La Bella Of Woodstock
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodstock, Illinois.
- Location
- 309 Mchenry Avenue, Woodstock, Illinois 60098
- CMS Provider Number
- 145222
- Inspections on file
- 56
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at La Bella Of Woodstock during CMS and state inspections, most recent first.
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.
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 with COPD, chronic hypoxic respiratory failure, CHF, and dementia, who was on chronic 2 L/min O2 via nasal cannula, was transported by stretcher to an outpatient procedure without oxygen. Facility staff had requested transportation that included 2 L of O2, and the dispatcher confirmed the stretcher service itself did not supply oxygen but could accommodate a travel tank from the facility. When the driver arrived, the resident was in bed without oxygen, and staff did not indicate an oxygen requirement or provide a portable tank. The resident was transported without O2 and later arrived at the hospital with an O2 saturation below 90%, with the first documented saturation of 91% after oxygen was applied.
A resident admitted for rehab and pain control after multiple rib fractures, previously managed with IV hydromorphone, experienced severe uncontrolled pain rated 8–9/10 for approximately 7.5 hours before receiving any pain medication. The admitting RN delayed entering admission orders because they were completing a med pass and reported the unit was challenging, and the resident’s ordered pain medication was not available on hand. The NP, who assessed the resident with multiple left rib fractures and primary diagnoses of rib fracture and pain, was not informed until hours later that the pain medications were unavailable and stated an alternative could have been ordered sooner if notified. The resident reported extreme pain, difficulty performing basic tasks, and ultimately left the facility due to the lack of timely pain relief, contrary to the facility’s own pain management policy for acute pain.
Two cognitively intact residents with significant physical impairments and dependence on staff for ADLs reported concerns about a CNA’s care and conduct, including refusal to assist one resident out of bed, improper handling of transfers with a full-body mechanical sling lift, and prior incidents involving another resident left hanging in a lift. Both residents stated they reported their concerns to the DON rather than using grievance forms, with one resident citing inability to write and fear that documents disappear, and the other unaware of the grievance form. The Administrator, DON, RN, Social Service Director, Human Resource Director, and a CNA trainer gave conflicting accounts of complaints and the grievance process; some staff reported multiple complaints about the CNA’s behavior and lift use, while others denied receiving resident complaints. The Ombudsman stated residents feel grievances reported to staff are not resolved, and review of the grievance log for the relevant period showed no entries reflecting these residents’ concerns, despite a written policy requiring documentation and follow-up of all grievances.
Two residents with orders for nighttime CPAP therapy, one with obstructive sleep apnea and one with COPD, were not receiving their prescribed treatment because their CPAP masks did not fit and had not been replaced. In both cases, the residents reported not using CPAP due to ill-fitting masks, and documentation showed NPs had noted the complaints, requested refitting, and notified facility staff that new or smaller masks were needed. Despite these notifications and referrals, the residents continued without appropriate masks, with one resident’s CPAP equipment appearing unused at bedside and another’s stored in a plastic bag. A RN stated both residents had been waiting at least a month for pulmonary to refit their masks and that calls to pulmonary had not been returned, while the DON reported being unaware of the need for new masks, contrary to the facility’s policy to replace malfunctioning noninvasive ventilation equipment immediately.
A cook was observed serving food without a beard guard despite having facial hair, in violation of facility policy requiring beard nets for staff with beards. The dietary manager confirmed the requirement for beard guards when facial hair is more than an inch long. This deficiency had the potential to impact all 73 residents in the facility.
A resident's privacy was not maintained when housekeeping staff, under the direction of the Maintenance Director, performed a deep cleaning in the room while the resident was receiving personal care from a CNA. Despite objections from the resident and staff, the cleaning proceeded, causing the resident discomfort and distress. Staff interviews confirmed this was not standard practice and that the resident's consent was not obtained.
A CNA was observed touching her face and nose while feeding a resident and then delivered food to the resident without washing or sanitizing her hands. The Dietary Manager confirmed this action was not in accordance with facility policy, which requires handwashing before handling food and after touching bare body parts.
A resident with a history of behavioral symptoms took another resident's wallet and debit card without consent, used the card at a vending machine, and was found with cash reported missing by the wallet's owner. Staff interviews and record review confirmed the misappropriation, as the resident did not have permission to use or possess the other resident's property.
A resident with multiple medical conditions and moderate cognitive impairment was found to have a half side rail positioned in a way that prevented voluntary exit from bed, with staff confirming the resident could not lower the rail independently. The side rail was used for positioning without a physician's order or proper assessment as a restraint, contrary to facility policy.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report highlights a lack of environmental safety and insufficient oversight, but does not specify particular residents or incidents.
A resident reported verbal abuse by a CNA, including reluctance to provide care and inappropriate language. The facility did not provide documentation or confirmation that the allegation was investigated, despite policy requirements for thorough investigation and documentation of abuse allegations.
A resident with moderate cognitive impairment was able to leave the facility unsupervised at night. Although the front door alarm was triggered, staff were not alerted by the alarm and only became aware of the situation when a visitor noticed the resident outside and rang the doorbell. The resident was outside for several minutes before being brought back inside, indicating a failure in supervision and monitoring.
Two cognitively intact residents experienced theft of money and personal property from their bedside drawers, with one resident's locked drawer accessed by removing the back panel and another resident's wallet going missing. Staff and family confirmed that both residents regularly kept money in their bedside drawers, and the incidents occurred around the same time. The facility's policy prohibits misappropriation of resident property.
Three residents reported missing money from their personal belongings, with staff and administration made aware of the incidents. Despite this, no formal investigation was completed and the required reports to the state agency were not submitted, in violation of facility policy.
The facility did not thoroughly investigate multiple allegations of misappropriation involving three residents. In each case, reports of missing money or personal items were not followed by comprehensive investigations or proper documentation, despite facility policy requiring immediate and thorough action. Only minimal documentation, such as progress notes, was completed, and key investigative steps were omitted.
A resident weighing 324 pounds was injured during a transfer from bed to wheelchair when a single CNA attempted to use a bariatric mechanical lift without assistance, contrary to facility policy requiring two staff for such transfers. The lift tipped over, causing the resident to fall and sustain a forearm contusion and head injury, with subsequent unresponsiveness and low oxygen saturation. The mechanical lift was later found to be faulty, and the resident's transfer status was not documented in the Kardex.
Four residents with anxiety or related diagnoses were prescribed PRN lorazepam without required stop dates or durations, contrary to facility policy. Physician orders for these psychotropic medications included start dates but omitted the necessary stop date or duration, an issue confirmed by the DON during interview.
A CNA was observed standing while feeding a resident, contrary to facility policy requiring staff to be seated and interact at eye level during mealtimes. The DON confirmed that this practice is essential for maintaining resident dignity and social engagement.
Two residents who required staff assistance for ADLs were found with long, untrimmed, and dirty fingernails. One had visible scratches on the face and body, and staff confirmed the resident scratches himself when anxious. Another resident, who is diabetic and has memory impairment, was observed with long nails and debris underneath, with staff stating that nail care is only done on shower days and that nurses are responsible for diabetic residents. The facility could not provide a nail care policy when requested.
A resident with congestive heart failure did not receive daily weights as ordered by the physician, with documentation showing weights were only recorded on three occasions during the month. The resident was observed to have edema, and staff confirmed that daily weights are necessary to monitor for fluid overload.
A resident at risk for pressure injuries, as indicated by a Braden Scale assessment and a physician's order for an air mattress, was repeatedly observed in bed with the air mattress pump turned off. Staff confirmed the pump was not in use, resulting in the ordered pressure relieving intervention not being provided.
A resident with a history of neurological conditions and a one-sided functional limitation in ROM was not properly assessed for a contracted hand, and the care plan did not address the need for a splint or ball. The resident was also provided with a high back wheelchair that did not fit properly, causing discomfort and limiting mobility. Therapy and care records failed to address these issues, and the facility lacked a formal restorative program, contributing to the deficiency.
Two residents with documented weight loss did not receive dietitian-recommended interventions, including double breakfast portions and prescribed dietary supplements. Despite active orders and staff awareness, supplements were not provided as required, and the facility's weight monitoring policy was not followed.
A resident with end stage renal disease and on dialysis did not receive daily weights as recommended by the dialysis provider, despite an active physician order. Staff confirmed the resident did not refuse to be weighed, and the order for daily weights was not properly carried over to the MAR, resulting in missed documentation after one recorded weight.
Staff did not consistently follow infection prevention protocols, including failing to wear required PPE when caring for a resident with a urinary catheter, not changing gloves or performing hand hygiene after incontinence care, and handling medications with bare hands without hand hygiene. These lapses were observed during care and medication administration for three residents.
Surveyors found that two residents lacked documentation indicating whether they received or declined the pneumococcal vaccine. The DON confirmed the absence of this documentation, and the facility could not provide its immunization policy when requested.
A resident with congestive heart failure and lymphedema did not receive scheduled doses of bumetanide and potassium within the facility's required time frame on two occasions. The LPN delayed administration due to concerns about the resident's verbally abusive behavior, waiting for assistance from other staff before giving the medications. This resulted in the medications being administered more than two hours late, contrary to facility policy.
Two residents with anxiety and mood disorders experienced undue stress and anxiety after witnessing the Regional Director of Operations/Former Administrator publicly reprimand and yell at staff in the hallway, in the presence of residents. Staff confirmed that these incidents were demeaning and created an environment of fear, contrary to facility policy and residents' care plans requiring a calming and supportive atmosphere.
Two residents were involved in a verbal altercation where one used foul language and a derogatory term toward the other. The DON was aware of the incident but did not report it to the state agency, as required by facility policy, believing it was not abuse. The administrator later learned that the affected resident considered the event verbally abusive.
A resident with a history of verbal aggression became agitated after a delay in receiving water, leading to a verbal altercation with another resident who intervened. The second resident, with a history of anxiety and depression, felt threatened and required anxiety medication. The facility failed to prevent verbal abuse, as per their policy.
A facility failed to report a resident-to-resident verbal abuse incident promptly and accurately. A CNA witnessed a verbal altercation between two residents, involving offensive language, and informed the DON without details. An RN assessed the residents and informed the Administrator and DON but omitted specific abusive language. The state agency was notified two days later, contrary to the facility's policy requiring immediate reporting.
A resident on anticoagulant medication was physically abused by another resident with mental health disorders after a wheelchair collision in the dining room. The incident, which resulted in head pain for the victim, occurred without staff supervision, highlighting a failure to implement the facility's abuse prevention policy.
A resident experienced a significant weight loss of 13.9% over six months due to the facility's failure to implement the dietitian's recommendations for an increased tube feeding order. Despite the dietitian's efforts to adjust the feeding regimen, the resident continued on a lower-calorie formula, contributing to the weight loss. The resident, who relies on tube feeding for nutrition, showed signs of muscle wasting, and the facility's Weight Monitoring policy was not effectively followed.
A resident with a history of aggression and wandering was inadequately supervised, leading to an altercation with another resident in the dining room. The aggressive resident, who was supposed to be monitored every 15 minutes, was left unsupervised, resulting in him hitting another resident after a minor collision. Staff were not present in the dining room at the time, and the facility had been unsuccessful in finding a more appropriate placement for the aggressive resident.
A resident with heart failure and other conditions did not consistently receive prescribed diuretics and potassium due to an LPN's refusal to provide care following verbal aggression from the resident. The DON and other staff occasionally administered the medications, but the MAR indicated multiple missed doses over several months.
The facility failed to ensure residents were treated with dignity and respect, as multiple residents reported rude and inattentive behavior by agency CNAs, particularly during overnight shifts. Complaints included long wait times, dismissive attitudes, and inappropriate tones. The facility's policy on resident rights was not upheld, and management issues were noted with agency staff scheduling.
A resident in an LTC facility sustained second-degree burns after spilling hot coffee on herself due to a lack of supervision and inconsistent adherence to hot liquid safety policies. The resident, who required full care, was left unsupervised in the dining room, and the coffee served was above the recommended temperature, highlighting failures in staff supervision and policy implementation.
A resident was moved to a different room without her consent to accommodate a COVID-positive resident, despite her refusal and the facility's policies not mandating such a move. The resident's belongings were relocated while she was out, and she was not given proper notice or consented to the transfer.
A resident experienced verbal abuse when a staff member insisted she move rooms, closing the door and yelling at her. The incident was witnessed by a nurse and heard by others in the facility. The staff member admitted to raising his voice, which violated the facility's abuse policy.
A cognitively intact female resident accused the facility's administrator of hitting her during a room change discussion. The incident was witnessed by staff, but they failed to report it immediately due to uncertainty about protocol when the accused is the administrator. The facility's policy requires immediate reporting, but the state agency was notified three days later, highlighting a breakdown in communication and policy adherence.
A facility failed to investigate an abuse allegation and remove the alleged perpetrator, the administrator, after a resident claimed to have been struck. Despite police involvement and no evidence of physical abuse, the facility did not conduct an independent investigation or interview key witnesses. The administrator continued working, contrary to the facility's abuse policy, which requires removal of the accused until an investigation is completed.
The facility failed to isolate residents with norovirus-like symptoms during an outbreak, affecting all 76 residents. Several residents, including those sharing rooms, were not isolated despite symptoms like vomiting and diarrhea. The DON acknowledged the oversight, and residents on contact isolation were improperly sharing a bathroom. The facility's policy for isolation and disinfection was not followed.
A resident with multiple diagnoses was discharged from a facility without proper documentation or a physician's order. The resident was informed of the discharge on the same day it occurred, and there was no prior discussion or summary of discharge plans in the medical records. The discharge was initiated without a thirty-day notice, and the resident's nurse practitioner was not informed until two days later.
A resident with severe cognitive impairment eloped from a facility due to a non-functional exit door alarm. The resident, who was agitated and confused, left the facility unnoticed and was later found by police. The door alarm failed to alert staff, and the gate leading outside was unsecured, allowing easy exit.
A resident with known aggressive behaviors physically abused another resident, causing pain and fear. The facility failed to implement adequate interventions and monitoring, resulting in the victim not feeling safe. Despite the aggressor's history, the facility delayed moving them to another room, citing family involvement in the transfer.
A resident was allowed to leave the facility with another resident without proper supervision or assessment, leading to an incident where inappropriate behavior was reported. The facility failed to follow its Therapeutic Leave Policy, which required an order and assessment for unsupervised leave. Staff were unaware of the arrangement, and there was no confirmation of the driver's license or insurance for the resident providing transportation.
Two residents with limited range of motion did not receive necessary orthotic devices, leading to a deficiency in care. A resident with hemiplegia was without an ankle brace recommended for stability, preventing her from walking. Another resident, post-stroke, lacked a hand splint needed to prevent further decline in mobility. Despite therapy recommendations and notifications to the Assistant Administrator, the devices were not provided, and the facility lacked a policy for managing orthotic devices.
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 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 Provide Ordered Oxygen During Resident Transport to Outpatient Procedure
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who was on continuous oxygen at 2 L/min via nasal cannula received appropriate oxygen services during transportation to an outpatient procedure. The resident had diagnoses including COPD, chronic respiratory failure with hypoxia, chronic diastolic congestive heart failure, and dementia, and was observed in the facility with oxygen at 2 L/min via concentrator. A health status note documented that the resident received chronic 2 L nasal cannula oxygen for COPD. The facility’s receptionist/transportation coordinator contacted the resident’s insurance and requested transportation services that included 2 L of oxygen, and the insurance representative confirmed that this request was made. The transportation dispatcher/operations manager confirmed that the transportation arranged was a non-emergency medical stretcher ride that did not provide oxygen on the vehicle, but stated the facility could provide oxygen and that the stretcher could hold a travel oxygen tank. When the transportation driver arrived, the resident was lying in bed without oxygen in place, and facility staff did not indicate that the resident required oxygen or provide an oxygen canister for the trip. The driver transferred the resident to the stretcher and transported the resident without oxygen, reporting no observed shortness of breath or distress during the trip. The manager of care coordination reported that the resident arrived at the hospital for outpatient surgery with an oxygen saturation below 90%, and the first recorded saturation was 91% after oxygen via nasal cannula was provided. The nurse practitioner stated the resident had a history of COPD and chronic hypoxic respiratory failure and would prefer the resident be transferred to hospital appointments with oxygen.
Failure to Provide Timely Pain Management for Resident With Rib Fractures
Penalty
Summary
The facility failed to provide timely pain management for a resident admitted for rehabilitation and pain control following multiple traumatic rib fractures. The resident reported having been discharged from the hospital on intravenous hydromorphone and described their pain as “20 out of 10” upon admission. Vital signs documented the resident’s pain as 8/10 at 1:00 PM and again at 5:44 PM. Despite this, the Medication Administration Record shows the first dose of pain medication was not administered until 6:49 PM, resulting in the resident waiting approximately 7.5 hours for pain medication. During this period, the resident reported being in severe pain, stating they could not even open the door to their room and ultimately called a friend to pick them up and left the facility. Staff interviews revealed that the admitting RN stated the resident arrived during medication pass, and that she needed to finish the pass before entering the resident’s orders, noting that the admission made the already challenging hall more difficult. She acknowledged not entering the orders quickly enough and that the facility did not have the resident’s pain medication on hand, leading to a delay of several hours before treatment. The NP reported assessing the resident later that afternoon, with the resident rating pain at 9/10 and having multiple left rib fractures from ribs 6 to 9, with primary diagnoses of rib fracture and pain. The NP stated they were not notified that the ordered pain medications were unavailable until around 6:00 PM and indicated that, had they been informed earlier, an alternative pain medication would have been provided immediately. The facility’s own pain management policy defined acute pain as pain caused by injury or trauma and stated its purpose was to help residents attain or maintain their highest practicable well-being and to prevent or manage pain, which was not followed in this case.
Failure to Document and Investigate Resident Grievances About CNA Care
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without reprisal by not recording, investigating, or documenting grievances reported about a CNA. One resident with cerebral palsy, cognitively intact and dependent on staff for most ADLs, reported that a CNA refused to get her out of bed on a specific date, telling her it had to be done the CNA's way or not at all, and left her for second shift to get her out of bed. The resident stated she reported this interaction to the DON and to the Ombudsman but did not complete a grievance form because she could not write legibly and would need staff assistance; she also expressed concern that documents tend to disappear and preferred to complain to the Ombudsman. The DON reported having no reports about this CNA. The CNA acknowledged that the resident was upset when she was not gotten out of bed before the end of the CNA's shift and that the resident later told her she had spoken to the DON and did not want the CNA to help her anymore. Another cognitively intact resident with bilateral upper and lower extremity impairments, who requires staff assistance for ADLs and supervision with eating, reported that the same CNA did not follow rules and had previously been written up after leaving the resident’s roommate hanging alone in a full-body mechanical sling lift, as reported by a nurse. This resident stated she reported the incident to the DON and later described an episode where she refused care from the CNA one day, then allowed the CNA to transfer her the next day; during that transfer, despite the resident’s instructions on positioning, the CNA left her in the sling to go get help, later claiming inadequate training. This resident was unaware of any grievance form and found it easier to tell the DON. Multiple staff gave conflicting accounts of the grievance process and knowledge of complaints: the Administrator knew only that one resident had called the CNA “bad” and was unaware of the second resident’s grievance; a CNA trainer reported “a lot of complaints” from residents about the CNA’s speech, use of the full-body lift without a second staff member, and a political argument with a resident, which she said she reported to Human Resources. The Human Resource Director, Social Service Director, RN, and DON each described a process in which staff should complete grievance forms and report to social services or administration, but each denied having resident complaints about this CNA. The Ombudsman reported that residents feel that when they report grievances to staff, nothing gets resolved. Review of the facility’s grievance log for the relevant months showed no entries reflecting the concerns of the two residents about this CNA, despite the facility’s written form stating it is to be used to document any grievance or concern and the follow-up actions and results.
Failure to Ensure Properly Fitting CPAP Masks and Provision of Ordered Therapy
Penalty
Summary
The facility failed to ensure that prescribed CPAP therapy was effectively provided by not securing properly fitting masks for two residents with orders for nighttime CPAP use. One resident with obstructive sleep apnea had a physician order for CPAP at night, but the CPAP machine and mask at bedside appeared clean and unused. The resident reported not using the CPAP for months because the mask did not fit, leaked air, and blew into his eyes, and stated he had informed nursing staff and a pulmonary NP of the problem. Documentation showed that a NP noted the resident’s complaint of an ill-fitting mask and referred him for refitting, and a subsequent pulmonary NP note recorded the resident’s request for a new mask and that facility staff were notified he needed one. A later health status note documented that the resident still had not received a new mask, and facility nursing staff again notified the pulmonary NP. The pulmonary NP stated the resident required CPAP at night and that she was not informed until a later date that the mask did not fit, and explained that a poorly fitting CPAP or BiPAP mask can result in the resident not receiving enough oxygen during sleep, potentially leading to respiratory distress and/or failure. Another resident with COPD had an order for CPAP at night but had her CPAP machine, tubing, and mask wrapped in a plastic bag on the bedside table. She reported not using the CPAP for a long time because the mask was too big and stated she had been waiting for pulmonology to refit her mask despite repeatedly asking when they would come. A pulmonary NP note documented that the resident requested replacement of her medium-sized mask with a small one and that facility staff were notified. A subsequent NP note recorded that the resident complained of an ill-fitting CPAP mask, was not using CPAP at night, and had lost approximately 50 pounds since the mask was first fitted, with an order for pulmonary NP evaluation for refitting. The pulmonary NP stated she had notified facility nursing staff that the resident needed a small mask so it could be ordered and that once ordered, a mask should arrive within a couple of weeks. A RN reported that both residents had been waiting at least a month for pulmonary to come fit them for CPAP masks, that their masks were too big so they did not use CPAP, and that she had called pulmonary twice without receiving a return call. The DON stated she was not aware that either resident needed new CPAP masks, despite the facility’s noninvasive ventilation policy stating that equipment should be replaced immediately when broken or malfunctioning.
Failure to Ensure Use of Beard Guard During Food Service
Penalty
Summary
During a lunch meal service, a cook was observed plating meals without wearing a beard guard, despite having a beard. The facility's policy requires beard nets for employees with facial hair, and the dietary manager confirmed that a beard guard is required if facial hair exceeds one inch in length. This observation was made while food was being served to residents, and the incident had the potential to affect all 73 residents residing in the facility, as documented on the facility's data sheet.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
A deficiency occurred when a resident's right to privacy during personal activities of daily living was not honored. The resident reported that while she was being assisted by a CNA with personal care, including cleaning and dressing, the Maintenance Director instructed housekeeping staff to perform a deep cleaning of her room despite objections from both the resident and the housekeeping staff. The curtains were closed, but the resident still felt uncomfortable and expressed her distress to the staff and later to the Ombudsman. Multiple staff members confirmed that it is not standard practice to clean rooms while residents are receiving personal care, and that they felt uncomfortable with the situation but proceeded due to the Maintenance Director's insistence. Interviews with the involved staff corroborated the resident's account, indicating that the housekeeping staff and CNA communicated their concerns about the timing of the cleaning, but were directed to proceed regardless. The Director of Nursing stated that housekeeping should only clean if the resident consents. The incident resulted in the resident feeling upset and uncomfortable, as her privacy was not respected during a vulnerable moment.
Failure to Perform Hand Hygiene Before Handling Resident Food
Penalty
Summary
A Certified Nursing Assistant (CNA) was observed feeding a resident in the dining room and, during the process, rested her head on her hand, rubbed her hands together, and ran them over her nose. Without performing hand hygiene, the CNA then proceeded to obtain more garlic bread from the serving counter and delivered it to the resident. The Dietary Manager confirmed that staff are expected to wash or sanitize their hands after touching their face or nose and before handling food, as outlined in the facility's hand washing policy. The policy specifies that staff should wash hands before handling food and after touching bare human body parts, and that hand sanitizer does not replace handwashing.
Failure to Prevent Misappropriation of Resident Property
Penalty
Summary
A resident with hemiplegia, COPD, major depressive disorder, and anxiety disorder was admitted to the facility and was functioning independently in leisure activities, alert, oriented, and able to express needs. Another resident with diabetes, syphilis, adjustment disorder, schizophrenia, ataxia, and depression, who displayed behavioral symptoms including frequently asking others for money and snacks, was observed in possession of the first resident's wallet and debit card. Staff interviews revealed that the second resident used the debit card at a vending machine without permission and was later found to have $100 cash, which the first resident reported missing from his wallet. The second resident claimed to have found the wallet on the floor in the first resident's room and denied taking any cash, but admitted to using the debit card to purchase a drink. Staff confirmed that the first resident did not give permission for the wallet or debit card to be used, and that the second resident had a history of taking items that did not belong to her when they were not in their proper place. The facility's policy prohibits misappropriation of resident property, defined as the wrongful use of a resident's belongings or money without consent. The incident was substantiated through staff and resident interviews, as well as review of records, confirming that the facility failed to ensure the resident was free from misappropriation of property.
Failure to Ensure Resident Free from Restraints Due to Improper Bed Rail Use
Penalty
Summary
A resident with diagnoses including chronic respiratory failure, heart failure, history of falls, bipolar disorder, and unsteadiness on feet was found to have a half side rail positioned on the bed in a manner that prevented voluntary exit from bed. The resident had moderate cognitive impairment and was unable to independently lower the side rail. Staff interviews confirmed that the side rail was routinely used for positioning and to prompt the resident to ask for help before getting up, but also acknowledged that the resident would have to scoot to the end of the bed or climb over the rail to exit, which was not considered safe. The Minimum Data Set (MDS) nurse, who lacked formal restorative nursing training, assessed the side rail for bed mobility but not as a restraint, and there was no restorative nurse on staff. Further review revealed that there was no physician's order for the use of side rails for bed mobility or positioning for this resident, and facility policy required assessment to determine if a bed rail meets the definition of a restraint. The policy defined a bed rail as a restraint if it restricts a resident from voluntarily getting out of bed due to inability to lower it independently. The Director of Nursing confirmed that the side rails were intended for positioning, not for fall prevention, and that documentation of alternatives or prior interventions was lacking. The facility failed to ensure the resident was free from restraints as required.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and there was insufficient oversight to protect residents from potential harm. Specific actions or omissions by staff or management that led to the deficiency are not detailed in the report, nor are any particular residents or incidents described.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to provide evidence that an allegation of verbal abuse made by a resident was thoroughly investigated. The resident reported that staff gave him a hard time when he called for help and specifically mentioned a CNA who expressed reluctance to provide care and used inappropriate language while walking down the hallway. The resident stated he informed the administrator and reviewed security footage with them, but the video did not have sound. At the time of the survey, the administrator was not present in the facility, and the CNA involved was unavailable for interview. Despite requests from surveyors, the facility was unable to provide documentation or verbal confirmation that an investigation into the resident's allegation had been conducted. The facility's abuse policy requires thorough documentation and investigation of all alleged violations, but no such evidence was available for this incident. The lack of investigation and documentation constitutes a failure to respond appropriately to the reported allegation of verbal abuse.
Resident Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
A resident with moderate cognitive impairment was able to leave the facility unsupervised during nighttime hours. The resident was observed to be capable of moving herself in a wheelchair, though not quickly. On the evening of the incident, the resident exited the facility while wearing a nightgown and carrying a bag of belongings. The facility's front door alarm was triggered, but there was no receptionist present at the time to respond. Staff were not alerted by the alarm; instead, a visitor noticed the resident outside and rang the doorbell to alert staff. According to written statements and the facility's elopement investigation timeline, the resident exited the building at 9:23 PM and was not brought back inside until approximately 9:34 PM. The staff only became aware of the situation after being notified by a visitor, not through their own monitoring or the alarm system. This sequence of events demonstrates a failure to provide adequate supervision and to ensure the area was free from accident hazards, as required for residents with cognitive impairments.
Failure to Safeguard Resident Funds and Prevent Misappropriation
Penalty
Summary
The facility failed to safeguard and prevent misappropriation of resident funds for two cognitively intact residents. One resident kept money in a locked bedside drawer, which was found to have its back panel partially removed, allowing access to the contents. After returning from a day out, the resident discovered that a bag containing between $200 and $300 had been ripped and most of the money was missing, with only about $25 remaining. The resident reported the incident to facility staff but requested that neither the police nor her husband be contacted. It was noted that several staff members were aware of where the resident kept her money, and the resident had previously experienced theft from her purse, leading her to secure her funds in the locked drawer. The Business Office Manager confirmed the resident's practice of keeping money in the locked drawer and that the resident's husband regularly provided her with spending money. Another resident reported that a wallet containing approximately $45, which was kept in the top drawer of the bedside drawer, had gone missing. The resident could not recall the exact timing of the loss but informed staff of the missing wallet and money. The resident's family member confirmed that money was regularly provided and kept in the wallet in the bedside drawer. Facility staff indicated that the theft of the wallet and money was believed to have occurred around the same time as the other resident's loss. The facility's policy prohibits misappropriation of resident property, defined as the wrongful use of a resident's belongings or money without consent.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report allegations of abuse, specifically the misappropriation of resident property, to the state agency as required by policy. Three residents reported incidents involving missing money from their personal belongings. One resident stated that after losing a wallet, it was returned with a $100 bill missing, and this was known to staff, including the Social Services Director. Another resident reported returning from a pass to find their locked drawer tampered with and most of their money missing, and a third resident also reported missing money from an unlocked drawer. In each case, the residents informed facility staff, including the Administrator and Director of Nursing, about the missing money. Despite being aware of these allegations, the Administrator did not complete a formal investigation or confirm that the incidents had been reported to the state agency. The Director of Nursing also confirmed that no reports regarding missing money had been sent to the state agency during the relevant period. The facility was unable to provide documentation showing that any of the allegations had been reported as required by their abuse, neglect, and exploitation policy, which mandates immediate reporting of such incidents to the appropriate authorities.
Failure to Investigate Allegations of Misappropriation
Penalty
Summary
The facility failed to ensure that allegations of misappropriation involving three residents were thoroughly investigated, as required by policy. One resident reported losing a wallet, which was later found in the laundry but missing a $100 bill; although staff were notified, the resident was not reimbursed, and there was no documentation of a thorough investigation. Resident council minutes also indicated that missing money was discussed in a meeting attended by the affected resident. Another resident reported that after returning from a day out, money was missing from a bag in a locked drawer, and the incident was reported to the Social Services Director, Business Office Manager, and Administrator. Preliminary steps were taken, such as speaking with the ombudsman and reviewing some camera footage, but only a progress note was documented, and interviews with staff were not retained or fully documented. A third resident reported a missing wallet containing approximately $45 from an unlocked drawer, and while a room search was conducted, there was no evidence of a comprehensive investigation or police contact. Facility leadership confirmed that the only documentation for these incidents was a progress note in the electronic medical records, and no further evidence of completed investigations was provided. The facility's policy requires immediate and thorough investigation of abuse, neglect, or exploitation allegations, including identifying responsible staff, interviewing all involved parties, and maintaining complete documentation, none of which were fully met in these cases.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident was not safely transferred using a mechanical lift, resulting in a fall and injury. The resident, who weighed 324 pounds, was being transferred from bed to wheelchair by a single CNA using a bariatric mechanical lift. The CNA reported that she was alone during the transfer due to being busy, and as she attempted to move the resident, the lift's legs became stuck, causing the lift to tip over. The resident fell to the floor, sustaining a contusion to the right forearm and a head injury, and was subsequently sent to the hospital for evaluation. The resident also experienced a period of unresponsiveness and low oxygen saturation following the fall. Interviews and documentation confirmed that facility policy required two staff members for mechanical lift transfers, but only one CNA was present at the time of the incident. The CNA did not request assistance from other staff, and the LPN on duty was unaware of the transfer until after the fall occurred. The mechanical lift used was later found to have a wobbly boom and was removed from service. The resident's transfer status was not documented in the Kardex at the time of the incident.
PRN Psychotropic Medication Orders Lacked Required Stop Dates
Penalty
Summary
The facility failed to ensure that as needed (PRN) psychotropic medication orders for four out of five residents reviewed included a required stop date or duration. Specifically, physician orders for lorazepam prescribed for anxiety, restlessness, or agitation for these residents were found to have start dates but lacked any indication of a stop date or specified duration. This omission was identified through record review and confirmed in an interview with the Director of Nursing, who acknowledged that PRN psychotropic medications should have a stop date. The facility's own policy requires that PRN orders for psychotropic medications be limited to no more than 14 days unless the attending physician documents the appropriateness of extending the order and specifies a duration.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) was observed standing while feeding a resident lunch in the dining room, rather than sitting at eye level with the resident as required by facility policy. The Director of Nursing (DON) confirmed that staff are expected to sit and engage in conversation with residents during feeding to promote dignity and social interaction. The facility's policy, implemented in May 2025, specifies that all staff must be seated while feeding residents to maintain respect and dignity during mealtimes. This failure to follow policy resulted in the resident not being treated with dignity during feeding.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with personal hygiene for two residents who were dependent on staff for activities of daily living, specifically nail care. One resident was observed with long fingernails extending past the fingertips and had scratches on the face and body, with staff confirming that the resident scratches himself when anxious. This resident was documented as fully dependent on staff for personal hygiene. Another resident was observed on multiple occasions with very long nails and black debris underneath, and staff indicated that nail care is only performed on shower days, with nurses responsible for nail care for diabetic residents. The care plan for this resident indicated a memory impairment and a need for extensive staff assistance with ADLs. When requested, the facility was unable to provide a policy on nail care.
Failure to Perform Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of congestive heart failure (CHF) received daily weights as ordered by the physician. The resident's medical record included an active order for daily weights starting on 5/5/25, with instructions to notify the healthcare provider if there was an increase of more than two pounds, specifically to monitor for edema. However, documentation showed that weights were only recorded on three occasions during May 2025, rather than daily as ordered. Observation on 6/2/25 revealed the resident had visible edema in both legs, and the facility was unable to provide additional weight records for the month. A registered nurse confirmed that daily weights are necessary for residents with CHF to monitor for fluid overload.
Failure to Implement Ordered Pressure Relieving Intervention
Penalty
Summary
The facility failed to ensure that pressure relieving interventions were implemented for a resident identified as being at risk for pressure injuries. The resident had a Braden Scale assessment indicating risk for pressure injuries and a physician's order for an air mattress while in bed. Despite this, on multiple occasions over two days, the resident was observed in bed with the air mattress pump turned off, as confirmed by both direct observation and staff interview. The air mattress pump, intended as a preventive intervention, was not in use while the resident was in bed, contrary to the physician's order and the resident's care needs.
Failure to Assess and Address Resident's Contracted Hand and Wheelchair Fit
Penalty
Summary
The facility failed to identify and assess a resident's contracted left hand and did not ensure the resident's wheelchair was appropriately fitted for comfort and mobility. The resident reported discomfort and inability to self-propel in the high back wheelchair provided, stating he was not informed of the reason for the change and often became stuck in the hallway. Observations confirmed the resident's left hand was contracted, with fingernails pressing into the palm, and the resident recalled previously using a ball to help with his hand. Staff interviews revealed that a splint or ball was not currently in use, and there was no referral for a brace. The physical therapy assistant acknowledged the resident did not fit properly in the high back wheelchair, which caused his knees to bend up and did not provide adequate trunk support, further limiting his mobility. Review of the resident's records showed a history of neurological conditions, including epilepsy, transient ischemic attacks, and type 2 diabetes. The Minimum Data Set indicated a one-sided functional limitation in range of motion, but therapy discharge summaries and the current care plan did not address the contracted hand or the use of the high back wheelchair. The DON stated that the facility had only an informal restorative program, with no dedicated restorative nurse for the past five weeks, and was unaware of the resident's issues with the wheelchair and contracted hand until recently. The lack of assessment and care planning for the resident's range of motion and mobility needs led to the deficiency.
Failure to Implement Dietitian Recommendations and Provide Prescribed Supplements
Penalty
Summary
The facility failed to implement the dietitian's recommendations and ensure prescribed dietary supplements were provided to two residents experiencing weight loss. For one resident, weight records showed a downward trend over several months. The dietitian recommended double portions at breakfast and the addition of a house supplement twice daily to address the weight loss. However, these recommendations were not reflected in the resident's order summary or meal ticket, and there was no evidence that the double portions or supplement were provided. The dietitian confirmed she could not enter orders directly and relied on facility staff to implement her recommendations, which were not carried out. Another resident, who was on dialysis and had recently been hospitalized, experienced significant weight loss and was prescribed a Magic Cup supplement daily at lunch. Although the supplement was listed on the resident's meal card and the facility had it in stock, observation during a meal service showed the supplement was not provided with the resident's tray. Staff interviews confirmed the supplement should have been given, and the dietitian stated the order for the supplement was still active. The facility's weight monitoring policy requires interventions to maintain nutrition goals, but these were not implemented as required for the residents involved.
Failure to Follow Dialysis Orders for Daily Weights
Penalty
Summary
The facility failed to follow dialysis recommendations for daily weights for a resident with End Stage Renal Disease, dependence on renal dialysis, and dementia. Documentation shows that the dialysis provider requested a 1200 cc fluid restriction and daily weights for the resident, and this order was added to the active physician orders. However, the resident's records indicate that after being weighed on 5/24/25, no additional daily weights were recorded. Staff interviews confirmed that the resident did not refuse to be weighed and that the dialysis provider had specifically requested daily weights due to concerns about weight gain and fluid overload. The Director of Nursing acknowledged that there were issues with new scales and with weights not transferring from the MAR to the Weight Summary report, and verified that the daily weight order was not carried over to the MAR for completion.
Failure to Follow Infection Control Protocols During Resident Care and Medication Administration
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols during resident care activities. On one occasion, a Certified Nursing Assistant (CNA) emptied a resident's indwelling urinary catheter bag without wearing a gown, despite the resident being on Enhanced Barrier Precautions (EBP) as indicated by signage on the room door. The facility's EBP policy requires staff to wear gloves and gowns when providing care to residents with urinary catheters due to the risk of exposure to bodily fluids. Additionally, the facility's policy states that gowns and gloves should be readily available near or outside the resident's room for such activities. Further observations revealed that another CNA did not change gloves or perform hand hygiene after providing incontinence care, and subsequently handled the resident's clothing and wheelchair controls. During medication administration, an LPN dispensed medications directly into her bare hands and did not perform hand hygiene before, after, or between administering medications to two residents. The facility's policies require hand hygiene before and after glove use, and prohibit handling medications with bare hands to prevent contamination. These failures were observed in three residents reviewed for infection prevention and control.
Lack of Documentation for Pneumococcal Vaccination
Penalty
Summary
The facility failed to maintain documentation showing that two residents either received or declined the pneumococcal vaccine. Immunization records printed for these residents did not indicate administration or refusal of the vaccine. During an interview, the Director of Nursing confirmed that there was no documentation available for these residents regarding the pneumococcal vaccine. Additionally, when requested, the facility was unable to provide its immunization policy before the survey concluded. These findings were based on both interviews and record reviews, and involved a sample of residents reviewed for immunizations.
Failure to Administer Medications at Scheduled Times Due to Staff Concerns
Penalty
Summary
The facility failed to administer medications at the scheduled times for one resident diagnosed with congestive heart failure and lymphedema. The resident had physician orders for bumetanide and potassium to be given twice daily, with scheduled administration at 7:30 AM. On two separate occasions, the morning doses were administered significantly late: on one day, both medications were given nearly three hours after the scheduled time, and on another day, the medications were administered between two hours and five minutes to over three hours late. Documentation confirmed these late administrations, and the responsible nurse signed off on the medication administration records. Interviews revealed that the nurse assigned to the resident's hallway delayed medication administration due to concerns about the resident's verbally abusive behavior. The nurse reported waiting for a nurse manager or another staff member to accompany her before administering the medications. The facility's policy requires medications to be administered within 60 minutes before or after the scheduled time, which was not followed in these instances. The Director of Nursing confirmed the facility's expectations regarding medication timing.
Failure to Prevent Mental Abuse During Staff Reprimands
Penalty
Summary
The facility failed to protect residents from mental abuse, as evidenced by multiple accounts from residents and staff regarding the conduct of the Regional Director of Operations/Former Administrator. On several occasions, this individual lined up staff in the hallway, including in the presence of residents, and reprimanded them by yelling and pointing fingers in a manner described as demeaning, unprofessional, and intimidating. Residents who witnessed these events reported feeling upset, anxious, and stressed, with one resident experiencing such significant anxiety that he required increased oxygen during the interview and ultimately decided to transfer to another facility due to the environment. Both residents involved had documented histories of anxiety and mood disorders, with care plans specifically calling for a calming and reassuring environment to promote their psychosocial well-being. Staff corroborated the residents' accounts, noting that the administrator's approach was authoritative and instilled fear among both staff and residents. The facility's own policies and state guidelines prohibit mental abuse and require the protection of residents' rights and well-being, which were not upheld in these incidents.
Failure to Report Verbal Abuse Incident to State Agency
Penalty
Summary
The facility failed to report an incident of verbal abuse to the state agency as required by policy. On the morning of 6/9/25, one resident became verbally aggressive while being assisted back to their room, using foul language and racial slurs. As this resident passed another resident's doorway, a verbal exchange occurred, during which one resident called the other a derogatory name and acted in a hostile manner. The Director of Nursing was aware of the incident but did not report it to the state agency, considering it a verbal altercation rather than verbal abuse. The Administrator was initially unaware of the incident and, upon learning more, found that the affected resident did perceive the event as verbally abusive. The facility's policy requires immediate reporting of all alleged violations involving abuse, but this was not followed in this case.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from verbal abuse from another resident. This incident involved two residents, one of whom has a history of becoming verbally aggressive towards staff. On the evening in question, a Certified Nursing Assistant (CNA) was attending to another resident when they noticed a call light from the resident who later became verbally aggressive. The CNA acknowledged the request for water but did not immediately fulfill it, believing another CNA had attended to the request. This led to a delay in service, causing the resident to become agitated and verbally abusive towards the CNA. The situation escalated when another resident, who has diagnoses including adjustment disorder with mixed anxiety and depressed mood, intervened by yelling at the aggressive resident to respect the staff. This intervention led to a verbal altercation between the two residents, with the aggressive resident using derogatory language. The second resident felt threatened and requested anxiety medication following the incident. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the verbal abuse incident and the subsequent emotional distress experienced by the second resident.
Failure to Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to ensure that an allegation of resident-to-resident verbal abuse was immediately reported to the administrator and the state agency. During a shift, a Certified Nursing Assistant (CNA) witnessed a verbal altercation between two residents, where one resident used offensive language towards the other. The CNA informed the Director of Nursing (DON) via text message about the altercation but did not provide details about the residents involved. Subsequently, a Registered Nurse (RN) assessed the residents and informed the Administrator and DON about the incident but failed to convey the specific abusive language used. The facility's policy requires that all alleged violations be reported to the Administrator and state agency within specified timeframes. However, the Administrator and DON were not made aware of the severity of the incident, and the state agency was not notified until two days later. The Nurse Practitioner was also not informed of the incident, which could have impacted the psychological assessment and care of the residents involved. The facility's failure to report the incident promptly and accurately led to a deficiency in adhering to their abuse, neglect, and exploitation policy.
Resident on Anticoagulant Medication Suffers Physical Abuse
Penalty
Summary
The facility failed to protect a resident on oral anticoagulant medication from physical abuse, resulting in a significant incident involving two residents. On 3/16/25, a resident (R12) reported being hit on the head by another resident (R13) after accidentally bumping into him with her wheelchair in the dining room. R13, who has a history of mental health disorders, including bipolar and schizoaffective disorder, allegedly punched R12 several times on the right side of her head. This incident occurred in the absence of staff supervision, as they were occupied with assisting other residents back to their rooms after lunch. R12, who suffers from multiple health conditions including chronic respiratory failure and is on Eliquis, an oral anticoagulant, complained of sharp pain in the head following the incident. A nurse practitioner noted a 5/10 pain level and ordered neuro checks and cold compresses for R12. The facility's abuse policy, which prohibits physical abuse, was not effectively implemented, as evidenced by the lack of staff presence during the incident and the failure to prevent R13 from harming R12. Witnesses confirmed the altercation, and the facility's investigation acknowledged the occurrence of physical abuse.
Failure to Implement Dietitian's Recommendations Leads to Resident's Weight Loss
Penalty
Summary
The facility failed to implement the dietitian's recommendations for an increased tube feeding order for a resident, identified as R8, who experienced a significant weight loss of 13.9% over six months. R8, who has diagnoses including dysphagia following cerebral infarction and abnormal weight loss, was observed not receiving a bolus feed at the time of the survey. Despite the dietitian's recommendation to switch to a higher-calorie formula to promote weight gain, the resident continued on a lower-calorie formula until it was discontinued, contributing to the weight loss. The dietitian, V4, who has been monitoring R8 since admission, expressed concern over the resident's weight loss, noting that R8 is reliant on tube feeding for all nutrition. V4 had attempted various adjustments to the feeding regimen, including changing formulas and bolus volumes, but these efforts did not prevent the weight loss. The facility's Weight Monitoring policy emphasizes maintaining acceptable nutritional parameters, yet the failure to update the feeding order as recommended by the dietitian resulted in the resident's continued weight decline.
Inadequate Supervision of Aggressive Resident Leads to Altercation
Penalty
Summary
The facility failed to adequately supervise a resident with a history of wandering and physical aggression, leading to an incident involving two residents. One resident, a male with diagnoses including bipolar disorder, schizophrenia, and anxiety, was involved in a physical altercation with another resident in the dining room. The incident occurred when the male resident, who was known to have unpredictable and combative behaviors, was not being monitored as required. He was supposed to be under 15-minute checks due to his history of aggression, but this was not adhered to at the time of the incident. On the day of the incident, the male resident was observed self-propelling in his wheelchair in the hallway and later entered the dining room where the altercation occurred. The female resident involved reported that she accidentally bumped into the male resident with her wheelchair, prompting him to hit her on the head multiple times. Witnesses confirmed that there was no staff present in the dining room at the time, as they were occupied with other tasks. The male resident's care plan indicated that he should not be in crowded areas and should be monitored closely, but these measures were not in place during the incident. Staff interviews revealed that the male resident had previously been on one-to-one supervision due to his behaviors, but this was no longer the case. The facility had been attempting to find a more suitable placement for him due to his aggressive behaviors, but had been unsuccessful. Despite his known history of aggression and the need for constant monitoring, the facility failed to provide the necessary supervision, resulting in the altercation and injury to the other resident.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received their prescribed medications, specifically diuretics and potassium pills, as required. This deficiency was identified for one resident who was part of a sample of 15. The resident, who has multiple diagnoses including acute combined systolic and diastolic heart failure, respiratory failure, and hypokalemia, reported that a Licensed Practical Nurse (LPN) did not provide medications at the correct time, leading to frequent delays. The resident also mentioned improvements in their condition, such as reduced fluid in the legs, despite the medication issues. The LPN involved admitted to not providing care to the resident due to the resident's verbally aggressive behavior and racial slurs. Instead, the LPN stated that other nurses or the Director of Nursing (DON) would administer the medications when the LPN was on duty. However, the Medication Administration Record (MAR) showed multiple instances where the resident did not receive their morning medications over several months. The DON confirmed awareness of the situation but did not ensure consistent medication administration. A Nurse Practitioner, unaware of the medication lapses, noted no adverse symptoms during evaluations of the resident.
Failure to Ensure Resident Dignity and Respect by Agency Staff
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, as evidenced by multiple complaints from residents about the behavior of agency Certified Nurse Aides (CNAs). One resident expressed dissatisfaction with a specific agency CNA due to a bad attitude, loud tone, and delayed response in changing wet briefs. Despite reporting this to the CNA scheduler, the same aide was observed assisting the resident's roommate weeks later. Another resident reported that agency CNAs were rude, dismissive, and returned to the facility even after being reported. Additional residents echoed similar concerns, noting that agency staff displayed a lack of interest in their work, spoke rudely, and were inattentive, particularly during overnight shifts. The resident council minutes from the past six months revealed recurring complaints about staff treatment, including inattentiveness, bad attitudes, and long wait times for assistance. The facility's policy on Nursing Home Residents' Rights emphasizes the requirement to treat residents with dignity and respect, which was not upheld in these instances. The facility's administrator acknowledged an issue with an agency CNA mistakenly being scheduled to work after being placed on a do-not-return list, highlighting a lapse in the facility's management of agency staff.
Resident Burned Due to Unsafe Serving of Hot Coffee and Lack of Supervision
Penalty
Summary
The facility failed to ensure the safe serving of hot liquids and adequate supervision of residents, resulting in a resident sustaining second-degree burns. The incident involved a resident who was drinking coffee from a Styrofoam cup in the dining room when the coffee spilled onto her thighs, causing burns. At the time of the incident, no staff members were present in the dining room to supervise or assist the resident, who required full care and was dependent on staff for activities of daily living (ADLs). Interviews with staff revealed that there was an expectation for staff to be present in the dining room during meals for resident safety, but this was not consistently adhered to. The resident involved in the incident had a care plan indicating she required full assistance, yet she was left unsupervised. The facility's policy stated that residents with difficulties should receive appropriate supervision, and interventions should be individualized and noted on the resident's care plan. Additionally, there was confusion among dietary staff regarding the appropriate temperature for serving hot liquids. The facility's policy specified that hot liquids should not exceed 140 degrees Fahrenheit to prevent burns, but staff reported varying temperature guidelines, with some believing temperatures could be as high as 165 degrees Fahrenheit. This inconsistency in understanding and implementing the policy contributed to the unsafe serving of hot coffee, which was found to be above the recommended temperature during the investigation.
Unauthorized Room Transfer Due to COVID-19 Concerns
Penalty
Summary
The facility failed to honor a resident's right to remain in her room, resulting in an unauthorized room transfer. The resident, a cognitively intact female, was informed by the facility's administrator that she needed to move to accommodate a COVID-positive resident. Despite the resident's clear refusal to move on multiple occasions, her belongings were relocated to a different room while she was out of the facility. The facility's policies did not mandate such a move, and the resident was not given proper notice or consented to the transfer. The incident involved the resident being moved from her original room, which had a connecting bathroom to a COVID-positive resident's room. However, the COVID-positive resident was bed-bound and did not use the shared bathroom. The facility's infection control policy did not require a COVID-positive resident to have a private room, nor did it require a COVID-negative resident to vacate their room. The facility's policy on room changes required advance notice and consent, which was not adhered to in this case.
Verbal Abuse Incident Involving Resident and Staff Member
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse, as evidenced by an incident involving a cognitively intact female resident. The resident reported that a staff member, identified as V1, entered her room and insisted she move to accommodate a COVID-19 positive resident. Despite the resident's refusal, V1 returned later, closed the door, and began yelling at her, which made the resident feel worried. This altercation was witnessed by a registered nurse, V8, who noted the inappropriate tone and volume used by V1. The nurse opened the door to intervene, and V1 subsequently left the room. The resident remained angry and upset for the remainder of the shift. Additional accounts from other staff and residents corroborated the incident, with several individuals hearing the argument from various distances within the facility. V1 admitted to raising his voice at the resident, acknowledging it was unacceptable behavior. The facility's abuse policy, which aims to protect residents from abuse and neglect, was not adhered to in this instance, resulting in a deficiency related to the protection of residents from verbal abuse.
Failure to Timely Report Allegation of Abuse Involving Administrator
Penalty
Summary
The facility failed to report an allegation of abuse involving a cognitively intact female resident in a timely manner. The incident occurred when the administrator, identified as V1, entered the resident's room to discuss a room change and an altercation ensued. During the altercation, V1 attempted to pick up a pop from the floor, resulting in contact with the resident's face. The resident accused V1 of hitting her, while V1 claimed the contact was accidental. Despite the incident being witnessed by a registered nurse (V8) and a receptionist (V13), neither reported the allegation immediately to the appropriate authorities, as they were unsure of the protocol when the accused was the administrator. The facility's abuse policy mandates that allegations of abuse be reported immediately, but no later than two hours after the incident. However, the initial report was not made on the day of the incident, and the state agency was only notified three days later. The facility's abuse tracking log and final report summary confirmed the delay in reporting. The Chief Executive Officer (V4) was unaware of the specifics of the incident and the delay in reporting, indicating a breakdown in communication and adherence to the facility's abuse reporting policy.
Failure to Investigate Abuse Allegation and Remove Alleged Perpetrator
Penalty
Summary
The facility failed to initiate an investigation and remove an alleged perpetrator following an allegation of abuse involving a resident. The incident involved a resident who claimed to have been struck by the facility's administrator. Despite the police being called and finding no evidence of physical abuse, the facility did not conduct an independent investigation into the allegation. Interviews with staff members revealed that key witnesses, including a registered nurse and the resident's driver, were not interviewed by the facility regarding the incident. The facility's final incident report lacked documentation of any verbal allegations of abuse. Additionally, the facility did not follow its abuse policy, which requires the removal of the alleged perpetrator from the building until an investigation is completed. The administrator, who was accused of abuse, remained in the facility and continued to work after the incident. Staff members expressed confusion about the appropriate procedures to follow when the accused is an administrator, and the director of nursing acknowledged that the administrator should have been sent home. The facility's failure to act in accordance with its abuse policy and to conduct a thorough investigation contributed to the deficiency.
Failure to Isolate Residents During Norovirus Outbreak
Penalty
Summary
The facility failed to properly isolate residents exhibiting norovirus-like symptoms during an outbreak, potentially affecting all 76 residents. On December 17, 2024, it was noted that several residents, including those sharing rooms, were not isolated despite having symptoms such as vomiting and diarrhea. Residents R7, R8, and R13, who shared a room, all experienced symptoms over the weekend, yet were not placed in isolation as per the facility's policy. The Director of Nursing (DON) acknowledged that residents with symptoms were not isolated until December 17, 2024, despite receiving guidance from the Health Department Nurse on December 13 and 16, 2024. Additionally, residents R11 and R15, who were on contact isolation, were sharing a bathroom, which is against the facility's policy when one resident is symptomatic. R11 had been symptom-free for two days, while R15 continued to experience diarrhea. The DON admitted that R11 and R15 should not have been sharing a bathroom if one was symptomatic. The facility's policy requires residents with norovirus symptoms to be placed in single occupancy rooms and for routine cleaning and disinfection of frequently touched surfaces, which was not adhered to in this instance.
Improper Discharge Documentation and Communication
Penalty
Summary
The facility failed to ensure proper documentation and communication regarding the discharge of a resident, identified as R1, who was cognitively intact and had multiple diagnoses including seizures, foot drop, post-traumatic osteoarthritis, anxiety, post-traumatic stress disorder, and hypertension. R1 was discharged without a physician's order or adequate documentation in the medical record. The resident was informed of the discharge on the same day it occurred, and there was no prior discussion or summary of discharge plans in the resident's progress notes, social services notes, primary care notes, or psychiatric notes. The discharge was initiated by the facility without providing the required thirty-day notice, as the resident was transferred to another facility. The previous administrator, V5, was responsible at the time of discharge. The resident's parole agent, V10, stated that while R1 violated parole criteria, discharge from the facility was not a requirement. The referral to the new facility was sent less than ten hours before the resident left the facility. Additionally, R1's nurse practitioner, V12, was not informed of the discharge until two days later when she arrived to round on residents.
Failure to Prevent Resident Elopement Due to Non-Functional Door Alarms
Penalty
Summary
The facility failed to ensure that an exit door with an audible alarm was functional and alerting staff when opened, leading to a resident with severe cognitive impairment eloping from the facility. The resident, a male with diagnoses including unspecified dementia, COPD, hypertension, atrial fibrillation, and cerebral infarction, was last seen by staff at 12:30 AM walking down a hallway. The resident was later found outside the facility by police at 2:05 AM, having fallen and sustained injuries. The exit door used by the resident to leave the facility was supposed to alarm when opened, but it did not function as intended. The Maintenance Director confirmed that the door alarm was not working, and the gate leading to the outside was unsecured, allowing the resident to exit the premises easily. Staff interviews revealed that the alarm was not re-activated, and the door could be opened without triggering an alert, which was a known issue. The resident's care plan indicated he was at risk for elopement due to his cognitive deficits and required supervision. However, on the night of the incident, the resident was agitated and confused, and staff failed to adequately monitor him. The facility's policies on door alarms and elopement were not effectively implemented, contributing to the resident's unauthorized departure.
Removal Plan
- R1 has a wander guard on his left arm. R1 has been placed on 15-minute checks. R1's care plan has been updated to reflect the current interventions to address his elopement.
- The DON, designee(s) and/or MDS Coordinator(s) will re-evaluate residents at risk for wandering/elopement using an elopement risk assessment tool.
- Residents determined to be at risk for elopement will have had their care plans updated to reflect elopement risk if indicated.
- The facility has a list/photo of residents that are high risk for elopement that is kept at every nurse's station, the receptionist desk, and every manager's office.
- The facility initiated in-service training for all staff. This training includes: Residents identified to be at risk of elopement, Wandering/Elopement Policy, Door Alarm Policy, Daily Door Alarm checks to ensure proper functioning, Wander guard checks, The facility's northwest property gate between the storage shed and garbage dumpster has been repaired and secured, Steps to take when a resident has an increase in wandering behavior, Frequent rounding - Know where your residents are, Assisting/guarding residents back to bed to ensure their safety.
- The facility maintenance Director inspected all door alarms to ensure that they were in proper working order.
- New hires will receive education on wandering, elopement, and resident safety by the DON, Director of Social Services, or designee(s).
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident, R3, from physical abuse by another resident, R4, who had known aggressive and verbal behaviors. R4, diagnosed with dementia, had a history of aggression that had been escalating over time. On 10/29/24, R3 and R4 were involved in a verbal altercation, which was inadequately addressed by the facility, as the only intervention was to redirect and separate the residents. This lack of effective intervention led to a subsequent physical altercation on 11/2/24, where R4 entered R3's room, attempted to pull R3's hair, and slapped R3 across the face, causing pain and fearfulness for R3. The facility's failure to implement adequate interventions and monitoring for R4's aggressive behavior resulted in R3 not feeling safe in the facility. Despite R4's history of aggression, the facility did not move R4 to another room until days after the incident, citing the family's request to assist with the room transfer. The facility's policy on abuse, neglect, and exploitation emphasizes the need for ongoing assessment and care planning for residents with behaviors that might lead to conflict, which was not effectively executed in this case.
Failure to Ensure Supervision and Safety for Resident on Community Pass
Penalty
Summary
The facility failed to ensure appropriate supervision for a resident, R1, who went on a pass to the community with another resident, R2. R1 reported that during a trip to a local store, R2 drove her to a forest preserve and exposed himself. R1's records indicated she was cognitively intact but required substantial assistance for transfers and had not been assessed for unsupervised leave. Despite this, R1 was allowed to leave the facility with R2, who was also a resident and had a car at the facility. The facility's staff, including the Social Services Director and the Director of Therapy, were unaware of the arrangement between R1 and R2 until after the incident. The Social Services Director advised R2 not to give R1 rides after learning about the situation. The Director of Therapy noted that no functional assessment was completed for R1's safe community pass, and R1 had safety awareness issues and poor impulse control. The facility's Therapeutic Leave Policy required an order from a practitioner for a therapeutic leave, but no such order or assessment was found in R1's records. The facility's administration, including the Administrator and the Director of Nursing, acknowledged the lack of proper documentation and assessment for R1's unsupervised leave. They were unable to confirm whether R2 had a valid driver's license or insurance, which raised further safety concerns. The facility's policy required an order for therapeutic leave, but this was not followed, leading to the deficiency in supervision and safety for R1.
Failure to Provide Necessary Orthotic Devices for Residents
Penalty
Summary
The facility failed to provide necessary orthotic devices for two residents with limited range of motion, leading to a deficiency in care. The first resident, a female with hemiplegia and hemiparesis following a stroke, was observed without an ankle brace that was recommended by therapy to assist with stability and alignment during ambulation. Despite the resident and her husband repeatedly inquiring about the brace, the Assistant Administrator claimed to have no knowledge of the recommendation, although therapy notes from March 2024 documented the need for the brace. The resident's care plan did not include the use of the ankle brace, and she was discharged from therapy due to the lack of the device, which prevented her from walking. The second resident, a male with a history of stroke, was observed without a recommended right hand splint. The Director of Rehab had notified the Assistant Administrator about the need for the splint, but it had not been provided as of the survey date. Therapy notes from August 2024 documented the recommendation and the facility's awareness of the need for the splint. The resident was discharged from therapy pending receipt of the splint, which was necessary to prevent further decline in mobility. The facility did not provide a policy for the management of splints or orthotic devices.
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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