. The Director of Nursing confirmed the lack of documentation and stated that a pneumococcal vaccine clinic had not been offered recently.
Failure to Assess Side Rails for Entrapment Risk
Penalty
Summary
The facility failed to assess side rails for risk of entrapment for four residents. Observations revealed that residents had upright side rails on their beds, which they used for assistance with turning and transfers. However, there were no documented assessments or measurements to evaluate the risk of entrapment for these side rails. Interviews with staff, including a CNA, the Director of Nursing, the Maintenance Director, and a Physical Therapy Assistant, confirmed that no formal assessments or measurements were conducted to ensure the safety of the side rails. The facility's policy requires regular inspections and assessments to prevent entrapment, but these were not performed. Resident 7, Resident 38, Resident 41, and Resident 55 were all observed to have side rails on their beds, with varying degrees of cognitive impairment and dependency on staff for mobility. Despite the facility's policy and FDA guidelines outlining the risks and necessary precautions for bed rail use, the facility did not follow through with the required assessments. This oversight could potentially lead to entrapment hazards, as the gaps between the bed rails, mattress, and bed frame were not measured or evaluated for safety.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to accurately complete the comprehensive assessments for two residents. For Resident 54, the Minimum Data Set (MDS) inaccurately documented that the resident received intravenous (IV) medications, despite the Physician Order Sheets (POS) for March, April, and May 2024 indicating no such prescriptions. The Director of Nursing confirmed that Resident 54 had never received IV medications. For Resident 15, the MDS incorrectly indicated that the resident was receiving hospice services, while the Physician Orders Sheet and an untitled document from an outside care company both confirmed that the resident was actually receiving palliative care. The Director of Nursing confirmed the incorrect coding on the MDS for Resident 15.
Failure to Implement Physician Orders and Properly Manage Diabetic Wounds
Penalty
Summary
The facility failed to implement physician orders for laboratory results and withholding medication, and failed to assess, measure, and implement treatments for diabetic wounds for one resident. The resident had a history of Type 1 and Type 2 Diabetes Mellitus, Atherosclerosis of Coronary Artery Bypass Graft, Peripheral Vascular Disease, Chronic Kidney Disease, and a Left Tibia Shaft Fracture. The resident was admitted with toe wounds, which were not properly documented or assessed upon admission. The facility's records showed inconsistencies in wound assessments and treatments, with some treatments not being administered as ordered and laboratory orders not being completed. The resident's medical records indicated that the wounds were initially documented as resolved by the wound physician, but subsequent notes from the nurse practitioner indicated ongoing issues with necrosis and new wounds. The facility's Treatment Administration Records did not consistently document treatment orders for the resident's diabetic wounds, and there were no descriptions or measurements of the wounds in the medical record. The resident's May Medication Administration Record showed that Lisinopril was not held for the full five days as ordered, and laboratory orders for a Complete Blood Count and Basic Metabolic Panel were not implemented. The Director of Nursing (DON) acknowledged the lack of proper wound assessments and treatments, citing the absence of an Assistant DON and a wound nurse as contributing factors. The DON also noted that the wound physician had canceled some visits and did not enter progress notes into the electronic medical record until the day after visits. The facility's policy required weekly documented assessments and measurements of wounds, which were not consistently followed. The DON confirmed that the laboratory orders and medication withholding were not completed as ordered, and there was no documentation to show that the physician was aware of the ongoing wound issues or that treatment orders were not necessary.
Failure to Complete Wound Assessments and Follow Treatment Orders
Penalty
Summary
The facility failed to complete timely wound assessments, follow physician orders for wound treatments, and monitor dressings for two residents with pressure ulcers. Resident R69 was admitted with a stage 2 pressure ulcer to the coccyx, but no wound assessments were documented until six days after admission. Additionally, the prescribed foam dressing was not applied correctly, and the dressing was not in place during a subsequent check. The Director of Nursing confirmed that wounds should be assessed immediately and weekly thereafter, which was not done in this case. Resident R15 had a stage 1 pressure ulcer on the coccyx, but the wound assessment form was left blank, and the prescribed treatments were not followed. The treatment administration record did not reflect the correct orders, leading to the application of an incorrect treatment. The Director of Nursing acknowledged that the treatment orders were not updated correctly in the system, resulting in the wrong treatment being administered. The facility's policy requires wound assessments to be documented and dressings to be checked daily, which was not adhered to in these instances.
Failure to Properly Date and Maintain Respiratory Equipment
Penalty
Summary
The facility failed to properly date and maintain respiratory equipment for two residents, leading to deficiencies in respiratory care. For one resident, the oxygen tubing and humidification bottle were not signed or dated, despite the resident having significant respiratory conditions such as Chronic Obstructive Pulmonary Disease (COPD) and Acute and Chronic Respiratory Failure with Hypercapnia. The Director of Nursing confirmed that the equipment should have been dated according to the facility's policy, which mandates weekly changes and proper labeling of respiratory supplies. Another resident's nebulizer mask, chamber, and tubing were found uncovered and improperly stored on a recliner. The nebulizer equipment was supposed to be changed weekly and stored in a dated plastic bag when not in use, but this was not done. The resident's nebulizer treatment was last administered three days prior, and the equipment was last dated nearly a month ago. The Licensed Practical Nurse confirmed that the nebulizer equipment should be stored in a bag and dated, as per the facility's policy.
Failure to Identify and Care Plan Specific Behaviors and Nonpharmacological Interventions
Penalty
Summary
The facility failed to identify and care plan specific targeted behaviors and nonpharmacological interventions, and complete psychotropic medication assessments for a resident with severe cognitive impairment. The resident's care plan did not specify which cares the resident was resistive to and did not identify specific behaviors for the use of antipsychotic, antianxiety, and antidepressant medications. The resident's behavior tracking was generic and did not document specific behaviors or nonpharmacological interventions attempted prior to administering PRN psychotropic medications. The resident's medication administration records showed multiple instances of PRN psychotropic medication administration without documentation of specific behaviors or nonpharmacological interventions attempted beforehand. Interviews with CNAs revealed that the resident exhibited various behaviors such as cussing, threatening to hit staff, playing with feces, and refusing care. However, the CNAs did not have specific behavioral interventions to respond to these behaviors, and the resident's care plan did not include personalized nonpharmacological interventions. The Director of Nursing confirmed that the behavior tracking record was generic and did not identify the resident's specific targeted behaviors or personalized nonpharmacological interventions. The DON also confirmed that psychotropic medication assessments should be done on admission and quarterly, but the resident did not have a psychotropic medication assessment prior to a recent evaluation. The facility's Behavioral Health Services Program requires individualized behavioral interventions and documentation of interventions attempted before using PRN psychotropic medications, which was not followed in this case.
Failure to Administer Insulin Properly and Timely
Penalty
Summary
The facility failed to administer insulin according to the manufacturer's instructions and facility policy, resulting in a medication error rate of 9.09%. Specifically, the facility did not prime insulin pens before administration and did not ensure that residents received their meals within the recommended time frame after insulin administration. This affected three residents who were administered rapid-acting insulin without proper priming and without timely access to food, increasing the risk of hypoglycemia. For instance, one resident received Fiasp insulin without priming, and their meal was served over 30 minutes after the insulin administration. Another resident received Lispro insulin without priming, and their meal was served 50 minutes later. A third resident also received Lispro insulin without priming, and their meal was served 42 minutes later. The Director of Nursing confirmed that insulin pens should be primed before each administration and that residents should eat within 30 minutes of receiving short-acting insulin. The failure to follow these procedures was observed during a survey, and it was confirmed through interviews and record reviews. The deficiency affected three out of six residents reviewed for medication administration in a sample list of 36, highlighting a significant lapse in adherence to proper insulin administration protocols.
Failure to Accurately Label Intravenous Medications
Penalty
Summary
The facility failed to ensure intravenous medications were accurately labeled for two residents, leading to discrepancies between the physician orders and the labels on the IV bags. For one resident, the physician ordered a one-time IV micronutrient/hydration therapy with specific additives, but the IV bag label did not match the ordered dosages. The same issue occurred with another resident, where the IV bag label included different dosages of additives than those specified in the physician's order. The Registered Nurse from the infusion company confirmed that the labels used were outdated and did not reflect the new formulations, resulting in the administration of IV therapy that did not match the physician's orders. The facility's Medication Administration Policy and Medication Storage Policy both emphasize the importance of accurate labeling and administration of medications. However, the infusion company recently changed the IV formulations, and the old labels were mistakenly used on the IV bags for the two residents. This error was identified during the administration of the IV therapy, and the Registered Nurse acknowledged the discrepancy between the labels and the physician orders. The failure to use the correct labels led to the administration of incorrect dosages of additives in the IV therapy for both residents.
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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