La Bella Of Rochelle
Inspection history, citations, penalties and survey trends for this long-term care facility in Rochelle, Illinois.
- Location
- 1021 Caron Road, Rochelle, Illinois 61068
- CMS Provider Number
- 146152
- Inspections on file
- 53
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at La Bella Of Rochelle during CMS and state inspections, most recent first.
A resident with an indwelling urinary catheter, gallbladder drain, and Jackson Pratt drain was not placed under Enhanced Barrier Precautions (EBP) as required by facility policy. Surveyors observed no EBP signage or PPE cart outside the room, and the resident reported not recalling staff wearing gowns when handling her catheter or drains. An LPN confirmed the presence of the devices and acknowledged EBP should be in place, while the DON verified that no EBP measures were implemented and could not explain the absence of the sign and PPE cart. Record review showed the resident had a history of septic shock and an order for drain dressing changes but no order for EBP, despite a facility policy requiring gowns, gloves, and accessible PPE for residents with indwelling catheters or drains.
Two residents with severe cognitive impairment and histories of falls experienced multiple witnessed and unwitnessed falls, including incidents where they rolled or fell from bed and struck their face or head, were sent to the ER, and returned with injuries such as a nasal laceration. Despite facility policy and a fall risk tool requiring neuro checks, full sets of VS, head-to-toe assessments, and change-of-condition charting every shift for 72 hours after a fall, nursing documentation lacked ongoing post-fall assessments, VS, and shift-by-shift follow-up for 72 hours after these events.
A resident with severe cognitive impairment, weakness, and a history of falls was care planned as high risk for falls with an intervention for a bedside floor mat after multiple prior bed falls. During observation, the resident was found in bed without a fall mat in the room, despite this being a documented intervention. A CNA reported not knowing about the resident’s prior falls or the need for a fall mat, and an RN confirmed that a mat should have been in place but was not. The DON stated that nursing and management are responsible for ensuring fall interventions are implemented, and the facility’s accident and supervision policy requires implementation and monitoring of interventions to reduce hazards and risk.
A nurse misappropriated a discharged resident's prescribed Cyclobenzaprine, with medication cards later found in the nurse's possession after an unrelated arrest. The medications, which should have been returned to the pharmacy, were not properly handled, violating the facility's policy against misappropriation of resident property.
Multiple staff observed an LPN repeatedly falling asleep and displaying abnormal behavior while providing care. Despite these reports, the Administrator and DON allowed the LPN to continue working after a brief assessment and an undocumented negative drug test, failing to remove her from resident care duties as required by facility policy.
A resident with multiple chronic conditions did not receive a physician-ordered physical therapy evaluation. Although occupational therapy services were provided, there was no documentation of a PT evaluation, and staff interviews confirmed it was not completed due to administrative approval requirements for Medicaid coverage. This resulted in a failure to provide specialized rehabilitative services as ordered.
Two residents, both with no cognitive impairment, were involved in a physical altercation after one entered the other's room and went through personal belongings. The assaulted resident responded by punching the other in the face. Staff and management were aware of the incident, but it was not documented in medical records, not reported externally, and no initial report was filed, despite facility policy requiring such actions for abuse events.
Two residents were involved in a physical altercation after one entered the other's room and went through personal belongings, resulting in a punch to the face. Although staff and administration were made aware and an internal investigation was started, the incident was not reported to the state agency as required by facility policy. Both residents had no cognitive impairment and did not sustain injuries.
A resident with a fractured leg and multiple comorbidities did not receive scheduled pain medication on time, resulting in unmanaged severe pain. The RN delayed administering the ordered narcotic pain medication by several hours, only responding after being notified by a CNA, despite the resident's care plan and facility policy requiring timely pain management and prompt response to pain complaints.
A resident with multiple complex diagnoses did not receive scheduled morning medications on time because an RN was delayed by supervising another resident and did not delegate the task. The medications were administered 2.5 hours late, outside the facility's policy window, resulting in a compressed schedule for subsequent doses.
Seventeen residents who smoke were not allowed their scheduled 5:30 PM smoke break after being told it would continue through the weekend, but staff failed to provide supervision and ended the break earlier than communicated. Multiple residents expressed confusion and frustration, and staff confirmed the change was implemented before the planned date, contrary to facility policy and resident notification.
Two residents with behavioral health diagnoses engaged in a physical altercation after one became agitated over a change in smoking break times and struck the other, despite existing care plans and behavioral interventions. Staff intervened and emergency services were called, but the facility failed to prevent the abuse as required.
The facility did not employ a certified dietary manager or certified food service manager, and the RD worked only remotely, never entering the kitchen or providing staff education. Nutritional assessments were completed remotely without in-person resident interviews, and there was no policy or job description for these roles. These failures had the potential to affect all residents.
The facility did not provide enough dietary staff to safely and effectively manage food service, with only two staff members present during a breakfast service and the use of disposable plates due to staffing shortages. Additionally, key dietary staff, including the manager and several aides, lacked required certifications, and the facility had no policies addressing staffing sufficiency or certification requirements.
The facility did not serve mandarin oranges as listed on the breakfast menu to any residents, as the dietary manager forgot to include them and there was no policy in place to ensure menu adherence. This affected all residents receiving breakfast that day.
A resident with a stage 4 pressure ulcer did not receive the prescribed wound care because the required iodoform gauze packing strips were out of stock for several days. The DON was aware of the low supply and placed an order, but there was no inventory process to ensure availability. The wound nurse did not notify the physician for new orders, and an LPN substituted a different dressing without a physician's order, resulting in the resident not receiving the ordered treatment.
A resident admitted for skilled care with multiple comorbidities and a recent hospitalization for a blood clot did not receive physical therapy at the frequency ordered by the physician. Despite a care plan specifying PT five times per week, the resident received only three sessions per week due to therapy staffing issues, as confirmed by staff interviews and therapy logs.
A resident with multiple diagnoses and a high risk for falls experienced a fall resulting in injury when the bed alarm failed to activate. There were no physician's orders or care plan documentation for the use of bed or chair alarms, and staff did not routinely check or document the functionality of these alarms, despite facility policy requiring such verification.
A facility failed to provide medical records to a resident's legal guardian and POA despite multiple requests. The resident, who was cognitively impaired, had a guardian who requested access to records related to restorative and oral care. Despite verbal and written requests, including during a care plan meeting, the facility did not provide the records. The administrator claimed a release form was needed and denied receiving a request for it, but emails and staff confirmed the guardian's requests. The facility's policy on record access was not followed.
A resident with multiple diagnoses, including paraplegia, developed a stage three pressure injury on the left ischium due to the facility's failure to identify and address the issue in a timely manner. Despite being at high risk and having a care plan for daily skin checks, no skin abnormalities were documented between February and May, leading to the injury progressing to stage four. Interviews revealed that staff were expected to perform weekly skin checks, but there was a lack of documentation and attention during routine care.
The facility failed to provide adequate nutritional support and monitoring, resulting in significant weight loss for several residents. A resident with multiple diagnoses lost 16.5 pounds in one month due to inconsistent provision of supplements and lack of weekly weight documentation. Another resident lost 22.8 pounds in a month due to a failure in updating dietary orders. Additionally, dietary recommendations for increased supplements were not implemented for another resident, and a resident with a 10% weight loss did not receive prescribed shakes.
The facility failed to offer the influenza vaccine at the start of the season, leading to an outbreak and hospitalization of two residents. Despite having no vaccine shortage, the facility delayed administration until January, after the outbreak began. The residents, who were willing to receive the vaccine, were hospitalized with influenza A. The facility's policy required annual vaccinations from October to March, but this was not followed, contributing to the outbreak.
The facility failed to ensure proper plumbing of the dish machine, leading to potential cross-contamination. The dish machine and an adjacent sink were backing up with water and food debris due to improper plumbing connections. Despite the Dietary Manager's reports, the issue persisted since December 2024, and no plumber was called to fix it. The facility's administrator advised using an alternative method for dishwashing, but the dish machine continued to be used. A licensed plumber confirmed the plumbing was not up to code.
The facility failed to track and trend resident illnesses beyond influenza, COVID-19, and pneumonia, as admitted by the DON and Infection Control Preventionist. Additionally, Enhanced Barrier Precautions (EBP) were not consistently followed, with missing EBP signs and PPE during care for residents with wounds and indwelling devices, contrary to the facility's policy.
A facility failed to honor a resident's advance directive to be a full code, resulting in a DNR order being incorrectly entered into the system. The resident expressed a desire to be resuscitated, contradicting the DNR order placed by an RN based on hospital paperwork. The resident's cognition was intact, and the facility's policy supports residents' rights to formulate advance directives, which was not followed.
A facility failed to provide timely incontinence care for a resident with impaired cognition and incontinence. The resident was found with a saturated brief and reddened buttock after not being checked for over five hours. A CNA admitted to not having time to check the resident due to being busy, despite facility policy requiring checks every two hours.
The facility failed to ensure proper dressing orders for a resident's cholecystostomy drain and did not apply ace wraps as ordered for another resident with lower extremity edema. A nurse changed a dressing without specific orders, and another resident's legs were not wrapped despite an existing order for ace wraps to manage edema.
The facility failed to implement fall prevention measures for two residents. One resident with a bilateral below-the-knee amputation experienced a fall due to malfunctioning wheelchair locks, while another resident with multiple conditions had an inaccessible call light, increasing fall risk. Both residents were identified as having a moderate risk of falling, highlighting deficiencies in equipment and supervision.
The facility failed to ensure medications were available and administered as ordered for two residents. One resident did not receive their prescribed Buspirone due to unavailability, while another resident self-administered an Albuterol inhaler without supervision, contrary to facility policy.
A facility failed to implement monthly pharmacy recommendations for a resident with multiple diagnoses, including cerebral palsy and epilepsy. A consultation report recommended monitoring kidney function by checking serum creatinine levels every six months, but the last test was conducted over a year ago. The DON was unaware of the recommendations, and the facility lacked access to the pharmacy portal due to a recent ownership change.
The facility failed to maintain safe and functional wheelchairs for three residents, leading to safety concerns. A resident with major depressive disorder and amputations experienced a fall due to a faulty wheelchair, while another with anxiety and respiratory issues reported non-functional brakes. A third resident with impaired mobility also faced similar issues despite previous maintenance attempts. These deficiencies highlight the facility's failure to ensure essential equipment was maintained as required.
A resident with multiple mental health diagnoses was subjected to mental abuse by two CNAs who made her clean up her own vomit after a norovirus episode. The CNAs' actions were reported by the resident and corroborated by her roommate, leading to an investigation that confirmed the allegations of mental abuse. The facility's policy defines mental abuse as including humiliation and harassment, which was evident in this case.
The facility failed to have a full-time DON since a new company took over, affecting all 52 residents. RNs were contacting the non-nurse Administrator for nursing issues. A Nurse Consultant visited infrequently, and an RN was suggested to assist with nursing duties but was not designated as the DON.
A facility failed to provide a resident's sister and guardian access to medical records despite multiple requests. The resident had a bruise on her forehead and was on a blood thinner, raising concerns for her sister. The facility's administrator did not provide the necessary paperwork to access the records, contrary to the facility's policy on medical record release.
A resident on blood thinners was found with a bruise of unknown origin on her forehead, which was not investigated by the facility. The resident's sister/guardian noticed the bruise and expressed concern, but there was no documentation or assessment conducted. The staff initially mistook it for a previous bruise from a fall, and the facility lacked a policy for handling such injuries.
The facility failed to document reasons and obtain physician orders for the discharge of two residents. One resident exhibited aggressive behavior and was sent to the hospital without proper documentation or physician orders. Another resident was transferred to a different facility without documented physician orders. The facility's policy requires obtaining physician orders and a complete discharge summary, which was not followed.
A resident was involved in an aggressive incident leading to hospitalization, after which the facility decided not to readmit them. The facility failed to notify the resident's guardian and the Ombudsman of this involuntary discharge, contrary to its policy.
A resident was not allowed to return to the facility after a hospital stay due to aggressive behavior, but the facility failed to document the refusal or initiate involuntary discharge paperwork. The decision was communicated to the hospital but not to the resident's guardian, causing distress. The facility did not follow its transfer and discharge policy.
A resident was transferred to another facility without proper discharge planning. The resident wanted to move closer to family, but there was no discharge planner available, and the agency RN on duty was unfamiliar with the process. The social services representative confirmed no interdisciplinary meeting occurred, and the discharge was arranged without a documented plan, violating the facility's policy.
A resident was transferred to another facility without a complete discharge summary. The facility failed to ensure the necessary documentation, including a recap of the resident's stay, medication reconciliation, and a post-discharge care plan, was completed. The RN on duty was unaware of the discharge arrangements, and there was no confirmation of physician notification or report to the receiving facility.
A resident with multiple diagnoses, including dementia and bipolar disorder, fell while transferring herself and was not properly assessed for changes in condition, leading to a delayed diagnosis of a hip fracture. Despite complaints of leg pain and difficulty bearing weight, these were not communicated to nursing staff or documented, contrary to the facility's policy requiring 72-hour post-fall assessments.
A resident with a recent UTI and multiple diagnoses, including dementia and chronic cystitis, did not receive proper incontinence care. Despite the care plan requiring checks every two hours, the resident was left in a soiled incontinence brief for several hours. A CNA stated that residents using a mechanical lift were not taken to the toilet, and the resident was not provided with perineal care when dressed for the day. This neglect contradicts the facility's policy on perineal care, which aims to prevent infections and skin irritation.
A resident with severe cognitive impairment and a history of elopement repeatedly exited an LTC facility unsupervised due to faulty door alarms and inadequate supervision. Despite being on 15-minute checks and having a care plan for 1:1 monitoring, the resident managed to leave the building multiple times, sometimes becoming aggressive when staff attempted to redirect him. The facility's maintenance director confirmed that the courtyard door alarm was not functioning properly, contributing to the resident's ability to elope.
A facility failed to ensure medications were administered by licensed personnel, as the Dietary Manager was observed distributing medications prepared by the DON. Multiple residents and staff confirmed these actions, which violated the facility's policy that only licensed individuals may administer medications.
A resident with spinal stenosis and other conditions did not receive prescribed Norco for back pain due to a lapse in communication and procedure at the facility. Despite efforts by staff to obtain a new prescription, the resident missed 12 doses over several days, leading to physical and emotional distress. The facility lacked documentation of timely action and did not utilize available resources to provide the medication.
A resident missed 12 doses of Norco due to the facility's failure to timely reorder the medication. Despite the resident's inquiry about having enough medication for a holiday weekend, staff assured him he did, but he ran out. Communication failures and procedural issues delayed obtaining a new prescription, resulting in the resident being without pain medication for several days.
A resident with Alzheimer's and a history of elopement left the facility unsupervised due to inadequate monitoring and faulty door alarms. The resident was found disoriented on a highway and taken to an emergency room. The facility failed to document 15-minute checks for all residents requiring frequent monitoring, and door alarms were not consistently operational.
The facility failed to implement and document interventions to mitigate Legionella growth and spread. The Maintenance Director was unaware of his responsibilities and had not received training, resulting in no Legionella testing or proper mitigation efforts being conducted.
The facility failed to ensure residents were provided with influenza and pneumococcal immunizations as required. The Administrator admitted that no screening or eligibility assessments had been conducted, and vaccine refusal forms were not available for review. The Director of Nursing confirmed that residents could have received the Prevnar 23 vaccine but were not offered it. The electronic medical records showed incomplete or missing documentation regarding vaccinations, and all requested immunization records were not received.
The facility failed to ensure residents were provided COVID-19 vaccinations as required. Interviews and record reviews revealed that the facility did not track or administer COVID-19 vaccinations, and no records of COVID-19 vaccinations were found for the residents reviewed. The facility's policies on vaccination were not followed, and proper documentation was not maintained.
Failure to Implement Enhanced Barrier Precautions for Resident With Catheter and Drains
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for a resident with an indwelling urinary catheter and multiple drains. During observation, the resident was found lying in bed with no EBP sign posted on the door and no PPE cart outside the room to indicate any type of isolation or precaution. An LPN at the bedside confirmed that the resident had a urinary catheter, a gallbladder drain, and a Jackson Pratt drain at the surgical site. The resident reported coming to the facility with two drains and a urinary catheter after a hospitalization for a severe infection that required a breathing tube, and stated she could not recall staff wearing gowns when handling her catheter or drains. The LPN later stated that the resident should have EBP in place due to the presence of the catheter and drains and that staff should be wearing gowns and gloves when providing direct care or handling the devices, but was unsure why the PPE cart was no longer outside the room. The DON also verified that there were no EBP measures in place for this resident and was similarly unsure why the sign and PPE cart were absent. Record review showed the resident was admitted with diagnoses including septic shock and had an order for dressing changes three times a week for the gallbladder drain, but there was no physician order for EBP. The facility’s EBP policy, dated 10/13/25, states that residents with indwelling urinary catheters or drains should be on EBP and that staff should wear gowns and gloves for direct care, with a PPE cart placed outside or near the resident’s room to identify the need for these precautions.
Failure to Complete Required Post-Fall Assessments and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to complete required post-fall assessments, including vital signs, head-to-toe assessments, and fall follow-up documentation, for two residents with severe cognitive impairment and histories of falls. One resident, admitted with diagnoses including adult failure to thrive, unspecified lack of coordination, and weakness, had a witnessed fall from bed on 10/8/25 with no further assessments documented related to that fall. On 11/3/25, this resident was again found on the floor at bedside with a fall mat in place and reported rolling over in bed; the risk management report documented the event, but there were no follow-up assessments in the progress notes for 11/4/25, and the post-fall assessment dated 11/5/25 only included vital signs taken on 11/3/25. On 1/2/26, the same resident fell forward from bed, striking his face on a nightstand, was sent to the ER, and returned with sutures to the bridge of his nose. Aside from a follow-up assessment of the nose laceration on 1/3/26, there were no further assessments or vital signs documented related to this fall. The second resident, admitted with a history of falling and diagnoses including dementia and bipolar disorder, had an unwitnessed fall in her room on 12/17/25, during which she reported hitting her face/head on the floor and was sent to the ER for evaluation. After her return, the progress notes contained no follow-up assessments related to this fall during the 72 hours following the incident. Interviews with an RN and the DON confirmed that facility practice and the post-fall tool require neuro checks for all falls, documentation of whether the fall was witnessed or unwitnessed, skin and physical assessments, pain assessments, full sets of vital signs, and monitoring every shift for 72 hours, with all information charted in the notes. The facility’s fall risk tool also specifies change-of-condition charting every shift for 72 hours, including full vital signs and, if skilled, a head-to-toe assessment and fall follow-up, which were not completed as required for these two residents.
Failure to Maintain Fall Mat Intervention for High-Risk Resident
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident identified as high risk for falls. The resident was admitted with multiple diagnoses including adult failure to thrive, unspecified lack of coordination, and weakness, and was documented on an annual assessment to have severe cognitive impairment. Nursing progress notes show that on one occasion the resident experienced a witnessed fall at the bedside after rolling out of bed onto the floor, as reported by his roommate and the resident himself. A subsequent risk management report documents another incident in which the resident was found lying on his right side on the floor at the bedside, with a fall mat in place, and the resident reported he had rolled over while in bed. The resident’s care plan identified him as high risk for falls due to a history of falling and poor safety awareness, and included an intervention initiated after the first fall to place a floor mat at the bedside while in bed, which was revised following the second fall. During a surveyor observation, the resident was seen lying in bed on his left side facing the wall, with no fall mat located next to his bed or elsewhere in the room, despite the care plan intervention requiring a floor mat. A CNA interviewed shortly afterward stated the resident required two staff for a stand-and-pivot transfer, was not aware of the resident’s previous falls out of bed, and did not know that a fall mat was supposed to be in place. An RN confirmed that the resident should have a floor mat next to the bed and, upon observing the room, acknowledged that no mat was present. The DON stated that it is the responsibility of nursing and management to ensure fall interventions are in place. The facility’s accidents and supervision policy states that the resident environment will remain as free of accident hazards as possible and that each resident will receive adequate supervision and assistive devices to prevent accidents, including implementing and monitoring interventions to reduce hazards and risk.
Misappropriation of Resident Medications by Staff
Penalty
Summary
A staff member failed to prevent the misappropriation of a resident's medications. The resident, who had diagnoses including Schizoaffective Disorder, Chronic Obstructive Pulmonary Disease, and Drug Induced Subacute Dyskinesia, was prescribed Cyclobenzaprine 10mg three times daily for muscle spasms. After the resident was discharged against medical advice, two medication cards containing Cyclobenzaprine with the resident's name were later found in the possession of a nurse who had access to medications during night shifts. The nurse was subsequently arrested for an unrelated domestic charge, during which the medications were discovered. Facility staff confirmed that medications for discharged residents are typically returned to the pharmacy, except for narcotics, which are destroyed. However, in this case, the medications were not properly handled and were instead found outside the facility. Photographic evidence provided by the nurse's significant other showed the medication cards, one of which was full and the other partially used. The facility's abuse policy prohibits misappropriation of resident property, including medications, but this policy was not followed in this instance.
Failure to Remove Impaired Nurse from Resident Care Duties
Penalty
Summary
The facility failed to ensure resident safety by allowing an LPN, who was observed by multiple staff members to be falling asleep and exhibiting abnormal behavior, to continue providing care throughout her scheduled shift. On the day in question, several staff—including CNAs, housekeeping, and dietary management—witnessed the LPN nodding off while standing, struggling to administer medications, and appearing disoriented while performing resident care tasks. These observations were reported to both the Administrator and the Director of Nursing (DON) early in the shift. Despite these reports, the Administrator and DON initially spoke with the LPN, who stated she was simply tired, and allowed her to return to work after providing her with coffee. Later, after continued staff concerns, the DON administered an over-the-counter urine drug test, which was reportedly negative, though neither the Administrator nor the DON could specify which substances were tested for or provide written documentation of the results. The LPN was permitted to complete her shift, and there was no evidence that she was removed from resident care duties at any point during the incident. The facility's own policy requires that staff conduct themselves in a manner that does not interfere with safe operation or bring discredit to the facility. However, the Administrator and DON did not follow this policy, as they did not remove the LPN from duty despite multiple, consistent reports of unsafe behavior. The LPN herself admitted to being excessively tired and acknowledged a history of substance abuse, though she denied current use. The Medical Director confirmed that any staff member appearing impaired should not be allowed to care for residents.
Failure to Provide Ordered Physical Therapy Evaluation
Penalty
Summary
A deficiency occurred when a resident with a complex medical history, including type 2 diabetes mellitus, hypertensive heart disease with heart failure, congestive heart failure, atrial fibrillation, and a history of transient ischemic attack, did not receive a physical therapy (PT) evaluation as ordered by the physician. The resident was admitted on 11/11/2025, and an order for PT and occupational therapy (OT) evaluation and treatment was placed on 11/21/2025. While the resident received OT services as ordered, there was no documentation of a PT evaluation or screening being completed by 12/02/2025. The resident reported not having received PT services since admission, and facility records confirmed the absence of a PT evaluation. Interviews with facility staff revealed that the resident was evaluated by OT but not by PT, and that the facility required administrative approval to cover PT services for Medicaid residents. The Regional Director of Therapy was unaware of the PT evaluation order and only knew of the OT evaluation. Facility protocol requires all new admissions to be screened by therapy for potential skilled therapy services, including PT, OT, or speech therapy. Despite this protocol and the physician's order, the PT evaluation was not completed, resulting in a failure to provide specialized rehabilitative services as required.
Failure to Prevent and Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent abuse between two residents when one resident physically assaulted another following an incident involving personal belongings. Both residents involved were assessed as having no cognitive impairment according to their Brief Interview of Mental Status (BIMS) scores. The altercation began when one resident entered the other's room and was found going through personal items, which led to a confrontation where the resident whose belongings were disturbed followed the other through a shared bathroom and punched her in the face. Multiple staff interviews confirmed that this was the first physical altercation between these residents, although one resident had a known history of entering other residents' rooms and taking items. Despite the physical altercation, there was no evidence of injury to either resident, and neither required hospitalization. Staff, including RNs and CNAs, were aware of the incident and reported it to facility management, including the Administrator and DON. However, the incident was not documented in the residents' medical records at the time, and there was no initial report filed for the altercation. The police were not notified, and the event was not reported externally as required by facility policy. Interviews with staff indicated that the resident who was assaulted had previously expressed frustration over repeated thefts and felt compelled to act due to perceived inaction by the facility. The facility's abuse, neglect, and exploitation policy defines abuse to include resident-to-resident altercations such as hitting and punching. Staff acknowledged that the resident who entered others' rooms had a history of such behavior and that interventions such as redirection and education had been attempted. However, the lack of timely documentation, failure to report the incident as abuse, and absence of an initial report represent failures in the facility's processes to protect residents from abuse and to follow established protocols for reporting and investigating such incidents.
Failure to Timely Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the state agency as required by policy. The incident involved one resident entering another's room and going through personal belongings, which led to a physical altercation where one resident punched the other in the face. Both residents were assessed to have no cognitive impairment, and neither sustained injury or required hospitalization. Staff interviews confirmed that the altercation was witnessed and reported internally, but no external report was made to the state agency or law enforcement at the time of the incident. The administrator initiated a preliminary internal investigation but chose not to report the incident externally, citing a desire to confirm the facts before making a report. The facility's policy requires immediate reporting of all alleged violations involving abuse to the administrator, state agency, and other required agencies within specified timeframes. Despite this, the administrator acknowledged that the incident should have been reported within two hours, as it involved physical abuse between residents. Interviews with nursing staff and the CNA present at the time corroborated the sequence of events and the lack of external reporting. Both residents involved expressed their perspectives on the incident, with one admitting to the physical act and the other acknowledging the provocation. The facility's failure to follow its own abuse reporting policy resulted in a deficiency related to timely reporting of suspected abuse to the appropriate authorities.
Failure to Provide Timely Scheduled Pain Medication for Resident with Fractured Leg
Penalty
Summary
A resident with a history of multiple complex medical conditions, including a recent nondisplaced acute fracture of the proximal tibial metaphysis and severe osteopenia, did not receive scheduled pain medication as ordered. The resident's care plan included both scheduled and PRN (as needed) pain medications, with specific interventions to anticipate and respond to pain, including non-pharmacological measures. Despite these orders, the electronic Medication Administration Record (eMAR) showed a significant delay in administering the resident's scheduled hydrocodone-acetaminophen dose, which was given 3.5 hours late. On the morning of the observed deficiency, the resident was found in bed, visibly in pain, rating her discomfort as 10 out of 10, and expressing distress about her condition. The RN on duty acknowledged being delayed due to other responsibilities and only administered the scheduled pain medication after being informed by a CNA of the resident's pain. The documentation also showed that the resident had received two doses of narcotic pain medication within a short interval the previous evening, and then had a prolonged period without pain medication until the next morning. The facility's policy required timely recognition, assessment, and management of pain, including adherence to scheduled medication administration and prompt response to pain complaints. However, the failure to administer the scheduled pain medication on time, as well as the lack of immediate response to the resident's pain, resulted in the resident experiencing severe, unmanaged pain. The Director of Nursing confirmed that the delay in medication administration and the approach to pain management did not align with facility expectations or policy.
Failure to Administer Medications Within Scheduled Timeframe
Penalty
Summary
The facility failed to ensure that medications were administered within the scheduled timeframe for one resident. The resident, who had multiple diagnoses including transient cerebral ischemic attack, pseudobulbar affect, bone disorders, major depressive disorder, spastic hemiplegia, insomnia, bipolar disorder, hyperlipidemia, mood disorder, and anxiety disorder, was observed receiving her scheduled morning medications significantly late. The medications, which were due at 7:00 AM, were administered at 10:36 AM, exceeding the facility's policy of administering medications within one hour before or after the scheduled time. The delay occurred because the registered nurse responsible for medication administration was occupied with another resident who required one-on-one supervision at the nursing station. As a result, the nurse was unable to administer the medications on time and did not delegate the supervision task to another staff member to allow for timely medication administration. This led to the resident receiving her medications 2.5 hours late, and the next scheduled doses were set to be administered only 1.5 hours later, further complicating the medication schedule.
Failure to Honor Resident Smoking Rights Due to Premature Schedule Change
Penalty
Summary
The facility failed to honor the rights of 17 out of 19 residents who smoke by not allowing them access to a scheduled 5:30 PM smoke break as previously communicated. Residents were informed that the 5:30 PM smoke break would be discontinued starting on a Monday, but were told they would still have access to this break over the weekend. However, on the weekend prior to the scheduled change, residents were not permitted to go outside for the 5:30 PM smoke break due to lack of staff supervision. Multiple residents reported being upset and confused when the break was not provided as expected, and staff confirmed that the activity aide responsible for supervising the break was unavailable, resulting in the discontinuation of the break earlier than planned. Facility documentation showed that residents were given notice of the upcoming change and signed forms acknowledging the new smoking schedule, which was to take effect on a specific date. Despite this, the 5:30 PM smoke break was eliminated prematurely, contrary to what was communicated to the residents. The facility's own policies state that residents deemed safe to smoke should be allowed to do so at designated times and areas, in accordance with their care plans. The failure to provide the scheduled smoke break as communicated resulted in residents not being able to exercise their rights to self-determination and dignity as outlined in the facility's policies.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in a physical altercation between them. One resident, who had a history of schizoaffective disorder, restlessness, agitation, and generalized anxiety disorder, became agitated after being informed of a change in smoking break times. This resident exhibited escalating behaviors, including yelling, hitting walls, and slamming doors. The other resident, with diagnoses including paranoid schizophrenia, dementia, adjustment disorder, and schizoaffective disorder-bipolar type, was sitting in the activity room when the incident occurred. The altercation began after the agitated resident entered the TV area, continued to yell, and was told to be quiet by the other resident. The agitated resident then physically struck the other, leading to a fight in which both exchanged blows. Multiple staff members witnessed the incident, confirming that the initial aggressor was the resident who had been agitated over the smoking policy. Staff intervened to separate the residents, and emergency services were called. Both residents were assessed by staff and paramedics, with no visible injuries observed at the time, though one resident was sent to the hospital for evaluation of a head contusion. The facility's investigation and background checks revealed that both residents had prior histories of behavioral issues and aggression, with one resident identified as requiring closer supervision due to a moderate risk rating. Despite care plans and interventions for behavior and aggression being in place, the facility did not prevent the altercation. The report documents that the resident identified as a moderate risk was on 1:1 supervision following the incident, later reduced to 15-minute checks. However, the altercation occurred prior to these increased supervision measures. The facility's policy defines abuse as the willful infliction of injury or intimidation, including resident-to-resident altercations, and the incident met this definition as the physical abuse was deliberate and not accidental.
Failure to Employ Qualified Dietary Staff and Complete In-Person Nutritional Assessments
Penalty
Summary
The facility failed to employ a qualified dietary staff member to oversee kitchen operations and did not ensure that residents' nutritional assessments were completed in-person by a qualified dietary staff member. The individual serving as the dietary manager had not received certification in dietary management or food service, despite being responsible for completing quarterly nutritional assessments. No staff member in the facility was a certified dietary manager or certified food service manager. The registered dietician (RD) hired by the facility worked exclusively remotely, had never been in the facility or its kitchen, and did not provide education to kitchen staff. The RD completed admission and significant change nutritional assessments remotely, without in-person assessment or direct resident interviews, relying instead on staff input. Interviews with facility staff confirmed awareness that the dietary manager was not certified and that the RD worked only remotely. The facility did not have a job description or policy outlining the roles of a certified dietary manager or registered dietician. These failures had the potential to affect all 51 residents residing in the facility at the time of the survey.
Insufficient and Uncertified Dietary Staffing
Penalty
Summary
The facility failed to provide sufficient dietary staff to safely and effectively carry out the functions of the food and nutrition service. On the morning of the survey, only the Dietary Manager and one Dietary Aide were present to prepare and plate breakfast trays for all residents, as the scheduled cook did not show up. The Dietary Manager reported that they were using disposable plates because there was not enough staff to run the dishwasher, and typically three staff members are present for breakfast service. The facility data showed a total of 51 residents at the time of the survey. Additionally, the facility did not ensure that dietary staff had the required certifications. The Dietary Manager stated she had never received certification in dietary management or food service. The DON confirmed that several dietary staff members, including cooks and aides, had not obtained their Food Handler Certifications. The Registered Dietician emphasized the importance of these certifications for safety and sanitation. The facility also lacked policies regarding sufficient and competent dietary staff, as well as the roles and required certifications for dietary staff.
Failure to Follow Posted Breakfast Menu
Penalty
Summary
The facility failed to follow the planned breakfast menu for all 51 residents on the specified date. The posted menu included hot or cold cereal, scrambled eggs, a Danish roll, mandarin oranges, milk, and assorted juices. During breakfast service, the dietary manager and dietary aide prepared and served meals, but mandarin oranges were not provided to any residents, nor were they available on the prep tray. The dietary manager later confirmed that mandarin oranges were omitted because she forgot they were on the menu. Additionally, the director of nursing stated that the facility did not have a policy regarding adherence to menus. This deficiency was identified through observation, staff interviews, and review of facility records, and had the potential to affect all residents in the facility.
Failure to Provide Prescribed Wound Care Due to Lack of Supplies
Penalty
Summary
The facility failed to provide the prescribed wound treatment for a resident with a stage 4 pressure ulcer. The resident had a physician's order for the wound to be packed with iodoform 5% gauze packing strips, but these supplies were not available for several days. The Director of Nursing (DON) was informed that the packing strips were running low and placed an order, but there was no inventory process in place to monitor supplies. The wound nurse did not contact the physician for new treatment orders when the prescribed supplies were unavailable, and the floor nurse substituted a different dressing (alginate 4x4) without a physician's order. Observations confirmed that the required gauze packing strips were not present on the treatment cart or in the supply room. The wound nurse acknowledged the lack of supplies and the absence of a process for reordering or notifying the physician for alternative orders. The resident's wound treatment was not performed as ordered, and documentation showed the facility's policy required evidence-based interventions and compliance with physician orders for pressure injury care.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
A male resident with a history of embolism, thrombosis of the lower extremities, chronic atrial fibrillation, diabetes mellitus, hypertension, COPD, CHF, and peripheral vascular disease was admitted to the facility following hospitalization for a blood clot in his right leg. The resident, who was ambulatory prior to hospitalization, was admitted for skilled services with physician orders for physical and occupational therapy. The plan of care specified physical therapy five times per week to improve strength, balance, activity tolerance, safety, and independence with transfers, bed mobility, and ambulation. However, the resident reported not receiving physical therapy five days a week and expressed dissatisfaction with his care, stating he was not receiving the therapy needed to return home. Interviews with facility staff, including the DON and therapy staff, confirmed that the resident did not receive the ordered frequency of physical therapy sessions. The physical therapy service log showed that over a three-week period, the resident received only three therapy sessions per week, with two sessions not provided as ordered. Staff attributed the missed sessions to therapy staffing issues, including no call/no show incidents. The deficiency was identified through observation, interview, and record review, confirming the facility failed to provide specialized rehabilitative services as required for the resident admitted for skilled services.
Failure to Ensure Functioning Fall Prevention Alarms and Adequate Supervision
Penalty
Summary
The facility failed to ensure that fall prevention measures were in place and did not implement a system to verify that bed and chair alarms were functioning for a resident identified as high risk for falls. The resident had multiple diagnoses, including schizophrenia, anxiety disorder, dementia, movement disorder, bipolar disorder, and unsteadiness on feet, and was assessed as having moderate cognitive impairment. The resident's care plan identified impulsive behavior, cognitive impairment, and gait/balance problems as risk factors for falls. Despite these risks, there were no physician's orders for bed or chair alarms, no routine documentation of alarm checks, and no care plan documentation indicating the use of alarms for this resident. On the date of the incident, the resident experienced a fall resulting in a forehead laceration, and it was noted that the bed alarm did not activate as expected. Staff interviews revealed that there were no established routines or documentation practices for checking the functionality of bed alarms. Maintenance staff confirmed that routine checks were not performed, and nursing staff indicated that they assumed alarms were working unless a low battery indicator was present. The facility's policies required verification of alarm functionality when alarms were used, but this was not consistently implemented or documented.
Failure to Provide Medical Records to Resident's Guardian
Penalty
Summary
The facility failed to provide medical records to a resident's legal guardian and power of attorney for healthcare (POA) despite multiple requests. The resident, who was cognitively impaired due to mild intellectual disability, bipolar disorder, and schizophrenia, had a legal guardian and POA who requested access to the resident's medical records related to restorative and oral care. The guardian made both verbal and written requests for these records, including during a care plan meeting attended by the facility's administrator, director of nursing, social services, a registered nurse, and an ombudsman. Despite these requests, the facility did not provide the requested records. The facility's administrator claimed that a release of information form was necessary to access the records and denied receiving an email request for such a form. However, emails showed that the guardian had requested the form, and other staff members, including the ombudsman and a registered nurse, confirmed that the guardian had asked for the medical records, not quality assurance documentation. The facility's policy stated that medical records should be accessible within 72 hours of a request and copies provided within five working days, but this policy was not followed in this case.
Failure to Identify and Address Pressure Injury
Penalty
Summary
The facility failed to identify and address a pressure injury in a timely manner, resulting in a resident developing a stage three pressure injury on the left ischium. The resident, who has multiple diagnoses including cerebral palsy, paraplegia, and schizoaffective disorder, was admitted to the facility with no noted pressure injuries and was assessed as being at high risk for developing pressure injuries. Despite having a care plan that included daily skin checks, the facility did not document any skin abnormalities between February 8, 2024, and May 24, 2024, when the stage three pressure injury was first identified. Interviews with facility staff revealed that the nursing staff was expected to perform weekly skin checks and document any skin issues, but there was a lack of documentation indicating that these checks were performed or that any skin issues were identified before the injury progressed to stage three. The Director of Nursing and the Wound Doctor both indicated that proper attention during routine care should have allowed for earlier identification of the pressure injury. The failure to identify the pressure injury in its early stages led to the development of a stage four pressure wound by February 28, 2025.
Failure to Provide Nutritional Support and Monitoring
Penalty
Summary
The facility failed to provide adequate nutritional support and monitoring for several residents, leading to significant weight loss in some cases. Resident 18, who was admitted with multiple diagnoses including paranoid schizophrenia and major depressive disorder, experienced a weight loss of 16.5 pounds or 11.8% in one month. Despite orders for a general diet with double protein, magic cups, and mighty shakes, these supplements were not consistently provided, and weekly weights were not documented as suggested by the dietitian. Resident 24 also experienced a significant weight loss of 22.8 pounds or 13% in one month. Although there was an order for yogurt with meals and a magic cup daily, these were not consistently provided due to a failure in updating the computer system. The dietary manager acknowledged the oversight, and the resident's meal ticket did not reflect the necessary nutritional supplements. Resident 5's dietary recommendations to increase oral nutrition supplements were not implemented, and Resident 34, who had a significant weight loss of 13.7 pounds or 10% in six months, did not receive the prescribed mighty shakes. The facility's weight monitoring policy indicates that unintended weight loss should prompt interventions, but these were not effectively carried out, as evidenced by the lack of supplements provided during meal services.
Failure to Timely Administer Influenza Vaccine Leads to Outbreak
Penalty
Summary
The facility failed to offer the influenza vaccine at the start of the influenza season to two residents, R40 and R4, which contributed to an influenza outbreak and their subsequent hospitalization. R40 was admitted to the facility with multiple diagnoses, including diabetes mellitus and chronic pain, and was cognitively intact. She was hospitalized with pneumonia and influenza A, and it was noted that she had not been offered the influenza vaccine prior to her hospitalization. R40 received the vaccine only after returning from the hospital. Similarly, R4, who had a history of respiratory issues and other health conditions, was hospitalized with influenza A and reported not being offered the vaccine before her hospital admission. Both residents expressed willingness to receive the vaccine if it had been offered earlier. The facility's Director of Nursing (DON) and Infection Control Preventionist acknowledged that the influenza vaccine was not ordered at the beginning of the season, which was an oversight by the previous administrator. The vaccine was eventually administered in January, after the outbreak had already begun in December. The facility's outbreak log indicated that ten residents tested positive for influenza between December and January, with only one resident having been vaccinated during the current season at a previous facility. The facility's policy stated that influenza vaccinations should be offered annually from October through March, but this was not adhered to in a timely manner. Interviews with staff and the local health department director revealed that there was no shortage of the influenza vaccine, and it was expected to be administered at the start of the season. The delay in vaccination contributed to the outbreak, as the facility did not have rapid influenza testing available and relied on hospital diagnoses. The facility's failure to administer the vaccine in a timely manner and the subsequent outbreak highlight the importance of adhering to vaccination policies to prevent such occurrences.
Improper Plumbing of Dish Machine Leads to Potential Cross-Contamination
Penalty
Summary
The facility failed to ensure that the dish machine was plumbed according to code, which could potentially affect all residents. During an observation, it was noted that the dish machine and an adjacent sink were backing up with water and food debris. The plumbing for the dish machine was improperly connected to the sink with a garbage disposal, leading to a back pitch and a leak. The Dietary Manager, V7, was aware of the issue and had reported it to the maintenance team and the facility's administration, but no plumber had been called to address the problem. The maintenance staff attempted to manage the situation by using a plunger to clear the blockage. The issue had been ongoing since December 2024, and despite the Dietary Manager's reports, the dish machine continued to be used. The facility's administrator, V1, who started in January 2025, was informed of the problem during audits but was not aware of the specific mechanical issues. V1 advised the dietary staff to stop using the dish machine and use the 3-compartment sink instead. A licensed plumber, V15, later confirmed that the plumbing was not up to code and provided a quote to fix the issues, including re-routing the drain line to prevent cross-contamination.
Infection Control Deficiencies in PPE Use and Illness Tracking
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of tracking and trending of resident illnesses. On March 4, 2025, the Director of Nursing (DON) and the Infection Control Preventionist admitted that they did not have a system in place to track and trend resident illnesses, except for influenza, COVID-19, and pneumonia. This oversight was acknowledged by the DON, who was unaware of the requirement to track other illnesses, potentially affecting all 49 residents in the facility. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) protocols. A resident with a large open wound, a cholecystostomy drain, and a urinary catheter did not have an EBP sign posted outside their room, and a nurse performed a dressing change without wearing a gown. Another resident with an indwelling urinary catheter also lacked an EBP sign and PPE bin outside their room. The facility's policy, implemented in April 2024, requires EBP for residents with wounds and indwelling medical devices, mandating the use of gowns and gloves during high-contact care activities. However, these protocols were not consistently followed, as evidenced by the absence of necessary signage and PPE during care activities.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to ensure a resident's advance directive to be a full code was accurately ordered. The resident, identified as R103, was discharged from the hospital with a discharge summary indicating a full code status. However, the physician's order sheet showed a DNR (Do Not Resuscitate) order dated the same day as the discharge. On March 4th, R103 expressed a desire to be resuscitated and was unsure why a DNR order was in place, especially after experiencing critical situations in the hospital. A registered nurse, V3, admitted to entering the DNR order into the computer based on hospital paperwork and did not notify social services due to the late return from the hospital. Another RN, V9, stated that in emergencies, she would rely on the electronic medical record to determine a resident's code status. Social Services, represented by V4, confirmed that R103 still wished to be a full code. The resident's cognition was noted to be intact, and the facility's policy supports residents' rights to formulate advance directives, which was not adhered to in this case.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who is dependent on staff for Activities of Daily Living (ADLs). The resident, identified as R33, has impaired cognition and is incontinent of urine and stool, requiring staff assistance for toilet hygiene. On March 3, 2025, at 11:55 AM, two Certified Nursing Assistants (CNAs) provided incontinence care to R33 and found her incontinence brief saturated with urine and stool, with her buttock reddened and her sheet and shirts wet from urine. CNA V23 admitted to last checking R33 at 6:20 AM, noting she was not wet at that time and did not provide care. V23 did not check R33 again until 11:45 AM due to being busy. The facility's policy requires incontinent residents to be checked and changed every two hours, as confirmed by a Registered Nurse (RN). R33's care plan also specifies changing disposable briefs every two hours and as needed.
Failure to Follow Dressing and Edema Management Orders
Penalty
Summary
The facility failed to ensure proper dressing orders were in place for a resident's cholecystostomy drain and did not apply ace wraps as ordered for another resident with lower extremity edema. A registered nurse (RN) changed the dressing for a resident's cholecystostomy drain without specific dressing orders from the hospital. The RN acknowledged that if a resident is admitted with a wound and no dressing change orders, the nurse should contact the physician to obtain them. The resident's hospital discharge summary included instructions to flush the drain with normal saline daily but did not mention dressing changes. The treatment administration record lacked documentation of dressing changes for the drain site over a specified period. Another resident, who was cognitively intact, was observed with swollen legs and reported that support stockings or wraps were not applied to manage her edema, despite her wishes. The RN confirmed that there was an existing physician's order for ace wraps to be applied to the resident's legs every morning and removed at bedtime due to edema. However, the resident's legs were not wrapped as per the order, indicating a failure to follow the prescribed treatment plan.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure fall prevention interventions were in place for two residents, leading to safety deficiencies. Resident 28, who has a bilateral below-the-knee amputation and a moderate risk of falling, reported that the locks on his wheelchair do not work, causing the wheelchair to move freely. This malfunction led to an incident where Resident 28 ended up on the floor while transferring himself from his bed to the wheelchair. The resident's progress notes confirmed a previous fall incident where he slid off the wheelchair, indicating a lack of appropriate equipment and supervision to prevent falls. Resident 31, diagnosed with multiple conditions including cerebral palsy and paraplegia, was also identified as having a moderate risk of falling. The care plan for Resident 31 specified that the call light rope should be within reach to prevent falls. However, observations revealed that the call light rope was positioned out of reach behind the head of the bed on multiple occasions. A registered nurse confirmed that the call light rope should always be within reach for residents like Resident 31, who are dependent on staff assistance. The failure to ensure the call light was accessible compromised the resident's ability to call for help, increasing the risk of falls.
Medication Administration and Supervision Deficiencies
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for two residents. For one resident, Buspirone, an anti-anxiety medication, was not available during the scheduled noon medication pass. The registered nurse (RN) was unable to locate the medication in the medication cart or the convenience box, indicating that it had not yet arrived from the pharmacy. As a result, the resident did not receive their prescribed dose of Buspirone at the scheduled time. Additionally, the facility failed to supervise a resident during medication administration. An Albuterol inhaler was found on a resident's nightstand, and the resident confirmed that they used it unsupervised for shortness of breath. The RN verified that there was no order for the resident to self-administer the inhaler or keep it at the bedside. The facility's policy requires that medications be administered according to standards of practice, including correct dosage and time, and that residents be observed during medication administration.
Failure to Implement Monthly Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that monthly pharmacy recommendations were carried out for a resident reviewed for drug regimen reviews. The resident, identified as R31, has multiple diagnoses including cerebral palsy, major depressive disorder, epilepsy, anxiety, schizoaffective disorder, paraplegia, hypokalemia, GERD, hyperkalemia, encephalopathy, hypertension, and hyperlipidemia. A consultation report dated 1/15/25 recommended monitoring the resident's kidney function by checking serum creatinine levels every six months. However, the last comprehensive metabolic panel, which includes serum creatinine, was performed on 3/29/24, and no more recent lab results were available. During interviews, the Director of Nursing (V2) stated they had never seen the monthly medication regimen review recommendation forms and did not take any action on them. The Regional Nurse (V20) indicated that V2 was responsible for following up on these recommendations. It was revealed that due to a change in facility ownership in November 2024, the facility did not have access to the pharmacy portal where recommendations were sent until two weeks prior to the survey date.
Deficient Maintenance of Wheelchairs Compromises Resident Safety
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating condition for three residents, leading to a deficiency in providing a safe environment. Resident 28, who has major depressive disorder and is a double amputee, reported that his wheelchair was in disrepair with worn and missing rubber on the wheels and non-functional locks, which resulted in a fall during a self-transfer. Despite filing a grievance in January 2025 requesting a new wheelchair, the issue persisted until March 2025. Resident 4, diagnosed with generalized anxiety disorder and other chronic conditions, also experienced issues with her wheelchair, which lacked functional brakes, compromising her safety. Similarly, Resident 19, with a history of impaired mobility due to a hip fracture and other health issues, reported that her wheelchair brakes were ineffective despite previous maintenance attempts. These deficiencies highlight the facility's failure to ensure that essential equipment was maintained in a safe and functional condition, as required by their Resident Rights policy.
Failure to Protect Resident from Mental Abuse
Penalty
Summary
The facility failed to protect a resident from mental abuse, as evidenced by an incident involving a resident with multiple diagnoses, including major depressive disorder, anxiety disorder, and autism. The resident reported feeling bullied by two CNAs after an episode of vomiting due to norovirus. The CNAs allegedly made the resident clean up her own vomit, stating that she was on an independent hall and needed to clean up after herself. This incident was reported to the facility's administration, leading to an investigation. Interviews conducted during the investigation revealed that the resident felt upset, uncomfortable, and angry due to the CNAs' actions. The resident's roommate corroborated the account, stating that the CNAs were rude and made the resident clean up the vomit. The roommate also reported the incident to the facility's social services, who found the resident's account credible. The facility's administrator and social services staff conducted interviews with other residents and staff, confirming the allegations of mental abuse. The facility's policy on abuse, neglect, and exploitation defines mental abuse as including humiliation and harassment, which aligns with the resident's experience. The investigation concluded that the CNAs' actions constituted mental abuse, as they made the resident feel bad and failed to provide appropriate care during her illness. The facility's response included suspending the involved staff members and conducting a thorough investigation to substantiate the claims of abuse.
Absence of Full-Time Director of Nursing
Penalty
Summary
The facility failed to ensure the presence of a full-time Director of Nursing (DON), affecting all residents. As of December 9, 2024, the facility had 52 residents and had been without a DON since November 1, 2024, when a new company took over. Registered Nurses (RNs) V4 and V5 confirmed that they had been contacting the Administrator, V1, for nursing issues, despite V1 not being a nurse. The facility had a Nurse Consultant, V7, who had only visited a few times since the takeover. V6, another RN, stated she was not the DON designee and had not been asked to take on that role. The Administrator, V1, acknowledged the absence of a DON and admitted to handling nursing issues despite lacking a nursing background. V1 mentioned discussing the situation with the Regional Nurse, V7, and during a Risk Management meeting, it was suggested that V6 assist with nursing duties, although she was not designated as the DON. The job description for the DON role, provided by the facility, outlines responsibilities such as planning, organizing, and directing nursing services in compliance with regulations and facility policies, which were not being fulfilled due to the vacancy.
Failure to Provide Access to Medical Records
Penalty
Summary
The facility failed to ensure that a resident's representative had access to the resident's medical records. This deficiency was identified during an observation, interview, and record review involving a resident's sister and guardian, who had requested access to the resident's medical records on three separate occasions. The resident, who had a bruise on her left forehead and was on a blood thinner, raised concerns for her sister. Despite these requests, the facility's administrator had not provided the necessary paperwork to access the records. The facility's policy on the release of medical records, dated November 2024, states that medical records will be released with a valid request in accordance with state and federal laws. However, the administrator confirmed that the request form had not been provided to the resident's sister.
Failure to Investigate Bruise of Unknown Origin in Resident on Blood Thinners
Penalty
Summary
The facility failed to investigate a bruise of unknown origin on a resident who was on blood thinners, which was a significant oversight given the potential health implications. The resident was observed with a fading bruise on the left side of her forehead, which was first noticed by her sister/guardian. The sister expressed concern due to the resident's use of blood thinners and requested to see the medical record regarding the bruise. However, there was no documentation in the resident's progress notes about the bruise, and the staff initially believed it was the same bruise from a previous fall, which was on the opposite side of the forehead. The resident's physician indicated that any head injury or bruise in a resident on blood thinners should be evaluated. Despite this, the registered nurse could not recall being informed about the bruise, and the administrator admitted that no investigation had been conducted until the day of the survey. The facility did not provide a policy on handling injuries of unknown origin, indicating a lack of protocol in addressing such incidents. This lack of investigation and documentation represents a deficiency in the facility's response to potential injuries of unknown origin.
Failure to Document and Obtain Physician Orders for Resident Discharges
Penalty
Summary
The facility failed to properly document the reasons for discharging two residents and did not obtain necessary physician documentation prior to their discharge. In the case of one resident, identified as R10, the facility's records show that the resident exhibited aggressive behavior, including verbal threats and physical aggression towards staff, which led to the involvement of emergency services and the resident being sent to the hospital. However, there was no documentation in the resident's medical record regarding the transfer to the hospital, nor were there any physician orders for the discharge. The facility's administrator acknowledged the lack of documentation and was uncertain if the physician had been contacted. Similarly, another resident, identified as R9, was transferred to another facility without documented physician orders for the discharge. The facility's administrator and social services staff were unsure if the resident's primary physician had been notified or if discharge orders had been obtained. The facility's policy requires obtaining physician orders and ensuring a complete discharge summary, which was not adhered to in these cases.
Failure to Notify Guardian and Ombudsman of Involuntary Discharge
Penalty
Summary
The facility failed to notify a resident's guardian and the Ombudsman of an involuntary discharge. The incident involved a resident who exhibited aggressive behavior, including verbal threats and physical aggression towards staff, which led to the resident being sent to the hospital. The facility decided not to readmit the resident after the hospitalization but did not inform the resident's guardian or the Ombudsman of this decision. The facility's administrator confirmed that the decision not to readmit the resident was made shortly after the incident, but the guardian was only informed by the hospital days later. The facility's policy requires that both the resident's representative and the Ombudsman be notified of any discharge decisions, which was not adhered to in this case. The lack of documentation in the resident's progress notes further supports the failure to provide the required notifications.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to allow a resident to return after a hospital stay and did not document the reason for the refusal. The resident, identified as R10, was involved in an incident where they exhibited aggressive behavior, including verbal threats and physical aggression towards staff, which led to the facility calling 911 and transferring the resident to the hospital. Despite the hospital's assessment that the resident could be discharged safely and did not require acute placement, the facility decided not to readmit the resident due to safety concerns. The facility's administrator communicated the decision not to readmit the resident to the hospital but did not initiate any involuntary discharge paperwork or document the decision in the resident's progress notes. The resident's guardian was informed by the hospital, not the facility, about the decision, which caused distress. The facility's transfer and discharge policy requires documentation and evidence when a resident is not allowed to return, but this was not followed in this case.
Failure in Discharge Planning for Resident Transfer
Penalty
Summary
The facility failed to implement proper discharge planning for a resident who was transferred to another facility. The resident expressed a desire to move closer to family, and the ombudsman communicated this to the facility staff. However, there was no discharge planner available at the time, and the agency registered nurse on duty was not familiar with the discharge process. Consequently, there was uncertainty about whether the necessary discharge arrangements were made, including notifying the physician or the receiving facility. The social services representative confirmed that no interdisciplinary team meeting was held to discuss the resident's discharge needs, and the discharge was arranged without a documented plan. The facility's transfer and discharge policy requires orientation for transfer or discharge to ensure a safe and orderly process, but this was not documented in the resident's progress notes. The lack of a documented discharge plan and the absence of coordination among staff members led to the deficiency in discharge planning for the resident.
Incomplete Discharge Summary for Resident Transfer
Penalty
Summary
The facility failed to ensure a complete discharge summary for a resident who was transferred to another facility. On the day of the transfer, the Ombudsman communicated the resident's desire to move closer to family, but there was no discharge planner available. An agency RN was present but unaware of the discharge arrangements or the resident's needs. The resident's paper chart and medications were sent with him, but there was no confirmation that the physician was notified or that a report was given to the receiving facility. The facility's policy requires a comprehensive discharge summary, including a recap of the resident's stay, a final summary of their status, medication reconciliation, and a post-discharge care plan. However, the resident's electronic medical record lacked this summary, and the progress notes did not document the necessary details, such as the resident's status or physician notification. This oversight indicates a failure to adhere to the facility's discharge policy, resulting in an incomplete discharge process for the resident.
Failure to Assess Change in Condition After Resident Fall
Penalty
Summary
The facility failed to assess and identify a change in condition for a resident, R2, after a fall, resulting in a delay in identifying and obtaining treatment for a right hip fracture. R2, who has diagnoses including Schizoaffective Disorder Bipolar Type, unspecified abnormalities of gait and mobility, unspecified dementia, and mild intellectual disabilities, fell on 11/13/24 while attempting to transfer herself from her wheelchair to a chair. Despite being assisted back into her wheelchair by staff, no immediate skin concerns were noted, and R2 was agitated at the time. Following the fall, there was a lack of documented assessment or follow-up on R2's condition until 11/14/24, when it was noted that she was not feeling well and remained mostly in her room. On 11/15/24, R2 was found to be in significant pain, with one leg shorter than the other, prompting her transfer to the emergency room where she was diagnosed with a right femoral neck fracture. Interviews with staff revealed that R2 had been complaining of leg pain and had difficulty bearing weight, but these complaints were not communicated to the nursing staff or documented appropriately. The facility's Fall Prevention and Management Policy requires documentation and assessment for 72 hours following a fall, including physical assessments and any new interventions. However, this protocol was not followed, as evidenced by the lack of documentation and communication regarding R2's condition post-fall. The physician was not informed of R2's change in condition, which could have led to earlier intervention. The failure to adhere to the policy resulted in a delay in diagnosing and treating R2's hip fracture.
Inadequate Incontinence Care for Resident with UTI
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident with a recent urinary tract infection. The resident, who has diagnoses including paranoid schizophrenia, dementia, hypertension, chronic cystitis, dysphagia, and a urinary tract infection, was observed to have inadequate care. The care plan indicated that the resident should be checked every two hours for incontinence and provided with perineal care. However, on the day of observation, the resident expressed a need to use the bathroom, but a CNA stated that residents using a mechanical lift were not taken to the toilet and were expected to use their incontinence briefs instead. The resident's incontinence brief was last changed at 6 AM, and no incontinence or perineal care was provided when the resident was dressed for the day. Later, it was confirmed that the resident had been sitting in a chair without a change of incontinence brief for several hours. When incontinence care was finally provided, the brief was found to contain a large amount of foul-smelling urine. A registered nurse stated that all incontinent residents should be offered toileting options and should not be left to sit in urine, as this could increase the risk of infections. The facility's policy on perineal care emphasizes the importance of cleanliness to prevent infections and skin irritation, which was not adhered to in this case.
Resident Elopement Due to Inadequate Supervision and Faulty Door Alarms
Penalty
Summary
The facility failed to ensure adequate supervision and safety for a resident with severe cognitive impairment and a history of elopement. The resident, identified as R4, has multiple diagnoses including disorders of the brain, dementia, and epilepsy, which contribute to poor safety awareness and wandering behaviors. Despite being on 15-minute checks and having a care plan that includes 1:1 monitoring, R4 managed to exit the facility multiple times, including through a courtyard door whose alarm was not functioning properly. On several occasions, R4 left the building unsupervised, sometimes becoming aggressive when staff attempted to redirect him back inside. The facility's staff, including CNAs and RNs, reported incidents where R4 exited through various doors, including the C hall door and the activity south exit, and was found in nearby areas such as a hospice parking lot. The facility's maintenance director confirmed that the courtyard door alarm was not working for a period, and repairs were delayed, contributing to the resident's ability to elope. Interviews with staff and the resident's physician highlighted concerns about R4's unpredictable behavior and the need for a more secure environment. The facility's administrator acknowledged the high risk of elopement and the inadequacy of the current setting for R4, who requires a locked facility. Despite efforts to monitor and redirect R4, the facility's failure to maintain functional door alarms and provide constant supervision led to repeated elopement incidents, compromising the resident's safety.
Unlicensed Staff Administering Medications
Penalty
Summary
The facility failed to ensure that medications were administered by individuals with the appropriate skills, knowledge, and licensure, affecting 8 out of 14 residents reviewed. On September 20, 2024, it was observed that the Dietary Manager, who is not licensed to administer medications, was involved in passing medications to residents. This was corroborated by multiple residents and staff members who witnessed the Dietary Manager distributing medications prepared by the Director of Nursing (DON). Residents, including those with complex medical histories such as chronic embolism, bipolar disorder, diabetes, and hypertension, reported receiving medications from the Dietary Manager. The DON was reportedly preparing the medications and allowing the Dietary Manager to distribute them, which is against the facility's policy that only licensed individuals may administer medications. Several staff members, including CNAs and the MDS Coordinator, confirmed these observations, noting that the Dietary Manager was seen passing medications during both day and night shifts. The facility's policy on medication administration, last reviewed in June 2021, clearly states that only licensed personnel are permitted to administer medications. Despite this policy, the Dietary Manager was observed passing medications, and the facility's administration was unable to conclusively determine whether this occurred, despite multiple reports from residents and staff. The incident highlights a significant breach in protocol, as the facility could not ensure that medications were administered safely and by qualified personnel.
Failure to Administer Pain Medication
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R1, who was admitted with diagnoses including spinal stenosis, bipolar disorder, and depression. R1 was cognitively intact and had a physician's order for Norco to be administered four times a day for back pain. However, due to a lapse in communication and procedure, R1 was without his prescribed pain medication from 9/1/24 to 9/4/24, missing 12 doses. The issue arose when the facility ran out of Norco, and attempts to obtain a new prescription from the physician were unsuccessful due to fax issues. Despite R1's inquiries and the involvement of the facility's Administrator and Director of Nursing, the medication was not obtained from the convenience box as suggested, leaving R1 without pain relief. Interviews with staff revealed that there was no documentation of efforts to secure a refill until 9/3/24, and the nurses failed to communicate effectively about the medication shortage. R1 reported feeling physically and emotionally affected by the lack of medication, experiencing symptoms such as shakiness and nausea. The facility's policy required medications to be administered safely and timely, but there was no specific policy for pain management. The failure to adhere to these protocols resulted in a significant lapse in care for R1.
Failure to Timely Reorder Pain Medication
Penalty
Summary
The facility failed to timely reorder a controlled substance pain medication, Norco, for a resident, resulting in the resident missing up to 12 doses. The resident, who was cognitively intact and admitted for conditions including spinal stenosis, bipolar disorder, and depression, was prescribed Norco for back pain. The issue arose when the resident ran out of Norco over a holiday weekend, and the facility did not have a current prescription to obtain more from the pharmacy or the convenience box. Despite the resident's inquiry about having enough medication for the weekend, the staff assured him he did, but he ran out on Sunday. The delay in obtaining a new prescription was due to communication failures and procedural issues within the facility. The Registered Nurse (RN) on duty attempted to contact the physician's office but faced difficulties with the fax machine and did not successfully obtain a new prescription. The Director of Nursing (DON) and the Administrator were informed of the situation on Tuesday, but by then, the resident had already missed several doses. The facility's policy required a refill request to be initiated when there were 3-4 doses left, but this was not done, leading to the deficiency.
Failure to Prevent Resident Elopement and Inadequate Monitoring
Penalty
Summary
The facility failed to ensure the safety of a resident at high risk for elopement, resulting in an Immediate Jeopardy situation. The resident, a female with Alzheimer's Disease, severe cognitive impairment, and a history of elopement, was not adequately monitored as per her care plan, which required 15-minute checks. On the day of the incident, there were significant gaps in the documentation of these checks, and the resident was able to leave the facility unsupervised. She was found disoriented and confused by a passerby on a busy highway and was subsequently taken to a local police department and then to an emergency room. The facility's failure extended to the documentation and execution of 15-minute checks for all residents identified as needing frequent monitoring. The report highlights that none of the 14 residents reviewed had consistent and timely documentation of their checks. This lack of documentation raises concerns about the actual performance of these checks and the overall safety and supervision provided to residents at risk. Additionally, the facility's door alarm system was not functioning properly, which contributed to the resident's ability to elope. Temporary alarms were placed on the doors, but they could be easily disengaged, and the facility did not have a reliable system to ensure that door alarms were consistently operational. The facility's policies regarding elopement and missing residents were not followed, as evidenced by the lack of immediate notification to law enforcement and the absence of documentation of the elopement incident in the resident's medical record.
Removal Plan
- All residents residing in the facility had Elopement Risk Assessment reviewed per the QA team. Those with a High Risk were verified to have their picture and identifiers completed and placed in the Elopement Binder maintained at the nurse's station.
- The facility QA team reviewed/revised the Plan of Care for each individual with a High-Risk Assessment.
- All staff in the facility are identified as responsible for resident's safety.
- All staff was in-serviced by the facility Administrator regarding the facility Door Alarm Policy and the responsibility of all staff to ensure the exit door alarms are activated.
- All staff was in-serviced by the facility Administrator regarding the facility Elopement Policy/Procedures.
- All staff was in-serviced by the facility Administrator regarding Missing Resident Policy/Procedures.
- All staff was in-serviced by the facility Administrator regarding 15-minute check Policy/Procedures.
- Paper logs for 15-minute checks moving on residents on 15-minute checks and one on ones.
- During meal services a CNA not conducting hall trays will take over the 15-minute checks during the meal hall pass.
- CNAs in the dining rooms will chart the 15-minute checks while that resident is in the dining room.
- Facility maintenance personnel will continue to check door alarms.
- Facility maintenance personnel will randomly throughout their shift monitor doors to ensure they are engaged.
- All staff will be educated during the orientation period of employment as to how to properly turn on and off exit door alarms and to those with elopement risk and location of the information.
- Director of Nursing or designee will be responsible for coordination the completion of QA audits to ensure ongoing performance improvement with 15-minute checks and documentation.
- Trends and/or concerns will be reported to the QAPI committee for review and identification of changes in monitoring based on outcomes.
- Staff will be in-serviced upon hire and annually to ensure continued compliance.
Failure to Implement Legionella Mitigation Measures
Penalty
Summary
The facility failed to have interventions in place to mitigate the growth and spread of Legionella and did not maintain logs of such interventions. The CMS 671 form indicated that 52 residents reside in the facility. During an interview, the Administrator stated that the Maintenance Director oversees Legionella management but admitted that no Legionella testing had been conducted. The Maintenance Director revealed that he was unaware of what Legionella is, how to prevent it, and that he was responsible for its management. He also confirmed that he had not received any training on Legionella mitigation and had no logs of mitigation efforts, except for random weekly water temperature checks. The facility's Legionella policy and procedure outlined specific interventions for Legionella mitigation, including annual cleaning of water heaters, quarterly disinfection of shower heads, and weekly flushing of unused taps and shower heads, none of which were being documented or evidently performed.
Failure to Provide Required Immunizations
Penalty
Summary
The facility failed to ensure residents were provided with influenza and pneumococcal immunizations as required. This deficiency was identified for three residents within the sample and two residents outside the sample. The Administrator admitted that the previous administrator did not adequately track immunizations, and no screening or eligibility assessments had been conducted. Additionally, vaccine refusal forms were not available for review. The Director of Nursing confirmed that the residents could have received the Prevnar 23 vaccine but were not offered it, and it was unclear whether the residents had refused the vaccine or were simply not offered it. The electronic medical records for the residents showed incomplete or missing documentation regarding their influenza and pneumococcal vaccinations, and all requested immunization records were not received. The facility's policy from September 2017 stated that residents would be offered immunizations unless medically contraindicated or otherwise ordered by the attending physician. The policy also required the facility to explain the importance of vaccinations to the resident or their guardian, obtain a written order for the vaccination, verify the date of the last vaccination, and offer the PCV13 or PPSV23 vaccines as indicated. Despite this policy, the facility did not adhere to these procedures, resulting in the failure to provide necessary immunizations to the residents. The lack of proper documentation and tracking contributed to this deficiency, as evidenced by the missing records and the absence of vaccine refusal forms.
Failure to Provide and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to ensure residents were provided COVID-19 vaccinations as required. This deficiency was identified through interviews and record reviews, revealing that the facility did not track or administer COVID-19 vaccinations to residents. The current administrator, V1, acknowledged that the previous administrator did not adequately track immunizations, and since taking over, V1 has been unable to locate COVID-19 vaccination information for the residents. No screening, eligibility assessments, or COVID-19 vaccinations have been conducted, and refusal forms were not available for review. The Director of Nursing, V2, confirmed that she oversees influenza and pneumonia vaccines, while V1 is responsible for COVID-19 vaccines. However, no records of COVID-19 vaccinations were found for the residents reviewed in the sample and outside the sample (R20, R21, R46, R51, R54). The facility's policy and procedure on COVID-19 vaccination, revised on 11/7/22, states that the vaccine will be offered to all residents, and documentation of vaccination information will be maintained in medical records. Additionally, the 09/2017 policy on immunization of residents indicates that the facility will offer immunizations to prevent infectious diseases unless medically contraindicated or otherwise ordered by the resident's attending physician or the facility's medical director. The deficiency was observed in the cases of three residents in the sample and two residents outside the sample. For instance, R20, R21, R46, R51, and R54's electronic medical records showed no past or present COVID-19 vaccination records, and all requested immunization records were not received. This lack of documentation and administration of COVID-19 vaccines indicates a failure to comply with the facility's policies and procedures, potentially compromising the health and safety of the residents. The facility's failure to educate residents on the benefits and risks of the COVID-19 vaccine and to maintain proper documentation of vaccination status further underscores the deficiency in adhering to established protocols for immunization.
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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