Lacon Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Lacon, Illinois.
- Location
- 401 9th Street, Lacon, Illinois 61540
- CMS Provider Number
- 146123
- Inspections on file
- 28
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Lacon Rehab And Nursing during CMS and state inspections, most recent first.
Two residents were not provided meal options that accommodated their food dislikes, despite a facility policy stating that resident likes and dislikes would be considered for substitutions. One resident ate a fish entrée he disliked only by covering it with tartar sauce and reported that the only alternative offered was a peanut butter and jelly sandwich, which he also disliked, and he was not offered a substitute for a dessert he did not eat. Another resident, who also disliked fish, skipped the facility meal and obtained outside food instead. The Dietary Manager reported there was no anytime menu and that available substitutes were limited to peanut butter and jelly or possibly a cheese sandwich, which were acknowledged as not nutritionally equivalent to the main meal.
The facility failed to follow its own policy requiring all transported food to be covered and maintained at proper temperatures, contributing to ongoing complaints about cold and poorly executed meals. During an observed lunch service, plated meals were transported from the kitchen to the dining room uncovered and placed on tables before residents arrived, with no warming plates used. A resident later found his fish only slightly warm and reported that this occurs frequently, while two other residents’ plates sat uncovered for an extended period before being removed. Staff acknowledged that plates are usually covered and that covers were available, and the Dietary Manager confirmed both the requirement to cover transported food and the presence of repeated complaints about cold food.
Surveyors found that multiple residents were living in rooms that were not clean, well-maintained, or safely equipped. One resident’s bathroom sink was inoperable with a black, slimy ring and torn wallpaper on the walls. Another resident’s call light was reportedly always on due to a short, leaving them without a reliable way to summon help, and their bathroom had a strong urine odor and a large puddle of yellowish liquid on the floor that remained wet later in the day. A third resident’s toilet had dried bowel movement on the seat, rim, and front of the bowl, with urine odor extending into the hallway and visible splatter on enabler bars, despite a housekeeper stating the room had been cleaned. Nursing staff reported that housekeeping was expected to clean rooms and bathrooms daily and as needed, and to address issues such as the soiled floor.
The facility failed to maintain adequate heating and hot water, and did not effectively implement its emergency protocols during extreme cold. On one wing, hallway and room temperatures were documented as low as the mid-50s°F, while residents and staff reported that it had been cold there for an extended period. A resident with spinal stenosis, chronic severe pain, and opioid use reported that the persistent cold increased back spasms and pain and prevented comfort, while other residents reported that the cold worsened breathing and pain. The DON could not explain why residents were not relocated to warmer rooms or why additional heat sources were not obtained, and the Administrator’s account of temperature checks conflicted with later low readings. In addition, one side of the building had no true hot water for weeks, with residents reporting they had to go to the other side for showers and staff using kettles for basic hygiene, while measured water temperatures on the affected side were near cold and the other side only lukewarm. Leadership acknowledged ongoing mixing valve problems and that the affected side had been without hot water for about a month.
The facility failed to develop and implement required discharge care plan interventions for four of five residents reviewed for discharge planning. Policy required a post-discharge plan addressing care preferences, access and payment for services, coordination among caregivers, specific discharge needs (e.g., ADLs, self-medication, diet, dressings, therapy), referrals, and preparation for discharge, as well as measurable objectives and timetables. One resident reported discharge was not discussed until an involuntary discharge notice was issued, and others stated no one had discussed discharge with them, with one relying on family to explore home health independently. In each of these cases, the EMR and care plans lacked any documented discharge plan or interventions. The MDS Director/RN stated discharge planning should begin on admission and identified the Social Service Director as responsible for the discharge portion of the care plan, and the Social Service Director admitted she had fallen behind and confirmed the absence of discharge plans for these residents.
The facility failed to maintain its boiler in working order, causing indoor temperatures to fall into the mid to upper 50s Fahrenheit, despite policies requiring regular maintenance of heating systems and safe, comfortable temperature levels. On the day of the deficiency, a seam in the boiler had broken, leaving the building without heat, and staff confirmed the low temperatures. Multiple residents were observed wearing winter coats, stocking caps, and several blankets while in bed or seated in common areas, and a family member reported that a resident’s room was very cold and that the resident’s head was cold to the touch upon arrival. The census records showed that 60 residents were present at the time, all with the potential to be affected by the lack of adequate heat.
The facility failed to maintain adequate heating, hot water, functional call systems, and building repairs, resulting in cold rooms, lack of hot water, and unsafe, unsanitary conditions. Water temperatures were appropriate on one hall but only in the mid‑70s°F on another, with the Maintenance Director citing unresolved mixing valve and boiler issues. Several bathrooms lacked running water, had clogged sinks and toilets, wet and stained bath blankets on the floor, black slimy material in toilets, and suspected mold-like areas, while ceiling tiles in a main hallway were stained and associated with a mildew odor. Multiple residents were observed bundled in coats, blankets, and shawls, reporting that their rooms were cold and that prior complaints to staff went unanswered; one resident’s room temperature was documented at 63°F. Call systems were unreliable or absent, including cords with exposed wires, call lights that only worked while held down, call lights that stayed on continuously or activated spontaneously, and a resident resorting to a handheld bell for assistance. Staff confirmed long‑standing issues with water temperature and call lights and reported heating water in an electric tea pot at the nurses’ station for bathing and hygiene.
Surveyors found that the facility's dishwasher was not properly monitored for required sanitizing temperatures, with staff using incorrect test strips and unable to provide temperature logs or appropriate testing materials. Both dietary and maintenance staff were unfamiliar with proper procedures and responsibilities, resulting in a failure to ensure dishes were sanitized according to facility policy for all residents.
Water temperatures in several resident rooms were found to exceed the facility's policy limit, with one resident reporting that the water was sometimes too hot. The Maintenance Director confirmed that routine water temperature checks had not been conducted as required.
A resident admitted with Alzheimer's dementia and high risk for pressure injuries had a coccyx pressure ulcer identified at admission, but wound treatment orders were not obtained until nearly two weeks later. The delay occurred because the resident was not seen by the wound care provider as scheduled, resulting in a lapse in timely wound care.
A resident with full cognitive capacity was repeatedly gotten out of bed for meals against her wishes, resulting in emotional distress. Despite the facility's policy supporting resident choice, staff followed instructions to get her up, disregarding her expressed preferences. Leadership later confirmed that residents should not be forced to get up if they do not want to.
Surveyors found that the outdoor trash dumpster was missing two lids, with trash piled above the top and no surrounding security, allowing potential access by pests or animals. The Dietary Manager confirmed the dumpster should be kept closed and secured, in accordance with facility policy.
Medications and treatment supplies were left unsecured in a resident's room, contrary to facility policy, while multiple residents with cognitive impairment and wandering behaviors were able to enter another resident's room repeatedly. One such intrusion resulted in a resident being injured when a confused resident fell onto her, and no follow-up or investigation was documented by staff.
Staff failed to consistently follow infection control protocols, including proper use of PPE and hand hygiene, when caring for residents on contact precautions for ESBL and VRE and during wound care procedures. An LPN and other staff entered isolation rooms without required gowns, did not perform hand hygiene before or after glove use, and handled shared medication carts and supplies, increasing the risk of cross-contamination.
Two residents receiving psychotropic medications did not have specific behaviors or non-pharmacological interventions documented prior to medication administration. For one, the MAR only showed check marks without detailed progress notes, and the care plan behaviors did not match those recorded. For the other, behavior monitoring was noted but lacked specifics, and progress notes described combative behaviors without documentation of attempted interventions.
A resident was placed on contact isolation due to an active infection, with visible signage and a physician order in place. However, the care plan was not updated to reflect the new isolation precautions, despite facility policy requiring care plan revisions when a resident's condition changes.
A resident with a history of depression and recent bereavement expressed suicidal ideation, leading a psych NP via telehealth to order a hospital evaluation. Facility staff failed to document any physical or behavioral assessment, did not record vital signs or details of the resident's statements, and did not update the care plan or provide required follow-up monitoring. The DON confirmed that documentation and monitoring were inadequate following the incident.
The facility failed to ensure residents retained their personal items, affecting all 54 residents. Complaints were made about missing items and slow clothing returns due to a broken washing machine. The Housekeeping Supervisor noted understaffing and issues with marking resident clothing, leading to confusion and items being placed on a missing items rack.
The facility did not ensure that prior survey investigations were accessible or that signs were posted to inform residents and families of their availability. During a survey, it was found that Resident Council Members were unaware of the state investigations, and no notices or binders were visible. The Activity Director located the binder hidden behind the guest sign-in book, and the Administrator confirmed the lack of notification signs.
The facility failed to maintain a safe kitchen environment, with deficiencies in the dishwasher sanitation system and unsanitary conditions. The dishwasher's rinse cycle did not reach the required temperature, and there were leaks from a hole in the exhaust fan. Additionally, the steam table was unclean, and water pooled on the floor due to dishwasher splashes. These issues could affect all 54 residents.
A facility failed to implement enhanced barrier precautions (EBP) for a resident as ordered. The EBP policy required gowns and gloves during high-contact care activities, with signage on the door. However, no EBP sign or PPE was available outside the resident's door, and an LPN was unaware of the EBP order.
The facility failed to implement an effective antibiotic stewardship program, lacking documentation and monitoring of antibiotic use and infections. A resident hospitalized for severe infections was not properly documented in the facility's logs, and the DON acknowledged the tracking system's incompleteness.
The facility failed to follow its elopement policy and did not document the testing of elopement devices for residents at high risk for wandering. Residents with severe cognitive impairments were not consistently monitored, and some were found without proper elopement devices. Additionally, residents at high risk for falls were observed unsupervised, despite care plans requiring frequent rounding and supervision. Staff acknowledged these lapses, indicating a failure to implement safety protocols effectively.
The facility failed to monitor refrigerator and freezer temperatures as required, compromising the safe storage of medications. Temperature records were incomplete for the refrigerator/freezer in the Saint [NAME] Linen Room and the Saint [NAME]'s Medication Room, affecting the storage of medications like Basaglar, Insulin Lispro, Tresiba, Humalog, and Tuberculin Purified Protein. This deficiency could impact the health of residents relying on these medications.
A facility failed to provide a resident and their representative with a written notice of transfer to a hospital. The resident's medical record lacked evidence of such notification, and the facility administrator confirmed the oversight.
A facility failed to provide a resident or their representative with a copy of the bed hold policy upon the resident's transfer to a hospital. The resident's medical record lacked documentation of written notice regarding the policy. This was confirmed by the facility's administrator during an interview.
A facility failed to update a resident's care plan to include bilateral lower extremity edema and daily weight monitoring, despite the resident's diagnoses of congestive heart failure and the presence of a left ventricular assist device. The care plan did not reflect these critical needs, and there were significant gaps in the documentation of daily weights, contrary to the physician's orders. The DON acknowledged the oversight, noting the necessity for the care plan to specify daily weight monitoring and the protocol for contacting the cardiovascular team.
The facility failed to obtain daily weights for two residents, one on diuretic therapy and another with a Left Ventricular Assist Device, as per physician orders. Additionally, the facility did not ensure Hospice care plans were available and updated in residents' records, with one resident's plan not specific to the services needed and another's records inaccessible due to electronic documentation by Hospice staff.
A facility failed to create a person-centered dementia care plan for a resident with dementia and agitation. The care plan only included monitoring for changes and task segmentation, lacking individualized interventions. The Care Plan Coordinator confirmed the absence of person-centered strategies, contrary to the facility's dementia care policy.
The facility failed to implement fall prevention measures for two high-risk residents. One resident, with a history of falls, was not provided with a double cord call light and fell during a transfer without a gait belt. Another resident lacked non-skid strips in front of her recliner, as required by her care plan, increasing her fall risk. These deficiencies highlight a lack of adherence to the facility's fall prevention policies.
Failure to Provide Adequate Menu Substitutions Based on Resident Dislikes
Penalty
Summary
The facility failed to implement menus that addressed residents’ dislikes, despite a substitutions policy stating that residents’ likes and dislikes will be considered when making substitutions. One resident was observed at lunch with baked fish, broccoli, hash brown casserole, and baked apples; he stated he does not like fish and used three packets of tartar sauce to mask the taste so he could eat it, reporting that if he did not eat the fish he would not get anything else. He further stated that the only substitute offered is a peanut butter and jelly sandwich, which he also does not like and does not consider an appropriate substitute for the main meal, and he was not offered any substitute for the baked apples he disliked and left uneaten. Another resident’s lunch tray with fish was left on the dining room table while she was absent; staff later stated she had food delivered because she does not like fish, and the resident confirmed she does not like fish and therefore ordered outside food instead of eating the facility meal. The Dietary Manager stated that the facility does not offer an anytime menu and that the only substitutes available are a peanut butter and jelly sandwich or possibly a cheese sandwich, and verified that these substitutes are not equal in nutritional value.
Uncovered and Poorly Temperature-Controlled Meals During Transport and Service
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy requiring all food transported from the kitchen to other parts of the building to be covered and maintained at proper temperatures. The facility’s Transportation of Food policy, revised 11/5/19, states that all food must be covered during transportation and that food must maintain proper temperatures while being transported. Resident Council Meeting Minutes from two separate meetings document multiple complaints about meal execution, including burnt or overcooked items, cold food, undercooked or soggy eggs/omelets, and cold or late meals. On the observed lunch meal service, a cart with already-plated meals was taken from the kitchen to the dining room without any covers or warming plates to protect the main meal. The plates were set on the table uncovered before the residents were present. One resident arrived at the table and found his fish only slightly warm, stating that this happens all the time and that there was no one in the dining room to reheat the meal. Two other residents’ plates remained uncovered on the table for an extended period until a staff member removed them, with the staff member acknowledging that plates are usually covered but not knowing why they were not covered that day. The Dietary Manager confirmed that all transported food is supposed to be covered, that covers were available next to the service line, that no warming plates are used, and that there have been complaints about cold food.
Failure to Maintain Clean, Repaired Environment and Functional Call System
Penalty
Summary
Surveyors identified failures to maintain the building in good repair and cleanliness and to ensure a functional call system for multiple residents. For one resident, the bathroom sink had no running water, with a sign posted instructing not to turn on the water, and the sink bowl had a black, slimy ring. The wallpaper inside the door was ripped from the ceiling to about three feet from the floor in a section approximately two feet wide, with another large piece missing near the heating vent. The Assistant Maintenance Director confirmed that the sink was not working and the wallpaper was peeled off the walls. Another resident was observed sleeping in bed with the call light activated while a CNA in the hallway stated that this resident’s call light was always on due to a short or similar issue and suggested the resident should have a handheld bell, which could not be located. When asked how the resident would request help if they fell, the CNA stated she did not know. The same resident’s bathroom had a strong urine odor and a large puddle of yellowish liquid in front of the toilet with footprints leading from the toilet to the bed; later in the day the floor remained wet with paper towels covering the puddle and the odor unchanged. A third resident’s toilet had dry bowel movement on the seat, around the top rim, and down the front of the bowl, with a strong urine smell extending into the hallway and visible yellow and brown splatter on the enabler bars. A housekeeper reported she had finished cleaning that room and described her duties as emptying garbage, cleaning floors, and dropping off paper products, while the toilet and bathroom remained unchanged. A RN stated that housekeeping was supposed to enter the room several times a day to empty garbage and that rooms, including bathrooms, were to be fully cleaned daily and as needed, and verified that housekeeping should have cleaned the floor in the other resident’s room.
Inadequate Heating, Emergency Protocol Failures, and Prolonged Hot Water Loss
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe, comfortable indoor temperatures and to follow its emergency protocols during periods of extreme cold, as well as its failure to provide adequate hot water throughout the building. The facility’s own Homelike Environment and Cold Weather policies require maintaining comfortable and safe temperature levels, conducting regular maintenance and inspections of heating systems, and routinely monitoring indoor temperatures when outdoor temperatures fall below 65°F. Despite these policies, surveyors observed on 1/29/26 that the St. [NAME] wing (100 Hall) was chilly, with hallway thermostats reading 64–65°F and multiple room thermostats between 62–68°F. When the Maintenance Director used a temperature gun, hallway and room air temperatures on that wing ranged from 54–63°F. Staff interviews confirmed that the wing had been cold for an extended period, with staff wearing fleece jackets and stating they could not recall when it had not been cold on that wing. Residents reported ongoing cold conditions and associated discomfort. One resident in room 117, with diagnoses including spinal stenosis, diabetes with foot ulcer, morbid obesity, and restless legs syndrome, and documented as cognitively intact with frequent severe pain and chronic lower back pain requiring opioid medication, stated that it had been cold in his room since earlier in the month and that being cold all the time made him tense, increased his back spasms and pain, and prevented him from getting comfortable. Another resident in room 106-1 stated it was always cold on the wing and that it affected his breathing. A resident in room 118 reported that the constant cold made her tense and increased her pain. The Director of Nursing could not explain why residents had not been moved to open rooms on a warmer hall or why additional heating sources had not been obtained, and stated she was not part of those conversations with corporate while the Administrator was on vacation. The Administrator later acknowledged that staff had contacted her around 2:00 a.m. when temperatures began dropping, and that the Maintenance Director had checked temperatures and reported higher readings than those later observed by surveyors, indicating a lack of effective implementation of the facility’s emergency protocol as temperatures continued to fluctuate and remain low. The deficiency also includes the facility’s failure to provide adequate hot water to the entire building, particularly on the St. [NAME] side. Residents and staff reported that there had been hot water issues for weeks, with residents from the affected side needing to come to the other side to shower, and staff using kettles to warm water for face, hands, armpits, and perineal care. On 1/30/26, surveyors measured hot water temperatures and found zero hot water on the St. [NAME] wings, with room readings as low as 15.4°F, while the other side of the building had lukewarm water in the 86.7–93.7°F range. The Administrator stated that not all mixing valves had been replaced on the St. [NAME] wings and that this side of the building had been without hot water since a prior complaint survey on 1/12/26. Multiple residents confirmed that there had been no hot water on their side for about a month. The Maintenance Director and Regional Maintenance Director stated that the St. [NAME] side had been with and without hot water throughout the month, describing the problem as intermittent and related to mixing valves in the main system, the main shower, and individual room showers, with several room mixing valves identified as broken.
Removal Plan
- In-service all staff members present on the facility's Comprehensive Emergency Manual Policy by the Administrator and Human Resources.
- In-service the Maintenance Director on the facility's Cold Weather Policy by the Administrator.
- Notify the Medical Director of the Immediate Jeopardy and update on the plan by the Administrator.
- Move residents on the affected wing to available rooms on the same wing; offer remaining residents a transfer to another facility or warmer parts of the building; provide extra blankets and warm beverages to residents who choose to stay.
- Immediately assess identified residents by the DON and Nurse Practitioner to ensure needs are met and comfort is maintained; assess all other residents by nursing staff and outside physicians.
- Assess the air handler, determine the cause of fluctuating temperatures, install new blower fans into the air handler, and complete repairs to ensure adequate hot air circulation.
- Monitor temperatures in each resident room on the affected unit every hour.
- Initiate shift-by-shift temperature monitoring and continue until extreme cold weather has abated as determined by the QAPI committee.
- Assess and continuously monitor all residents remaining on the affected unit for pain, respiratory comfort, and general comfort until heat is fully stabilized; implement interventions to address identified distress or pain and monitor effectiveness.
- Install temporary flannel window coverings to reduce heat loss in rooms on the affected wing.
- Educate all staff via phone or in-person on the Comprehensive Emergency Management Plan and the Cold Weather Policy; educate staff unavailable prior to their next scheduled shift.
- Develop and implement a plan to monitor preventative maintenance for the heating system, including regular audits of maintenance logs by the Administrator to ensure HVAC inspections and radiator filter cleanings are completed; review results during scheduled QAA meetings; continue audits.
- Implement a mandatory education schedule ensuring all staff are educated on the facility emergency policies and procedures; make training a permanent part of orientation for all new hires and conduct annually for all existing staff by Human Resources.
Failure to Develop and Implement Discharge Care Plans for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive discharge care plan interventions for four of five residents reviewed for discharge planning. Facility policy on discharge care planning requires that, when a resident is discharged, a post-discharge plan be provided to the resident and/or representative, including the resident and family’s preferences for care, how services will be accessed and paid for, coordination of care among multiple caregivers, identification of specific needs at discharge (such as ADLs, self-administration of medications, diet, sterile dressings, and therapy), appropriate referrals by social services, and preparation for discharge. The comprehensive care plan policy also requires an individualized plan with measurable objectives and timetables to meet each resident’s medical, nursing, mental, and psychological needs. Despite these policies, the electronic medical records for four residents admitted for care did not contain discharge plans or related interventions. One resident reported that discharge plans were not discussed until an involuntary discharge notice was given, and his current care plan lacked any discharge planning or interventions. Another resident’s record similarly showed no documented discharge plan or interventions. A third resident, who stated he would be going home after completing therapy, reported that no one had discussed discharge plans with him, that his family was independently looking into home health services, and that discharge was never addressed during his care plan meeting; his care plan also lacked discharge planning or interventions. A fourth resident was admitted and later discharged home without any documented discharge plan or interventions in the care plan. The Minimum Data Set Director/RN stated that discharge planning is supposed to be initiated upon admission and that the Social Service Director is responsible for documenting the discharge portion of the care plan. The Social Service Director acknowledged being responsible for discharge care planning, stated she had fallen behind, and confirmed that these four residents did not have discharge plans on their care plans.
Failure to Maintain Boiler Resulting in Inadequate Indoor Temperatures
Penalty
Summary
The facility failed to maintain the boiler in working order to provide adequate heat, resulting in indoor temperatures ranging from 56.0°F to 58.0°F throughout the building. The facility’s own Homelike Environment/Maintenance policy, revised 12/1/25, requires housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior with safe temperature levels, and its Cold Weather policy, revised 11/24/25, requires regular building maintenance and inspection, including maintenance of heating and air conditioning systems and thermostats. On 1/18/26 at 1:00 p.m., the maintenance staff (V3) confirmed that a seam had broken in the boiler, leaving the facility without heat and temperatures in the mid to upper fifties, and the Administrator (V1) verified at 1:30 p.m. that the heat was out in the facility. On 1/18/26 at 1:30 p.m., residents were observed bundled in multiple layers of clothing and blankets due to the cold environment: one resident was in bed with several blankets and a stocking cap, and that resident’s family member reported the room was very cold and that the resident’s head was cold to the touch when she arrived and he was not yet wearing a cap; another resident remained in her room wearing a winter coat and several blankets; and a third resident sat in the front hall wearing a winter coat, stocking cap, and several blankets on his lap, stating that it was very cold in the facility. The Administrator later confirmed that the census on 1/18/26 was 60 residents, as documented on the Daily Census sheet dated 1/17/26, indicating that all 60 residents had the potential to be affected by the lack of heat.
Failure to Maintain Adequate Heat, Hot Water, Call Systems, and Building Repairs
Penalty
Summary
The facility failed to provide adequate heating, hot water, and building maintenance, resulting in an environment that was not safe, clean, or comfortable for residents, staff, and the public. Facility policies on homelike environment, cold weather, and resident call bells required maintenance of safe temperature levels, regular inspection and maintenance of heating and air conditioning systems, and a functional call system accessible from resident beds, toilets, and bathing areas. During a tour with the Maintenance Director, water temperatures on one hall measured 110–116°F, while on another hall they were only 75–77°F. The Maintenance Director acknowledged an ongoing problem with a mixing valve on the affected hall and stated that it was supposed to have been fixed by a plumber but was not. Multiple bathrooms were in disrepair: one resident’s bathroom had chipped paint and missing drywall under the sink; two other rooms had no running water to sinks or toilets, wet and stained bath blankets on the floor under sinks, black slimy-looking substances in toilets, and a black mold-like area in front of a toilet. The Maintenance Director stated that the sink and toilet were clogged and he had not had a chance to fix them. Ceiling tiles across the front hallway were discolored with brown stains and a mildew smell was noted; the Maintenance Director attributed this to condensation leaking into the tiles when boilers were turned up and stated he was the only maintenance person and had difficulty keeping up with repairs. Residents reported and demonstrated discomfort and lack of access to required systems. One resident was observed sitting in his room wearing a jacket and wrapped in a blanket, stating it was always cold on the southeast side of the building and that it smelled moldy in the front where ceiling tiles appeared wet; the wall behind his chair had gouges with crumbling plaster on the floor. When this resident pressed his call light, it illuminated only while the button was held down, and the second bed’s call cord consisted of open wires with no call button. Another resident was observed wearing a long-sleeve shirt and coat, reporting that his room had been warm until a recent weekend, that he told staff it was too cold but received no response, and that he stayed in bed wrapped in covers. A third resident, dressed in warm clothing with a shawl and blanket, stated her room was cold; a wall clock in her room showed 63°F. Another resident was using a handheld bell to call for assistance, stating he had no call light, and he and other residents confirmed there was no hot water in their rooms. Staff verified that certain room call lights stayed on all day or activated by themselves, that water on one side of the building only became warm but not hot, and that they heated water in an electric tea pot at the nurses’ station for showers and washing. The Administrator confirmed that water and room temperatures were not at proper levels and that many repairs were needed, while the Maintenance Director confirmed ongoing problems with the mixing valve and boiler and that water temperatures on one side of the building were in the mid‑70s°F.
Dishwasher Sanitization Failure Due to Improper Monitoring and Lack of Staff Knowledge
Penalty
Summary
The facility failed to ensure that the dishwasher used for sanitizing dishes was operating in accordance with professional standards and facility policy. During the survey, staff used quaternary ammonia test strips on a high-temperature dishwasher, which is not the correct method for verifying hot water sanitization. The test strips did not register any sanitizer, and staff were unable to locate appropriate hot water test strips in the building. Additionally, the final rinse temperature was not displayed on the dishwasher, and there were no temperature logs available for review. The Dietary Manager and Maintenance Director were both unfamiliar with the proper procedures for monitoring and servicing the dishwasher, and neither knew who was responsible for its maintenance or which company serviced it. These failures affected all 56 residents in the facility, as the dishwasher was not properly monitored or tested to ensure it reached the required sanitizing temperature of at least 180 degrees Fahrenheit, as specified in the facility's policy. The lack of proper testing materials, absence of temperature logs, and staff's lack of knowledge regarding the dishwasher's operation and maintenance contributed to the deficiency in food service sanitation.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to ensure that water delivered to resident rooms was maintained at a safe and comfortable temperature, as required by facility policy. During an observation, water temperatures from bathroom sinks in multiple resident rooms were found to exceed the policy limit of 110 degrees Fahrenheit, with specific readings recorded for six residents. One resident reported that the water was sometimes too hot. The Maintenance Director acknowledged that water temperatures in resident areas should not exceed 110 degrees Fahrenheit and admitted that required water temperature checks had not been performed due to lack of time. The facility's policy, dated 12/30/2024, specifies that water temperatures in resident rooms should not exceed 110 degrees Fahrenheit.
Delayed Pressure Ulcer Treatment Orders for High-Risk Resident
Penalty
Summary
A resident with Alzheimer's dementia, depression, and anxiety was admitted to the facility and identified as high risk for pressure injuries based on the Braden Scale. Upon admission, the resident had a pressure injury to the coccyx, which was documented as non-staged. The admission assessment indicated that the wound care company was notified and scheduled to see the resident on a future date. However, the resident was not seen by the wound care provider as planned, and no treatment orders were obtained at the time of admission. It was not until approximately 13 days after admission that a wound assessment was completed by the wound care physician, and specific treatment orders were initiated. During this period, the resident's wound care was delayed, as confirmed by interviews with the Director of Nursing and Assistant Director of Nursing, who acknowledged that wound treatment should be obtained as soon as a wound is discovered. Facility policy requires prompt identification and treatment of pressure ulcers, but this was not followed in the resident's case.
Resident Denied Right to Self-Determination Regarding Daily Routine
Penalty
Summary
A cognitively intact resident, as evidenced by a BIMS score of 15/15, was observed in emotional distress and crying in the dining room, expressing that she did not want to be out of bed and felt as though she was being punished. The resident reported pain, discomfort from the light, and stated that her repeated requests to return to bed were ignored by staff, who would say they would get help but did not return. The facility's policy affirms residents' rights to self-determination, including choices about daily routines and care. Interviews with staff revealed that a CNA acknowledged the resident's desire to remain in bed but stated that nurses instructed her to get the resident up for meals. An LPN confirmed the resident's ability to make her own care decisions but expressed personal opinions about the resident's dietary and activity choices, suggesting she should not always be allowed to decide for herself. Facility leadership, including the Administrator and Social Service Director, confirmed that residents should not be gotten up against their wishes, and the CNA involved believed she was following proper procedure until educated otherwise.
Improper Disposal and Securing of Outdoor Trash Dumpster
Penalty
Summary
Surveyors observed that the facility failed to ensure the outdoor trash dumpster was properly maintained according to facility policy. During an initial kitchen tour with the Dietary Manager, it was noted that the dumpster was missing two lids, and trash was piled above the top of the dumpster. The dumpster was not secured by any walls or access doors, and the open condition allowed for the possibility of pests or animals accessing discarded food and trash. The Dietary Manager confirmed that the dumpster should be kept closed and secured to prevent such access. Facility policy requires all garbage containers to have tight-fitting lids and to be kept covered when not in continuous use, as well as to store garbage in a manner inaccessible to vermin. At the time of the survey, 57 residents were documented as residing in the facility.
Failure to Secure Medications and Prevent Resident-to-Resident Intrusions
Penalty
Summary
The facility failed to store medications and treatment supplies in a secure environment, as observed with a bottle of Dakins solution and a tube of Therahoney left unattended in a resident's room. According to facility policy, such items should be locked away when not in use to prevent access by unauthorized individuals. Staff confirmed that these items should not have been left in the room, especially given the presence of multiple residents with wandering behaviors who could potentially access them. Additionally, the facility did not adequately address the issue of confused residents entering another resident's room. Two residents with documented cognitive impairments and high risk for wandering were observed entering the room of another resident on multiple occasions. The resident whose room was entered reported frequent disturbances, including one incident where a confused resident fell onto her, resulting in soreness and bruising. Despite these repeated intrusions, staff did not implement effective measures to prevent such occurrences. Furthermore, the facility failed to investigate and document follow-up care after the incident in which a confused resident fell onto another resident, causing physical discomfort. There was no evidence in the medical record of any assessment or follow-up regarding the injury, and the administrator was unable to provide information on steps taken to prevent further incidents or to investigate the reported injury. This lack of action left the affected resident without appropriate support or intervention following the event.
Failure to Follow Infection Control Protocols for PPE and Hand Hygiene
Penalty
Summary
Staff failed to adhere to the facility's infection prevention and control policies regarding the use of personal protective equipment (PPE) and hand hygiene in rooms under transmission-based precautions. In one instance, an LPN entered a resident's room, who was on contact precautions for ESBL in the urine, without donning a gown and without performing hand hygiene before putting on gloves. The LPN touched the resident and her environment, administered insulin, and then left the room with the insulin pen still in her gloved hand. The LPN then accessed the medication cart, removed the needle, and placed the insulin pen back with other residents' medications, removed her gloves, and failed to perform hand hygiene at any point during or after the process. The LPN later acknowledged that she should have worn a gown and performed hand hygiene as required by facility policy. Other staff, including a speech therapist and housekeeping staff, were observed not wearing the required PPE when entering rooms of residents on contact precautions for ESBL and VRE. The speech therapist stated she only wore gloves when seeing a roommate not on isolation and was unaware a gown was required. Housekeeping staff admitted to sometimes only wearing gloves, depending on how rushed they felt, despite being educated on the need for full PPE. The Assistant Director of Nursing confirmed that all staff, including therapy and housekeeping, are required to wear gloves and gowns when entering rooms of residents on contact precautions. Additionally, the Director of Nursing was observed performing wound care on a resident with pressure ulcers and skin impairment without performing hand hygiene between glove changes. The DON removed and replaced gloves multiple times during the procedure without washing or sanitizing hands, contrary to the facility's hand hygiene policy. The DON later confirmed that hand hygiene should have been performed between glove changes.
Failure to Document Behaviors and Non-Pharmacological Interventions Prior to Psychotropic Medication Use
Penalty
Summary
The facility failed to properly track and document specific behaviors and non-pharmacological interventions prior to administering psychotropic medications for two residents. For one resident with a history of fetal alcohol syndrome, intellectual disabilities, and various behavioral issues, the care plan listed multiple behaviors, but the Medication Administration Record (MAR) only showed check marks or a code for behavior without corresponding progress notes detailing the specific behaviors or any non-pharmacological interventions attempted. The administrator confirmed that there was no documentation describing what behaviors occurred or what interventions were tried, and that the behaviors listed on the care plan did not match those recorded on the MAR. During the survey, this resident was observed to be pleasantly confused and interacted with staff and other residents without agitation or aggression. Another resident, admitted with severe unspecified dementia, agitation, anxiety disorder, and depression, was prescribed antipsychotic and antianxiety medications. The care plan indicated the use of these medications but did not specify the indications for use. The MARs for several months documented behavior monitoring but did not specify the behaviors or any non-pharmacological interventions. Progress notes for this resident recorded combative and resistive behaviors but did not document any attempted interventions during these behaviors or prior to administering psychotropic medications.
Failure to Update Care Plan for Contact Isolation Precautions
Penalty
Summary
The facility failed to update and revise the care plan for a resident who was placed on contact isolation precautions due to an active infection with transmissible significant pathogens. Observation showed the resident's room door was closed, with contact isolation signage and a PPE cart present. The resident's electronic medical record included a physician order for contact isolation, specifying that the resident was to be isolated in the room without a roommate, and that all activities and services were to be brought to the resident. Despite these documented precautions and the visible implementation of isolation measures, the resident's care plan was not revised to reflect the new contact isolation status. The facility's policy requires care plans to be updated as changes in a resident's condition occur, but this was not done in this case. The administrator confirmed that the care plan should have been updated to include the contact isolation precautions.
Failure to Document and Monitor After Suicidal Ideation
Penalty
Summary
The facility failed to thoroughly document and monitor a resident after she verbalized suicidal ideation. According to the facility's policies, any staff member who becomes aware of a resident's intent to inflict self-harm is required to report the behavior to the Nursing Supervisor without delay, and the charge nurse or Nurse Supervisor must immediately assess the situation and determine necessary interventions. In this case, a resident with diagnoses including metabolic encephalopathy, anxiety, and major depressive disorder expressed suicidal ideation, stating she wanted to die by a specific date and did not want to live anymore. The psychiatric nurse practitioner, via telehealth, ordered the resident to be sent to the emergency room for evaluation, but there was no documentation of a physical or behavioral assessment, vital signs, or details of what the resident said to prompt the transfer. The nurse's notes only indicated the resident was sent to the hospital for being suicidal and later returned after being declared not suicidal, with no further documentation of assessments or follow-up. Additionally, the resident's care plan was not updated to reflect the suicidal ideation or to include new interventions or increased monitoring. The facility's documentation policy requires alert charting for incidents or changes in condition for at least 72 hours or until stable, but this was not completed. The Director of Nursing confirmed that follow-up alert charting should have been done and acknowledged the documentation was very poor in this case. The lack of thorough documentation and monitoring after the resident's expression of suicidal ideation constitutes the deficiency identified by the surveyors.
Failure to Ensure Residents Retain Personal Items
Penalty
Summary
The facility failed to ensure that residents retained their personal items, which has the potential to affect all 54 residents residing in the facility. During a resident council meeting, three residents complained about missing items and a slow response in returning clothes due to a broken washing machine that has not been repaired for over a year. The Resident Council Monthly Meeting minutes from October 2023 through June 2024 document ongoing complaints of missing clothes and slow return of clothing and items. The Housekeeping Supervisor stated that once a month, the Activity Director provides a form listing missing items, which the supervisor attempts to locate. However, the washing machine has been broken for over a year, and despite promises of parts arriving, the issue remains unresolved. The facility is understaffed in the laundry department, with only two staff members struggling to keep up with the workload. Resident clothing is often not properly marked with identifiers, leading to confusion and items being placed on a missing items rack. Observations confirmed that resident items were hanging on a rack and a bin labeled as missing items.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that prior survey investigations were accessible and that signs were posted to inform residents and families about the availability of these survey investigations. This deficiency was observed during a survey conducted on June 24, 25, and 26, 2024. Three Resident Council Members confirmed that they were unaware of the availability of state investigations for review. During observational tours, no posted notice or state survey inspection binder was visible. The Activity Director, upon inquiry, found the survey investigation binder hidden behind the guest sign-in book at the entrance, in a non-patient care area, making it inaccessible to residents and families. The Administrator acknowledged that signs were not posted to notify residents and families about the survey investigation binder's availability.
Deficiencies in Kitchen Sanitation and Maintenance
Penalty
Summary
The facility failed to maintain a safe kitchen environment, specifically in the operation and maintenance of the dishwasher sanitation system. The Dietary Manager admitted to not testing the dishwasher, relying solely on the temperature gauge, and was unable to explain the testing process. A Dietary Aide conducted a test strip through the dishwasher cycle, revealing that the rinse cycle only reached 143 degrees Fahrenheit, below the required temperature for proper sanitation. Despite daily testing claims, the rinse cycle consistently failed to meet the necessary temperature. Additionally, the dish room had multiple soaked ceiling tiles with a brown substance, and several ceiling lights were out. The Maintenance Director confirmed a hole in the dishwasher exhaust fan, causing leaks into the ceiling and near light fixtures, with no approval from Corporate to fix the issues. Further observations revealed unsanitary conditions, including a portable steam table with black crumbly substances and brown grease-like substances in its compartments, with no record of recent cleaning. A large pool of water was observed on the floor from the dishwasher room to the kitchen, attributed to splashes from the dishwasher pooling in a low spot, with the drainage system located on the opposite side of the room. These deficiencies have the potential to affect all 54 residents residing in the facility.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as ordered for a resident who required such measures. The EBP policy, dated March 27, 2024, mandates the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices to prevent the transmission of infectious organisms. On April 16, 2024, a physician's order specified that staff should wear gowns and gloves during direct patient contact with the resident, and signage should be posted on the door. However, on June 24, 2024, it was observed that there was no EBP sign posted at the resident's door, and no personal protective equipment was available outside the door. A Licensed Practical Nurse (LPN) admitted to being unaware of the order for enhanced barrier precautions.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of assessment and monitoring of residents for signs and symptoms of infections, and the absence of appropriate documentation for antibiotic usage. The facility's policy on Infection Control with Antibiotic Stewardship, dated January 2024, mandates the development of antibiotic use protocols and a system to monitor antibiotic use, including written documentation of clinical justification. However, the facility's Infection Control Logs for April and May 2024 were incomplete, lacking specific antibiotic usage details, justification for antibiotic use, and ongoing surveillance data for infections. A specific case involved a resident who was hospitalized from May 7 to May 28, 2024, for acute respiratory failure, hypotension, pneumonia, sepsis, and a urinary tract infection. Upon discharge, the resident was diagnosed with sepsis and MRSA infection, requiring isolation. The facility's Infection Control Monthly Log for May 2024 did not document the resident's infection details, such as the source and organisms. The Director of Nurses acknowledged the incompleteness of the Antibiotic Stewardship Tracking, which lacked a surveillance plan and justification for antibiotic use.
Failure to Monitor Elopement Devices and Supervise High-Risk Residents
Penalty
Summary
The facility failed to adhere to its elopement policy and did not document the testing of elopement devices for several residents identified as high risk for wandering or elopement. Specifically, residents with severe cognitive impairments and a history of wandering, such as those diagnosed with Alzheimer's Disease, were not consistently monitored. For instance, one resident's wander guard was not documented for placement or functionality in seven out of twenty-five opportunities, and another resident's wander guard was similarly neglected in eight out of twenty-five opportunities. Additionally, a resident identified as medium risk for elopement was not properly monitored, as evidenced by an incident where the resident set off an alarm and was later found without an elopement device secured to their person. The facility also failed to provide adequate supervision for residents at high risk for falls. Residents with severe cognitive impairments and physical weaknesses were observed unsupervised in various areas of the facility, despite care plans indicating the need for frequent rounding and supervision in high-visibility areas. One resident, who had a documented history of 19 unwitnessed falls, was repeatedly found unattended in common areas, contrary to their care plan's directives. Another resident, also at high risk for falls, was observed wandering without staff supervision, despite the care plan's requirement for increased monitoring. The Director of Nursing and other staff members acknowledged the lapses in documentation and supervision, confirming that the required checks and monitoring were not consistently performed. The facility's policies on fall reduction and elopement prevention were not effectively implemented, leading to multiple instances where residents were left vulnerable to potential accidents or elopement. These deficiencies highlight significant gaps in the facility's adherence to safety protocols and resident care plans.
Failure to Monitor Refrigerator/Freezer Temperatures for Medication Storage
Penalty
Summary
The facility failed to adequately monitor refrigerator and freezer temperatures, which is essential for the safe storage of medications. The policy requires that temperatures be recorded daily, with specific acceptable ranges for refrigerators and freezers. However, the temperature records for the refrigerator/freezer in the Saint [NAME] Linen Room showed a lack of monitoring for 25 out of 47 required times in June 2024. Additionally, the refrigerator/freezer in the Saint [NAME]'s Medication Room was not monitored 37 out of 62 times in May 2024 and 13 out of 50 times in June 2024. This lack of monitoring could potentially affect the safe storage of medications for multiple residents. During observations, it was noted that the refrigerator/freezer in the Saint [NAME]'s Medication Room contained several injectable pens and multidose vials that require refrigeration. These included medications such as Basaglar, Insulin Lispro, Tresiba, Humalog, and Tuberculin Purified Protein. The failure to consistently monitor and record temperatures as per the facility's policy could compromise the efficacy and safety of these medications, potentially affecting the health of the residents who rely on them.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide a resident and their representative with a written notice of transfer. This deficiency was identified during a review of a resident's medical record, which documented a transfer to a local hospital. The record lacked evidence of a facility notification to the resident or their representative regarding the transfer or discharge. The facility administrator confirmed that no written notice was provided.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to a resident or the resident's representative upon the resident's transfer to a hospital. The medical record of the resident, identified as R18, did not contain documentation of written notice regarding the facility's bed hold policy. This deficiency was confirmed during an interview with the facility's administrator, who acknowledged that neither the resident nor the representative received the necessary documentation or notice of transfer.
Failure to Update Care Plan for Edema and Daily Weights
Penalty
Summary
The facility failed to update the care plan for a resident, identified as R212, to reflect the presence of bilateral lower extremity edema and the requirement for daily weight monitoring. The facility's policy mandates that care plans be revised as changes in a resident's condition dictate, yet this was not adhered to in the case of R212. The resident was admitted with multiple diagnoses, including congestive heart failure and edema in the lower extremities, which necessitated daily weight monitoring to manage the condition effectively. However, the care plan did not incorporate these critical aspects, leading to a deficiency in care planning. Additionally, there were significant gaps in the documentation of daily weights for R212, despite orders requiring daily monitoring due to the presence of a left ventricular assist device and the risk of heart failure. The Director of Nurses acknowledged the need for the care plan to specify the requirement for daily weights and the protocol to contact the cardiovascular team if there was a weight gain of five pounds. Despite staff claims of obtaining daily weights, several dates were missing from the records, indicating a failure in executing and documenting the prescribed care regimen.
Deficiencies in Weight Monitoring and Hospice Care Documentation
Penalty
Summary
The facility failed to obtain physician-ordered daily weights for two residents, one of whom was on diuretic therapy for edema and had specific orders to administer additional medication if a weight gain was observed. The resident's daily weight records showed numerous missing entries over several months, which was confirmed by the Director of Nurses. Another resident with a Left Ventricular Assist Device also had missing daily weight records, despite having a doctor's order to monitor weight gain closely and contact the cardiovascular team if a significant gain occurred. Additionally, the facility did not ensure that Hospice plans of care were available and updated in the residents' records. One resident's Hospice care plan was not specific to the services they should receive, and the updated plan was only received on the day of the survey. Another resident's Hospice records were not available for review, and the facility did not have access to the Hospice's electronic documentation. The LPN confirmed that the Hospice staff documented on their own software, and the facility lacked access to these records.
Failure to Develop Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to develop a person-centered dementia care plan for a resident diagnosed with dementia with agitation. The facility's policy on dementia care, dated November 5, 2019, requires that residents with dementia receive appropriate treatment and services to maintain their highest practical well-being, including person-centered care that maximizes dignity, autonomy, and safety. However, the care plan for the resident, dated October 20, 2023, only included monitoring for changes in condition and task segmentation to support short-term memory deficits. The Care Plan Coordinator confirmed that the care plan lacked individualized person-centered interventions.
Failure to Implement Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to ensure safe resident transfer and fall intervention implementation for two residents, R2 and R3, who were identified as high fall risks. R2, who has diagnoses including lack of coordination, unsteadiness on feet, and repeated falls, was found without the required double cord call light in her room, which was supposed to provide additional access points for requesting assistance. During a transfer from a wheelchair to a toilet, R2 fell because the CNA did not use a gait belt, contrary to the resident's care plan and facility policy. The CNA claimed R2 refused the gait belt, but R2 denied ever refusing it, indicating a miscommunication or misunderstanding of the resident's needs. R3, also a high fall risk with diagnoses of lack of coordination and muscle weakness, was observed standing in front of her recliner without non-skid strips on the floor, which were specified in her care plan as a fall prevention measure. The absence of these strips was confirmed by an LPN, who was initially unaware of their necessity. R3 was seen leaning forward and wobbly, further highlighting the risk posed by the missing non-skid strips. The facility's policies on fall reduction and gait belt transfers emphasize the importance of providing an environment free of accident hazards and using assistive devices to prevent falls. However, the observations and interviews revealed that these policies were not adequately implemented for R2 and R3, leading to unsafe conditions and a fall incident for R2.
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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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