La Bella Of Mascoutah
Inspection history, citations, penalties and survey trends for this long-term care facility in Mascoutah, Illinois.
- Location
- 201 South 10th Street, Mascoutah, Illinois 62258
- CMS Provider Number
- 145518
- Inspections on file
- 36
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at La Bella Of Mascoutah during CMS and state inspections, most recent first.
Surveyors found that the facility did not develop or complete comprehensive care plans for three residents’ ROM/contracture management and activity needs. One resident with severe cognitive impairment, multiple complex diagnoses, and documented ROM impairment was observed with a fully contracted hand and no contracture management interventions in place, and the care plan lacked ROM and activity components despite a prior activity assessment noting specific preferences. Another resident with legal blindness, anxiety disorder, and psychotic disorder had intact cognition and required assistance with mobility and transfers, but the activity care plan entry was incomplete and the activity assessment was left blank. A third resident with paralytic syndrome, acute respiratory failure with hypoxia, moderate cognitive impairment, and dependence for bed mobility and transfers had no completed activity assessment and no care plan for activity preferences, contrary to staff statements and facility policy that assessments and care plans should be completed on admission and updated quarterly.
Two dependent residents who could not reposition themselves were observed in reclining wheelchairs for extended periods without repositioning, despite facility policy and administrative expectations that such residents receive assistance with mobility at least every two hours. Observations conducted at 15–30-minute intervals from the morning through early afternoon showed no repositioning until each resident was assisted to bed later in the day. CNAs reported that each resident had been laid down after breakfast for incontinence care and then returned to their wheelchairs but were unsure of the times and acknowledged no further repositioning occurred until the afternoon.
The facility failed to complete required activity assessments and care plans for three cognitively intact or mildly impaired residents with significant physical and psychiatric conditions, including legal blindness, hemiplegia, morbid obesity, major depressive disorder, paralytic syndrome, and acute respiratory failure. Quarterly/annual activity assessment forms for these residents were left blank and unedited, and one resident’s activity care plan was not completed beyond a generic preference statement. Surveyors observed that two residents were not engaged in any activities and did not receive 1:1 activity interventions, while another was only seen playing bingo once. One resident reported that bingo was the only available activity and that they participated solely to obtain snacks. Facility staff acknowledged that activity and social service assessments and care plans were expected to be completed on admission and updated quarterly, consistent with the facility’s policy for an ongoing program of activities to meet each resident’s needs.
A resident with severe cognitive impairment, cerebral palsy, seizure disorder, and wheelchair dependence, care planned for high fall risk, was found on the dining room floor next to her wheelchair after using a clear plastic lap tray intended as a fall-prevention device. Staff and family were aware that the Velcro-attached lap tray was loose, easily moved, and could lift and slide off when the resident shifted, allowing the resident to slide out of the wheelchair. Observation confirmed the tray slid up and down easily, and no new fall-prevention interventions were added to the resident’s care plan after the fall, despite a facility policy requiring identification of fall risks and development of appropriate interventions.
The facility did not maintain adequate CNA staffing, leading to delayed responses to call lights and unmet resident care needs. Multiple residents and family members reported long wait times for assistance, and staff interviews confirmed frequent short-staffing and high turnover. Staffing records showed fewer CNAs present than scheduled, contributing to lapses in care and resident dissatisfaction.
Multiple residents and family members reported that food was unpalatable, cold, and served in insufficient portions, with some residents stating they were left hungry and not offered adequate snacks. Surveyors observed that food was not always served at safe temperatures, and staff did not consistently check food temperatures before serving. The facility lacked a policy on food palatability, and these failures had the potential to affect all residents.
Surveyors found that kitchen and dry storage food items were not stored and labeled according to facility policy, creating a deficiency in safe food handling. Undated prepared foods labeled as sloppy joe and cheesy broccoli rice were stored in the refrigerator in clear plastic containers covered with plastic wrap but lacking dates. In the dry storage area, an uncovered clear plastic container held a plastic bag of an unlabeled white powdery substance that appeared to be flour, and a large plastic container of dry cereal was observed uncovered and undated on a rolling cart. The Dietary Manager confirmed that facility policy requires all refrigerated prepared foods to be covered and dated, and all dry goods, including cereal and flour, to be sealed, labeled, and dated, which was not followed in these instances.
Surveyors determined that the facility did not develop complete, individualized care plans for two residents with significant medical conditions. One resident had documented severe calorie protein malnutrition, but the care plan did not address nutritional status or needs. Another resident had documented ESRD and reported receiving dialysis, yet the care plan did not address ESRD or required hemodialysis. These omissions occurred despite a facility policy requiring comprehensive care plans with measurable objectives and timetables for all identified needs.
Three residents who required assistance with bathing did not consistently receive scheduled showers, as evidenced by gaps in shower documentation and resident reports. Despite care plans and facility policy requiring staff support for ADLs, showers were missed or delayed, often due to staffing shortages and scheduling issues.
A resident with a fractured femur, dementia, and total dependence for mobility was transported to a medical appointment without a facility staff escort. During the trip, the resident slid down in her wheelchair, causing her immobilized leg to drag on the ground, resulting in significant pain and distress. The facility's policy required an escort for residents needing assistance, but this was not provided.
A resident with multiple risk factors for skin breakdown developed open wounds on the buttocks and coccyx, but staff failed to consistently monitor, measure, and document the wounds as required. Despite orders for wound care, there was a lack of regular wound assessment, and the physician was not notified of changes in the wound's condition. This resulted in a deficiency related to inadequate pressure ulcer care and prevention.
Two residents with significant pressure ulcers did not receive wound care as ordered, including one instance where maggots were found in a wound and the wound NP was not notified. An LPN removed the maggots but did not send the resident to the hospital, and wound care documentation for another resident showed multiple missed treatments despite physician orders.
A resident did not receive treatment and care in accordance with physician orders and their personal preferences and goals, as required by their care plan.
A resident with cognitive impairment and behavioral issues entered another resident's room and, when asked to leave, grabbed and injured the resident's forearm, resulting in a skin tear. The incident was not promptly reported or investigated by facility staff, and administrative staff were unaware of the altercation, despite facility policy requiring review of such events as potential abuse.
A resident with multiple chronic conditions sustained a skin tear after being grabbed by another resident with severe cognitive impairment. Staff documented the injury but did not recognize or report it as a potential abuse incident, and facility leadership was not informed until weeks later, delaying the required investigation.
A resident with a history of falls, confusion, and involuntary movements was not properly positioned or supervised during a mechanical lift transfer by two CNAs. The resident, who was slouched and side-lying in a wheelchair, was lifted without being repositioned upright, and staff failed to maintain physical contact or ensure the sling was centered. As a result, the resident fell from the sling, hitting her head and body on the lift and floor.
Kitchen staff with facial hair were observed preparing meals without beard nets, and only main plates were covered during food transport, leaving side dishes and drinks uncovered. Multiple staff and residents confirmed these practices were routine, despite facility policies requiring all food to be covered and proper use of hair restraints.
Two residents with severe, chronic pain did not receive their prescribed opioid, muscle relaxant, and anticonvulsant medications due to repeated medication unavailability and administration failures. Both experienced ongoing, uncontrolled pain, with one requiring emergency room treatment for pain relief and reporting withdrawal symptoms. Staff interviews confirmed ongoing pharmacy and medication delivery issues, resulting in missed doses and significant resident distress.
Two residents with severe pain-related conditions did not receive their prescribed opioid, muscle relaxant, and anticonvulsant medications due to pharmacy and supply issues, resulting in ongoing, uncontrolled pain and withdrawal symptoms. Documentation showed multiple missed doses, and staff confirmed the medications were not administered as ordered, leading to significant resident distress and an emergency room visit.
The facility failed to maintain professional standards in food safety, with staff not wearing hairnets properly, using personal phones without hand hygiene, and serving food at improper temperatures. Residents reported dissatisfaction with cold and poor-quality food. Additionally, the facility lacked proper food storage and labeling, with expired items found and no active temperature logs maintained.
A facility failed to provide adequate heating in the Therapy Department, affecting residents' comfort and therapy performance. The heating issue persisted for about a month, with staff and residents resorting to wearing extra layers to stay warm. Despite ongoing maintenance efforts and corporate approval delays, the heating problem remained unresolved, violating residents' rights to a safe and comfortable environment.
The facility failed to secure smoking materials and supervise residents while smoking, as required by its policy. Residents were observed keeping cigarettes and lighters with them and smoking outside without staff supervision. Despite the facility's smoking policy mandating supervision and secure storage of smoking materials, residents were allowed to smoke unsupervised, leading to a deficiency in resident safety.
The facility did not have a full-time Director of Nursing (DON) for 18 days, affecting all 38 residents. The Acting DON, a floor nurse, only worked evenings and did not perform other duties. The facility lacked a staffing and DON policy.
The facility failed to provide a licensed Administrator to oversee their Administrator in training, affecting all 32 residents. The current Administrator has been in the role for three weeks and is awaiting processing of her temporary license by the state. The previous Administrator resigned early, and an Infection Control nurse temporarily filled the role before quitting. The facility lacks a policy for Administrator qualifications and has not provided documentation of a licensed Administrator.
Two residents reported missing property, including cash and a gift card, but the facility failed to investigate these incidents as required by its Abuse Prevention Policy. The administrator was unaware of the incidents until the survey, and no formal investigations were conducted, highlighting a deficiency in policy implementation.
Two residents reported missing property, including cash and a gift card, but the facility failed to initiate investigations as required by its policy. The administrator was unaware of the incidents until later and acknowledged the lack of action. The facility's policy mandates immediate reporting and investigation of such allegations, which was not followed in these cases.
A facility failed to implement effective fall interventions for three residents, leading to repeated falls and injuries. One resident with dementia and cognitive impairment experienced multiple falls, including a head injury requiring emergency treatment. Another high-risk resident had numerous falls with minor injuries, with interventions focused on medication reviews rather than new strategies. A third resident, severely cognitively impaired, was observed without anti-tippers on her wheelchair, leading to falls during self-transfers. The facility's fall management policy was not adequately followed.
The facility failed to properly store, prepare, and serve food, risking foodborne illness for all 42 residents. Observations included unlabeled and undated food items, expired products, and unsanitary kitchen conditions. Cold food items were improperly placed on the steam table, leading to incorrect temperatures. The facility's policies on food safety and labeling were not followed, as acknowledged by the dietary manager and administrator.
The facility failed to date insulin vials for four residents, violating medication storage policies. Observations revealed that insulin vials were not dated upon opening, as required. An LPN confirmed the need for dating vials, but this was not done, leading to a deficiency in medication management.
A resident with cognitive impairments repeatedly wandered into other residents' rooms at night, causing distress and discomfort. Despite grievances and staff interventions, the issue persisted, indicating a failure in monitoring and supervision. The facility's administrator was aware but the measures taken were insufficient to resolve the problem.
A facility failed to implement a resident-centered behavior care plan for a resident with Major Depressive Disorder and Generalized Anxiety Disorder. The care plan lacked specific interventions and non-pharmacological strategies to manage the resident's behaviors, despite documented issues such as agitation, depression, and anxiety. Facility staff acknowledged the absence of resident-specific interventions, contrary to the facility's Care Planning Policy.
The facility failed to properly assess and renew psychotropic medications for two residents, leading to deficiencies in medication management. One resident was prescribed Alprazolam and Xanax without proper reassessment, while another was given PRN Haldol without renewal by the hospice physician. Staff interviews revealed that medications were administered for restlessness without documented reassessment, indicating non-compliance with the facility's policy.
Failure to Develop Comprehensive Care Plans for ROM and Activity Needs
Penalty
Summary
Surveyors identified that the facility failed to develop comprehensive, individualized care plans addressing all assessed needs, including ROM/contracture management and activity preferences, for three residents. One resident with severe cognitive impairment, documented intracerebral hemorrhage, pulmonary hypertension, protein-calorie malnutrition, COPD, pain, and documented ROM impairment in one upper and one lower extremity was observed in a reclining wheelchair with a fully contracted left hand and no splints or washcloths in place for contracture management. The resident’s MDS showed dependence in ADLs and no ROM program in place, and the care plan dated several months earlier did not include any ROM/contracture management interventions or an activities care plan, despite an activity assessment indicating the resident enjoyed music, sitting outside, watching TV and movies, preferred to stay in the room, and preferred small group or in-room activities. Another resident, admitted earlier in the year, had documented diagnoses of legal blindness, anxiety disorder, and other psychotic disorders, with an MDS showing a BIMS score indicating intact cognition and a need for setup, clean-up, supervision, or touching assistance for various mobility and transfer tasks. The resident’s care plan entry regarding activity participation preferences was incomplete and not done, and the quarterly/annual activity assessment form was blank and unedited. A third resident with paralytic syndrome and acute respiratory failure with hypoxia had an MDS indicating moderate cognitive impairment and dependence for bed mobility and tub/shower transfers, but the quarterly/annual activities assessment was unedited and not completed, and there was no care plan addressing the resident’s activity preferences. Staff interviews confirmed that activity and social service assessments and related care plans were expected to be completed on admission and updated quarterly, and the facility’s care plan policy required an individualized comprehensive care plan based on the comprehensive assessment for each resident.
Failure to Reposition Dependent Residents as Required for ADL Care
Penalty
Summary
Surveyors identified a deficiency in providing positioning assistance to dependent residents who were unable to reposition themselves. One resident with multiple diagnoses including intracerebral hemorrhage, pulmonary hypertension, age-related debility, urinary retention, protein calorie malnutrition, HTN, COPD, anorexia, and pain was documented on the MDS as dependent with ADLs and care planned for an ADL self-care performance deficit requiring staff assistance. This resident was observed from the morning meal period until early afternoon in a reclining wheelchair, with observations made every 15–30 minutes showing no repositioning during that time. The resident was only observed being assisted to bed at 1:30 PM. A CNA later stated that the resident had been laid down and repositioned after breakfast with incontinence care, but could not provide an exact time and confirmed the resident was not laid down or repositioned again until 1:30 PM. Another dependent resident was observed in a reclining wheelchair in the dining room from the morning through early afternoon, also checked in 15–30-minute increments without any observed repositioning. This resident was observed being assisted to bed in the early afternoon. A CNA stated that this resident had been laid down after breakfast for incontinence care and then returned to the reclining wheelchair, but was unsure of the time. The Administrator stated that residents unable to reposition themselves should be assisted by staff every two hours. The facility’s Activities of Daily Living Policy states that residents who are unable to carry out ADLs independently will be provided appropriate care and services, including support and assistance with mobility, in accordance with their plan of care.
Failure to Complete Activity Assessments and Care Plans for Multiple Residents
Penalty
Summary
The facility failed to provide comprehensive activity assessments and care plans to meet the activity needs and preferences of three residents. For one resident with legal blindness, anxiety disorder, and another psychotic disorder, the MDS showed intact cognition with a BIMS score of 14 and a need for setup or supervision with mobility and transfers. However, the activity care plan entry stating "I prefer (Specify: to participate, little participation or no participation) in activity involvement" was not completed, and the quarterly/annual activity assessment form dated 12/3/25 was left blank and unedited. During the survey, this resident reported that there were no activities available except bingo and that they only participated in bingo to obtain snacks. No observations were made of this resident engaging in activities or receiving 1:1 activity interventions. A second resident with hemiplegia following cerebral infarction, morbid obesity, and major depressive disorder had an MDS BIMS score of 15 and required supervision or partial/moderate assistance for mobility and transfers. This resident’s quarterly/annual activity assessment dated 7/26/25 was also blank and unedited, although the resident was observed playing bingo on one occasion. A third resident with paralytic syndrome and acute respiratory failure with hypoxia, who had a BIMS score of 11 and was dependent for bed mobility and transfers, likewise had an activity assessment dated 8/29/25 that was unedited and not completed. During the investigation, no observations were made of this resident engaging in activities or receiving 1:1 activity interventions. The Activity Director/Social Service Designee and the MDS/Care Plan Coordinator both stated that activity and social service assessments and care plans should be completed on admission and updated quarterly, and the facility’s Activity Programs policy stated that an ongoing program of activities is designed to meet the needs of each resident, which was not carried out for these residents.
Failure to Maintain Secure Lap Tray and Update Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement effective safety measures to prevent falls for a resident with known fall risk and severe cognitive impairment. The resident, who has diagnoses including cerebral palsy, seizure disorder, dependence on a wheelchair, muscle disorder, and intellectual disability, was care planned as having potential for falls due to confusion, deconditioning, gait/balance problems, incontinence, poor communication/comprehension, and unawareness of safety needs. The care plan included use of a lap tray while the resident was up in her chair to prevent falls and ensure safety. On one occasion, the resident was found lying on her back/right side on the dining room floor next to her wheelchair, with no apparent physical injury at that time. Subsequent hospital evaluation included a CT of the head and urinalysis, and the resident was later returned to the facility. Staff observations and interviews revealed that the lap tray used as a fall-prevention intervention was not secure and was known by staff and family to loosen, lift, and slide off when the resident moved in the wheelchair, allowing the resident to slide out of the chair. A CNA reported returning from break to find the resident on the floor in the dining room, stating that the resident had the lap tray on but it was not secure and that she was sure the loose tray caused the fall, although she did not witness the fall. A later observation showed the resident in the dining room with a clear plastic lap tray attached to the wheelchair armrests by Velcro straps, with the tray easily moved and sliding up and down. Despite the fall and the known issue with the loose tray, there were no new interventions implemented in the resident’s care plan following the fall, and the facility’s fall reduction policy called for providing an environment as free of accident hazards as possible and developing appropriate interventions to prevent or minimize fall-related injuries.
Insufficient CNA Staffing Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide a sufficient number of Certified Nursing Assistants (CNAs) to meet the needs of all residents, as evidenced by multiple observations, interviews, and record reviews. On several occasions, there were fewer CNAs working than scheduled, resulting in delayed responses to call lights and unmet resident care needs. For example, one resident reported having their call light on for nearly two hours without assistance, expressing frustration over not receiving help to get up or take a shower. Another resident's family member observed that their loved one remained in bed, incontinent and undressed, due to a lack of available aides. Staff and family interviews consistently indicated concerns about inadequate staffing and the impact on resident care, with reports of overworked CNAs and high staff turnover. Review of staffing schedules and timecards revealed discrepancies between the number of CNAs scheduled and those actually present, with shifts often operating below the facility's stated requirements. Resident council meeting minutes and additional family interviews further documented ongoing concerns about insufficient CNA staffing and its effect on care continuity. The facility's own assessment and staffing policy emphasized the need for adequate staff to ensure resident safety and well-being, yet the documented staffing levels and observed care delays demonstrated a failure to meet these standards for the facility's 33 residents.
Failure to Provide Palatable and Safe-Temperature Food
Penalty
Summary
The facility failed to ensure that food and drink served to residents were palatable, attractive, and maintained at safe and appetizing temperatures. Multiple cognitively intact residents reported that the food was unappetizing, cold, and sometimes inedible, with some stating they were left hungry due to poor food quality and insufficient portions. Residents also reported that substitute meals and snacks were either not offered or were equally unsatisfactory. Family members echoed these concerns, describing meals such as cheese sandwiches on dry bread with barely warm tater tots, leading them to bring outside food for their loved ones. During a resident council meeting, additional complaints were raised about the poor quality and small portion sizes of meals, as well as the lack of adequate snacks. Observations by surveyors confirmed that food was not always served at the required safe temperatures. For example, a pan of scalloped potatoes was not temperature-checked before serving, and a pork loin was found to be below the minimum required temperature of 135°F after service. The dietary manager stated that hot food temperatures should be between 170-190°F and that temperatures are supposed to be taken before serving, but this was not consistently done. The facility administrator acknowledged that there was no policy on food palatability or taste, and facility policies required hot foods to be kept at or above 135°F. These failures had the potential to affect all 33 residents in the facility.
Improper Food Storage and Labeling in Kitchen and Dry Storage Areas
Penalty
Summary
Surveyors identified a deficiency in food storage practices when they observed multiple undated and improperly stored food items in the facility’s kitchen and storage areas, with the potential to affect all 33 residents. On 12/16/2025 at 10:35 AM, in a standing refrigerator, they found a clear plastic container covered with plastic wrap labeled “sloppy joe” and another clear plastic container covered with plastic wrap labeled “cheesy broccoli rice,” with neither container dated. In the dry goods storage area, they observed an uncovered clear plastic container holding a plastic bag filled with a white powdery substance that appeared to be flour, with no label or date. On 12/17/2025 at 12:30 PM, surveyors observed a large plastic container of dry cereal on the bottom of a three-tier metal rolling cart, uncovered and without a date. At 3:20 PM on the same day, the Dietary Manager stated that all refrigerated foods should be stored in covered containers and labeled with the date cooked, that cooked food is only good for three days in the refrigerator, and that all dry goods including cereal should be in sealed, labeled, and dated containers. The Dietary Manager also stated that opened flour should be placed in a plastic bag, then in a closed container, labeled with its contents and dated. The facility’s Food Storage Areas Policy, revised 12/30/2024, requires prepared food stored in the refrigerator until service to be dated and tightly sealed with plastic wrap, foil, or a lid, but the observed practices did not comply with this policy. The facility’s Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 12/16/2025 documents that 33 residents live in the facility, all of whom could be affected by these food storage deficiencies.
Failure to Develop Comprehensive Care Plans for Residents With Malnutrition and ESRD
Penalty
Summary
Surveyors found that the facility failed to develop comprehensive, resident-centered care plans addressing all identified needs for two residents. One resident’s face sheet documented a diagnosis of severe calorie protein malnutrition, but the resident’s care plan dated 10/30/24 did not include any care plan addressing nutritional status or needs. Another resident’s face sheet documented a diagnosis of end stage renal disease (ESRD), and the resident stated he receives dialysis; however, the care plan dated 11/11/25 did not include any care plan related to ESRD or the required hemodialysis. The facility’s own Comprehensive Care Plan Policy, revised 6/25/25, states that an individualized comprehensive care plan with measurable objectives and timetables is to be developed for each resident to meet medical, nursing, mental, and psychological needs within seven days of completion of the comprehensive assessment (MDS). Despite this policy, the care plans for these two residents did not address their documented diagnoses and associated care needs.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide showers to three out of five residents reviewed for Activities of Daily Living (ADL) care, despite documentation indicating their dependence on staff for bathing. For one resident with quadriplegia, records showed no documentation of showers being given or offered over multiple weeks. Another resident with cerebral infarction and hemiparesis/hemiplegia, who required partial to moderate assistance, also had gaps in shower documentation, with no showers recorded for extended periods. A third resident with fibromyalgia and congestive heart failure, who needed setup and cleanup assistance, similarly had no showers documented over several weeks. These findings were corroborated by resident interviews, where individuals reported not receiving showers, often attributing this to insufficient CNA staffing. The facility's own shower care policy requires staff to assist residents with bathing to maintain hygiene and prevent skin issues. However, review of shower sheets and care plans revealed that scheduled showers were not consistently documented as provided or offered, and residents' preferences for shower times were not always accommodated. Staff interviews confirmed that while efforts were made to adjust schedules based on resident preferences, some residents experienced delays or missed showers, particularly when they refused at scheduled times and requested showers later. Despite administrative claims that showers were being given, the lack of documentation and resident reports indicate a failure to consistently provide necessary ADL care.
Failure to Ensure Safe Transportation for Dependent Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure safe and quality transportation for a resident with a fractured right femur, dementia, and morbid obesity, who was non-weight bearing and dependent for transfers and mobility. The resident required a mechanical lift for transfers and total assistance for locomotion, as documented in her care plan. On the day of the incident, the resident was transported to a medical appointment without a facility staff escort, despite her significant care needs and cognitive impairment. During transport, the resident slid down in her wheelchair, causing her immobilized, fractured leg to come off the foot pedals and drag on the ground. The mat used to connect her foot pedals became dislodged, contributing to the incident. Multiple witnesses, including the resident, reported that she was in significant pain and was crying and screaming during the transport. Upon arrival at the doctor's office, staff there had to assist in repositioning her, and due to her distress and the incident, an X-ray was ordered and she was transported by ambulance to the hospital. The facility's policy requires that residents needing assistance, such as those with impaired decision-making or requiring help with activities of daily living, must have an appropriate escort during transport, which was not arranged in this case.
Failure to Monitor and Document Pressure Ulcer Development
Penalty
Summary
The facility failed to adequately monitor and document the development and progression of pressure ulcers for one resident with significant risk factors, including dementia, morbid obesity, and limited mobility. The resident was dependent for transfers and mobility, had a history of surgical incision on the right leg, and was identified as at risk for pressure sore development according to the Braden Scale. Despite the presence of non-blanchable areas, blisters, and open wounds on the buttocks and coccyx, there was a lack of consistent wound measurements and documentation in the electronic health record. Orders for wound care were present, but wound monitoring and assessment were not consistently performed or recorded, and the physician was not notified of changes in the wound status. Staff interviews revealed that wound measurements had not been regularly taken, and the wounds were sometimes attributed to friction or shearing rather than pressure, leading to inconsistent documentation. The physician stated that they were not informed of any worsening of the wound beyond a stage-1 sore. The facility's policy required systematic monitoring and documentation of wounds, but this was not followed, as evidenced by missing wound notes and measurements. The deficiency was identified through observation, interview, and record review, confirming a failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Failure to Provide and Document Wound Care and Provider Notification
Penalty
Summary
The facility failed to properly assess, monitor, and provide wound care treatments as ordered, and did not notify the appropriate provider when maggots were found in the wound of a resident with paraplegia and multiple pressure ulcers. The resident, who was cognitively intact and used a wheelchair, had a documented history of pressure ulcers and required specialized wound management. On one occasion, an LPN discovered maggots in the resident's foot wound during a dressing change, removed them, and applied hydrogen peroxide, but did not send the resident to the hospital or notify the wound nurse practitioner. The resident reported experiencing maggots in her wounds on two separate occasions and expressed distress over the incident, stating that the LPN did not perform the dressing change correctly. The wound nurse practitioner confirmed she was not informed of the maggot incident and stated that the standard procedure would be to remove the maggots and send the resident to the hospital. Additionally, another resident with quadriplegia and multiple pressure ulcers did not consistently receive wound care treatments as ordered by the physician. Documentation in the Treatment Administration Record (TAR) showed multiple dates where prescribed wound care was not completed for several pressure ulcers, despite clear physician orders and care plan interventions. The Director of Nursing confirmed that wound treatments should be administered and documented as ordered, in accordance with the facility's wound care policy.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident’s preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as specified, but the report does not provide further details about the resident’s medical history or condition at the time of the deficiency.
Failure to Prevent and Report Resident-to-Resident Abuse
Penalty
Summary
A resident with a history of major depression, anxiety, chronic pain, paraplegia, and other medical conditions sustained a skin tear to her left forearm after another resident, who is severely cognitively impaired with Alzheimer's disease and known for wandering and exhibiting physical and verbal behaviors, entered her room. The incident occurred when the cognitively impaired resident was asked to leave the room and instead grabbed and held the resident's arm, causing a skin tear that required cleansing and steri-strips. The injured resident reported significant pain and fear from the incident and expressed ongoing concern about encountering the other resident in the hallway. Staff interviews revealed that the cognitively impaired resident frequently enters other residents' rooms and sometimes lies in empty beds. Despite this known behavior, the facility's administrative staff, including the Administrator, Regional Administrator, and Interim DON, were not aware of the altercation at the time it occurred. There was a lack of immediate reporting and investigation, and the incident was not initially recognized as a resident-to-resident altercation by some staff. The facility's policy requires that such altercations be reviewed as potential abuse situations, but this protocol was not followed in this case.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving a resident with major depressive disorder, anxiety, paraplegia, and other chronic conditions, who sustained a skin tear on her left forearm after another resident with Alzheimer's disease and severe cognitive impairment grabbed her arm. The incident was documented in nursing progress notes, which indicated that the injured resident reported pain, a skin tear, and fear following the event. Despite documentation of the injury and the resident's expressed fear, staff did not recognize or report the event as a potential abuse incident at the time it occurred. Staff, including an LPN, did not assess the injured resident for emotional distress or document the presence of a bruise, and the incident was not reported to facility administration as a resident-to-resident altercation. The administrator and other leadership were unaware of the event until it was brought to their attention weeks later, at which point an investigation was initiated. The facility's policy requires prompt reporting and investigation of suspected abuse, but this was not followed in this case, resulting in a failure to respond appropriately to an alleged violation.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to perform a safe mechanical lift transfer for a resident with a history of falls, confusion, deconditioning, gait and balance problems, incontinence, and poor communication and comprehension. The resident was known to be unaware of safety needs and exhibited jerking movements and agitation during transfers. On the day of the incident, two CNAs attempted to transfer the resident from a wheelchair to a bed using a full body mechanical lift. The resident was observed to be slouched and lying on her right side in the wheelchair, and staff did not reposition her to an upright position before applying the sling and initiating the lift. During the transfer, the sling was not properly centered, and the resident remained in a side-lying position while being lifted. One CNA operated the lift controls while the other removed the wheelchair from beneath the resident, leaving her suspended in the sling without support. At this point, neither CNA maintained physical contact with the resident. As the lift was moved, the resident rolled through the lift straps and fell face forward out of the sling, hitting her head and body on the legs of the lift and the floor. The incident was witnessed by another resident and captured on video, which confirmed that the resident was not properly positioned and that staff did not maintain appropriate supervision or physical support during the transfer. Interviews with staff revealed a lack of understanding regarding proper sling sizing, positioning, and the need for additional assistance during transfers for residents with unpredictable movements. Staff acknowledged that the resident required close supervision and sometimes three or more people to ensure safety during transfers. Despite this, only two staff members were present, and they did not follow established procedures for safe mechanical lift use, including ensuring the resident was upright and centered in the sling and maintaining contact throughout the transfer. The failure to adhere to these safety protocols directly led to the resident's fall from the lift.
Failure to Follow Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices as required by professional standards and its own policies. Observations revealed that kitchen staff with facial hair, specifically two cooks with full beards, were preparing meals without wearing beard nets. Multiple staff and residents confirmed that beard nets were not consistently used, with one resident, a former USDA inspector, estimating compliance at only about 60%. Additionally, several staff and residents reported that only the main plate of food was covered during transportation to resident rooms, while side dishes and drinks were routinely left uncovered. This was corroborated by direct observation of meal trays being delivered on an open cart with only the main plate covered. Interviews with residents, CNAs, and a family member consistently indicated that the lack of beard nets and uncovered side dishes and drinks was a regular occurrence. The facility's own policies require all food to be covered during transportation and mandate the use of hair restraints and beard guards for staff with facial hair. The administrator acknowledged awareness of these issues and confirmed that beard nets had been ordered and that corrective actions would be taken, but at the time of the survey, the deficiencies persisted, potentially affecting all 38 residents in the facility.
Failure to Provide Prescribed Pain Management Medications
Penalty
Summary
The facility failed to administer prescribed opioid medications, muscle relaxants, and anticonvulsants for pain control to two residents who required such services. Both residents had documented histories of severe, chronic pain and complex medical conditions, including spinal muscular atrophy, neuralgia, muscular dystrophy, and chronic pain syndrome. Despite physician orders for scheduled pain medications, there were repeated instances where these medications were not available or not administered as prescribed, as evidenced by gaps in the Medication Administration Records (MARs) and Controlled Substances Proof of Use logs. One resident experienced ongoing, uncontrolled, and severe pain, rating it as a 9 out of 10, and reported that the pain became unbearable when pain medications were not available. The resident stated that no alternative interventions were provided, and he simply had to wait until the medication arrived. Another resident, with similar complex pain management needs, described her pain as excruciating and continuous, leading to an emergency room visit for pain relief after not receiving scheduled medications. She reported symptoms of medication withdrawal, a significant decrease in quality of life, and expressed feelings of being forgotten and wanting to die. Interviews with staff, including the DON and LPNs, confirmed that there were ongoing issues with pharmacy transitions, medication ordering, and delivery, resulting in delays and missed doses of critical pain medications. Staff acknowledged that the system required documentation for each medication administration, and blanks in the MAR indicated missed doses. The facility's own policies required timely administration of medications as ordered, but these were not followed, leading to significant unrelieved pain and withdrawal symptoms for the affected residents.
Removal Plan
- Medical Director consulted regarding the availability of pain medication for R1 and R2.
- Medication for R1 and R2 were ordered, received, and administered as prescribed.
- All medication orders received by pharmacy from the physician for R1 and R2 and delivered STAT to the facility.
- An audit for all resident medications for pain was completed by the ADON.
- Medical Director provided pain medication orders to pharmacy.
- Education provided to nursing staff by the Administrator to ensure appropriate identification, documentation, and timely treatment for pain, as well as processes and procedures that assure the accurate acquiring, receiving, dispensing, and administering of medication for pain.
- The Director of Nursing or Designee will provide on-going education to any new or agency nursing staff, not in-serviced, prior to the start of their next shift.
- Pain assessment on the MAR/TAR to be completed by nurse every shift and addressed if pain noted.
- Director of Nursing or designee will conduct audit of pain medication administration to ensure appropriate knowledge and understanding of narcotics delivery, documentation, and administration practices.
- The Director of Nursing or designee will address all concerns identified during the audit.
- The Director of Nursing or designee will report audit findings to the Quality Assurance and Performance Improvement Committee monthly and thereafter as determined by the QAPI Committee.
Failure to Administer Prescribed Pain Medications Resulting in Uncontrolled Pain
Penalty
Summary
The facility failed to administer prescribed opioid medications, muscle relaxants, and anticonvulsants for pain control to two residents with significant pain-related diagnoses. Both residents had documented orders for medications such as Xtampza ER, oxycodone, morphine, baclofen, gabapentin, and Lyrica, which were not administered as prescribed due to medications being out of stock, insurance issues, and pharmacy transition problems. Medication Administration Records and Controlled Substances Proof of Use showed multiple missed doses and blank entries, indicating that the medications were not given as ordered. One resident, with a history of cervical spinal cord injury and chronic pain syndrome, experienced ongoing, uncontrolled, and severe pain, rating it as a 9 out of 10. The resident reported that when pain medications were unavailable, the pain remained severe until the medication was finally received, and no alternative interventions were provided. The resident was dependent on staff for activities of daily living and had a care plan specifying the need for timely pain medication administration and evaluation of effectiveness, which was not followed. Another resident, diagnosed with spinal muscular atrophy, restless leg syndrome, neuralgia, neuritis, and muscular dystrophy, also did not receive prescribed pain medications due to similar issues. This resident experienced excruciating, continuous pain and withdrawal symptoms, leading to an emergency room visit for pain relief. Staff interviews confirmed awareness of the medication shortages and the impact on residents, with documentation that the medications were not administered from emergency kits or pyxis. The facility's own policy required medications to be administered as ordered and documented, which was not adhered to in these cases.
Deficiencies in Food Safety and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards in food handling and safety, as evidenced by multiple observations and interviews. Staff members, including the kitchen manager and dietary aides, were observed not wearing hairnets properly, with hair exposed while handling food. Additionally, there were instances of staff using personal cell phones without practicing hand hygiene before returning to food preparation. The facility also failed to maintain proper food temperatures, with biscuits and gravy being served at temperatures significantly below the required 135 degrees Fahrenheit. Residents reported dissatisfaction with the food, describing it as cold and of poor quality, which was corroborated by the Resident Council Meeting Minutes. Further deficiencies were noted in food storage and labeling practices. The kitchen freezer contained bags of chicken labeled for activities without dates, and expired milk was found in the refrigerator intended for resident consumption. The facility lacked active temperature logs for refrigerators and freezers since December 2024, and the kitchen manager was unaware of the requirement for daily temperature checks. These lapses in food safety and storage policies have the potential to affect all 38 residents in the facility.
Inadequate Heating in Therapy Department
Penalty
Summary
The facility failed to provide adequate heating in the Therapy Department, affecting the comfort and safety of residents receiving therapy. On January 22, 2025, the Therapy Department was observed to be cold and drafty, with staff wearing sweatshirts to stay warm. An occupational therapist confirmed that the heating had been out for about a month, and residents were given blankets or sweatshirts to keep warm. A resident receiving therapy expressed difficulty in performing therapy exercises due to the cold temperature, which required him to wear multiple layers of clothing. The facility's maintenance director reported ongoing issues with the building's heating system since October 2024, with the Therapy Department's heat never functioning. Despite notifying the previous administrator and submitting bids for repair approval, the process was delayed, and the heating issue remained unresolved. The administrator confirmed that corporate approval for repairs was only recently obtained, and the repair timeline was uncertain. The facility's policies emphasize residents' rights to a safe and comfortable environment, which were not upheld in this instance.
Failure to Supervise Residents While Smoking
Penalty
Summary
The facility failed to secure cigarettes and lighters, reassess residents' smoking risks, and provide appropriate supervision for residents while smoking. This deficiency was identified for four residents who were reviewed for safety while smoking. The facility's smoking policy requires that smoking materials be secured at the nurse's station when not in use and that all residents be supervised when they smoke. However, observations and interviews revealed that residents were keeping their smoking materials with them and smoking unsupervised. One resident, who has a moderate cognitive impairment and requires assistance with activities of daily living, was found to keep cigarettes and a lighter with him, smoking outside without staff supervision. Another resident, who is cognitively intact, also kept cigarettes and a lighter with him and smoked outside without supervision. A third resident, with a moderate cognitive impairment, was observed smoking outside alone, despite the care plan stating that smoking materials should be secured by staff and the resident should be supervised while smoking. The facility's administrator and a licensed practical nurse confirmed that residents who are alert and oriented can go outside to smoke whenever they want, and they have the code to re-enter the building. The facility's smoking policy, however, mandates that residents be supervised while smoking and that smoking materials be secured when not in use. The lack of adherence to this policy resulted in residents smoking unsupervised and keeping smoking materials with them, contrary to the facility's established protocols.
Failure to Provide Full-Time Director of Nursing
Penalty
Summary
The facility failed to provide a full-time working Director of Nursing (DON) for 18 of 18 days reviewed, potentially affecting all 38 residents. The previous DON resigned, and the Acting DON, who was a floor nurse, accepted the position but only worked evenings for RN coverage. The Acting DON did not perform any other duties except those requested by the Administrator. The facility's time report showed that the Acting DON did not work on several days in December 2024 and January 2025. Additionally, the facility did not have a policy for staffing and DON.
Facility Lacks Licensed Administrator
Penalty
Summary
The facility failed to provide a licensed Administrator to oversee their Administrator in training, which has the potential to affect all 32 residents living in the facility. The current Administrator, who has been in the position for the last three weeks, stated that she filed for her temporary license but is still waiting for processing by the state of Illinois. Prior to her stepping in, the previous Administrator resigned and left before the official resignation date, and an Infection Control and wound nurse temporarily filled the role for five days before quitting. The current Administrator confirmed that she does not work under anyone's license and that the facility does not have a policy for Administrator qualifications. As of the survey date, the facility had not provided any documentation of a licensed Administrator.
Failure to Implement Abuse Prevention Policy Leads to Misappropriation Incidents
Penalty
Summary
The facility failed to implement its Abuse, Prevention, and Prohibition Policy for two residents, leading to incidents of misappropriation of resident property. Resident R4, who has Major Depressive Disorder and moderate cognitive impairment, reported that $100 was missing from her room. She stated that a CNA was the only person aware of the money's location. The facility administrator, V1, acknowledged that no investigation had been conducted regarding this incident, as it occurred before her tenure as administrator. Despite being aware of the incident, V1 had not initiated an investigation until it was brought to her attention during the survey. Similarly, Resident R6, who is cognitively intact, reported a missing gift card valued at $150. R6 informed the previous Director of Nursing about the missing item but received no follow-up or investigation. The current administrator, V1, was unaware of this incident until the survey and had not conducted an investigation. The Social Service Director, V18, mentioned that an in-service was conducted due to the missing gift card, but no formal grievance was filed, and the investigation process was unclear. The facility's policy requires immediate reporting and investigation of any allegations of misappropriation of resident property. However, in both cases, the facility failed to adhere to its policy, as no investigations were initiated or documented. The lack of timely investigation and reporting of these incidents highlights a deficiency in the facility's implementation of its abuse prevention policy, leaving the residents' concerns unaddressed.
Failure to Investigate Alleged Theft of Resident Property
Penalty
Summary
The facility failed to initiate investigations into alleged thefts involving two residents, R4 and R6, which were reviewed for misappropriation of resident property. R4, who has moderate cognitive impairment, reported that $100 went missing from her room after a CNA assisted her in placing the money in a drawer. R4 informed the administrator, V1, about the missing money, but no investigation was initiated at the time. V1, who was not the administrator at the time of the incident, later acknowledged the lack of an investigation and stated she would follow up. R6, who is cognitively intact, reported a missing $150 gift card from her purse. R6 informed the previous Director of Nursing (DON) about the incident but did not receive any follow-up or investigation. V1, the current administrator, was unaware of R6's allegation until recently and confirmed that no investigation had been conducted. The Social Service Director, V18, was also unaware of the specifics of the missing items and did not file a grievance, believing that V1 was handling the investigation. The facility's policy on abuse prevention and prohibition requires immediate reporting and investigation of any alleged misappropriation of resident property. However, in both cases, the facility failed to adhere to its policy, as no investigations were initiated or documented for the missing money and gift card. The lack of action and communication regarding these allegations highlights a deficiency in the facility's handling of resident property misappropriation.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to implement effective fall interventions and progressive measures for three residents, leading to repeated falls and injuries. One resident, with a history of dementia, tremors, and hypertension, experienced multiple falls, including a significant incident resulting in a head injury that required emergency room treatment. Despite the resident's moderate cognitive impairment and need for assistance with transfers, the care plan did not include new or progressive interventions after each fall, relying instead on repeated education about using the call light, which was often out of reach. Another resident, identified as high risk for falls, experienced numerous falls over several months, some resulting in minor injuries. The care plan and interventions primarily focused on medication reviews and hospice care discussions, with little evidence of new strategies to prevent falls. The resident's falls were often unwitnessed, and interventions were reused without apparent effectiveness, as noted by the MDS coordinator. A third resident, with severe cognitive impairment and a history of falls, was observed without anti-tippers on her wheelchair, despite this being a documented intervention. The resident frequently attempted self-transfers without assistance, leading to falls. Staff interviews revealed a lack of consistent supervision and failure to implement new interventions after falls, such as ensuring wheelchair brakes were locked. The facility's fall management policy emphasizes the need for tailored interventions and updates to care plans, which were not adequately followed in these cases.
Improper Food Storage and Handling
Penalty
Summary
The facility failed to ensure proper storage, preparation, and serving of food, which could potentially lead to foodborne illness affecting all 42 residents. During an inspection, it was observed that the dry storage area contained a large clear tub with unpackaged tea pods without a lid, and pitchers of liquid that were neither labeled nor dated. Additionally, several opened food items in the standing freezer and refrigerator were not labeled or dated, including bags of donuts, garlic bread, and various condiments. The facility also had expired food items, such as milk and prune juice, which were not discarded according to the facility's policies. Further observations revealed unsanitary conditions in the kitchen area, including a dusty fan blowing directly onto a bowl of pancake batter. Chemicals were stored in close proximity to food items, and containers of dry cereal were not labeled or dated. During lunch service, the cook was not wearing a beard net, and cold food items were placed on the steam table alongside hot items, resulting in improper food temperatures. The cold food items, such as pineapple, honeydew melon, and peaches, were measured at temperatures above the facility's policy requirements for cold food service. The facility's policies on food safety, labeling, and storage were not adhered to, as evidenced by the lack of date marking on opened food items and the presence of expired products. The dietary manager acknowledged the issues with food storage and labeling, and the administrator stated that staff are expected to follow the facility's food service policies. However, the observations during the survey indicate a failure to comply with these policies, potentially compromising the safety and quality of food served to residents.
Failure to Date Insulin Vials
Penalty
Summary
The facility failed to properly date insulin vials for four residents, leading to a deficiency in medication storage practices. During an observation, it was noted that insulin vials for residents R10, R7, R28, and R196 were not dated upon opening, as required by the facility's policy. This policy mandates that when the original seal of a manufacturer's container or vial is broken, it should be dated, and a discard date sticker should be placed on the medication. The Licensed Practical Nurse (LPN) confirmed that insulin vials should be dated the day they are opened. The Physician's Order Sheets for these residents documented specific insulin administration instructions, but the lack of dating on the vials indicates non-compliance with the facility's medication storage policy.
Failure to Monitor Resident Wandering
Penalty
Summary
The facility failed to adequately monitor and supervise a resident, identified as R37, who was wandering into other residents' rooms at night, causing distress among the residents. This issue was reported by multiple residents, including R4, R8, R25, and R39, who expressed discomfort and concern over R37's behavior. Despite grievances being filed and the facility being aware of the situation, the problem persisted. R37, who has a diagnosis of schizophrenia, Alzheimer's disease, anxiety, and insomnia, was noted to be severely cognitively impaired and continued to enter other residents' rooms, often taking belongings such as television remote controls. The facility's records, including progress notes, documented multiple instances of R37 being redirected by staff after entering other residents' rooms. However, these interventions were not effective in preventing further incidents. The facility's administrator acknowledged awareness of the issue and had previously arranged for a sitter for R37 during specific hours, but this measure did not resolve the problem. The facility's policy on resident rights emphasizes the need for prompt resolution of grievances, yet the ongoing issue with R37 indicates a failure to uphold these standards, as residents continued to experience disturbances and expressed feelings of insecurity.
Failure to Implement Resident-Centered Behavior Care Plan
Penalty
Summary
The facility failed to implement a resident-centered behavior care plan for a resident diagnosed with Major Depressive Disorder and Generalized Anxiety Disorder, who also has moderate cognitive impairment. The care plan, dated 9/14/24, lacked documentation of specific behaviors exhibited by the resident and did not include resident-specific interventions or non-pharmacological strategies to manage these behaviors. Despite the resident's ongoing agitation, depression, and anxiety, as documented in multiple progress notes, the care plan did not adequately address these issues with tailored interventions. The resident's progress notes reveal a pattern of behavior issues, including agitation, exit-seeking, refusal to eat due to depression, and expressing dislike for staff without specific reasons. The facility's Social Services Director and Director of Nurses acknowledged the lack of resident-specific interventions in the care plan. The facility's Care Planning Policy emphasizes the need for a comprehensive plan of care based on the resident's assessment, but this was not effectively implemented for the resident in question.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to properly assess and renew psychotropic medications for two residents, leading to deficiencies in medication management. Resident R19, diagnosed with Alzheimer's Disease, unspecified dementia, panic disorder, and unspecified psychosis, was prescribed Alprazolam and Xanax without proper reassessment and reordering after 14 days, as required. The care plan for R19 included monitoring for signs of depression and anxiety, but the facility did not ensure the necessary evaluations and renewals of the psychotropic medications. Observations and interviews revealed that R19 was given PRN Xanax for restlessness without documented reassessment by the physician. Similarly, Resident R21, with diagnoses of unspecified psychosis, bipolar disorder, major depression recurrent, and anxiety disorder, was prescribed PRN Haldol without proper renewal by the hospice physician. The care plan noted behavior problems, and interventions included keeping the resident's room in direct visualization of the nurse's station. However, the facility failed to document a physician's order to renew the PRN Haldol, despite the resident's increased anxiety and restlessness. Interviews with staff indicated that Haldol was administered for restlessness without documented reassessment, highlighting a lack of compliance with the facility's policy on psychotropic medication use.
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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