Landmark Of Hyde Park Rehabilitation And Nursing C
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 6125 South Kenwood, Chicago, Illinois 60637
- CMS Provider Number
- 145938
- Inspections on file
- 63
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Landmark Of Hyde Park Rehabilitation And Nursing C during CMS and state inspections, most recent first.
A cognitively intact resident with depression and schizophrenia, who shared a room with a cognitively intact spouse diagnosed with schizoaffective disorder and alcohol abuse, reported to a social worker that the spouse’s behavior was frightening, that the spouse sometimes drank alcohol, and that the spouse had dumped the resident’s wallet contents into a toilet. The resident appeared fearful, stated the spouse did not want anything disclosed, and reported feeling afraid and nervous around the spouse. The social worker, despite prior abuse training and knowing the administrator was the abuse coordinator, did not immediately report these concerns to the administrator as required by the facility’s Abuse Prevention Program, instead delaying to "gather facts," resulting in a failure to promptly report suspected abuse or mistreatment.
A resident with intact cognition reported that their room was not clean, and surveyors observed that the resident’s bathroom had a hole in the lower wall, a hanging baseboard, a black substance between the floor and wall, and an area of unpainted plaster that did not match the other walls. The Maintenance Director confirmed these conditions and acknowledged they were not homelike, despite facility policies and maintenance job descriptions requiring that resident rooms be kept safe, clean, comfortable, and attractively maintained.
A resident’s right to retain and use personal possessions was not honored when the facility failed to implement its own policy for inventorying and tracking belongings. The DON and Administrator confirmed there was no inventory sheet for the resident, despite a policy requiring CNAs to list personal items at admission and have the list placed in the chart. A CNA reported that staff are supposed to log belongings on admission and bag and store items at discharge, but new items brought in later are not recorded. During the survey, the Administrator found an unlabeled bag containing the resident’s personal items, including a Bible, stored on a floor of the building and not returned to the resident.
The facility failed to prevent resident-to-resident physical abuse when a resident with multiple psychiatric diagnoses and a documented moderate risk for aggression, including prior episodes of agitation and aggression, slapped another resident on the back of the head during a behavioral episode. Staff, including the administrator and an RN supervisor, were aware of the aggressor’s history of anger and aggressive behavior, yet the incident still occurred, resulting in physical contact that met the facility’s own definition of abuse. The affected resident was assessed with no visible injuries and denied pain, but the event violated the care plan expectation that residents remain safe, treated with dignity, and free from mistreatment.
Two residents became involved in a verbal altercation that escalated to physical abuse when one resident pushed the other, causing a head injury that required stitches and hospital evaluation. Staff attempted to intervene but were unable to prevent the assault, resulting in a violation of the facility's abuse prevention policy.
Staff did not immediately report an allegation that a CNA hit a resident during an altercation between two residents. The incident was not brought to the administrator's attention until two days later, despite facility policy requiring immediate reporting of suspected abuse. Multiple staff members either failed to report or were unaware of the allegation until after the fact.
A resident with a urostomy and two roommates experienced repeated incidents of urine on the floor and strong urine odors in their shared room. Despite awareness by nursing and housekeeping staff, the spills and odors persisted over several days, and the environment was not kept clean or safe as required by facility policy.
A resident with a urostomy and cognitive impairment was left without appropriate urostomy supplies, leading to repeated episodes of urine leakage onto the resident's body and bedroom floor. Staff confirmed the resident was out of urostomy bags, and attempts to use a colostomy bag were unsuccessful. Communication lapses and supply management failures contributed to the deficiency, despite facility policies requiring adequate stock and regular care.
A resident with diabetes was not provided the physician-ordered diabetic diet during a special occasion meal, receiving foods high in sugar such as a frosted cookie and pie. Staff confirmed that all residents were served the same meal regardless of dietary restrictions, and there was no physician order to alter the therapeutic diet for the event. Facility policy and care plans required adherence to prescribed diets unless otherwise ordered by a physician.
The facility failed to maintain proper food safety and sanitation standards. Open and unlabeled food items were found in the refrigerator, and the kitchen area was unsanitary with uncovered garbage cans, a dirty mop bucket, and personal items on food preparation tables. These practices risk cross-contamination and foodborne illness.
The facility failed to properly dispose of kitchen garbage and maintain a sanitary dumpster area. Observations revealed uncovered dumpsters surrounded by debris and foul odors, with squirrels eating the garbage. The Dietary Manager and housekeeping staff acknowledged the lack of a cleaning schedule and the shared responsibility for maintaining the area. The facility's policy requires cleanliness and contacting garbage services when dumpsters are full.
The facility failed to maintain an effective pest control program, as evidenced by multiple resident reports and observations of cockroaches and mice in rooms and common areas. Despite weekly visits from a pest control company, residents continued to report infestations, and Pest Control Sighting Logs documented numerous sightings across different floors. Housekeeping staff and the Assistant Director of Nursing acknowledged the ongoing pest problem, indicating a failure to adhere to the facility's policy to keep the environment free of insects and rodents.
A facility failed to implement proper infection control measures for a resident with a surgical wound and PICC line by not placing them on Enhanced Barrier Precautions (EBP) and lacking necessary signage and isolation setup. Additionally, an LPN did not disinfect a blood pressure monitor between uses for three residents, despite EBP signage indicating the need for such precautions. These actions were contrary to the facility's policies on equipment cleaning and infection control procedures.
The facility failed to provide timely pneumonia vaccinations to five residents and did not offer the influenza vaccine to a resident. Additionally, the facility administered the flu vaccine to a resident without obtaining written consent. The planned pneumonia clinic was not conducted, and consents were incomplete, leading to these deficiencies.
The facility failed to accommodate the preferences of two residents regarding their daily care routines. One resident, with end-stage renal disease, wanted to be out of bed daily but was only assisted during shower times. Another resident, with chronic heart failure and dementia, requested a shower due to itchiness but was given a bed bath instead. These actions did not align with the facility's policies on resident preferences and quality of life.
The facility failed to notify a physician when a resident's blood pressure was outside ordered parameters, did not follow proper procedure for blood pressure measurement, and neglected to maintain a dressing on a resident's permacath. These deficiencies involved residents with conditions such as End Stage Renal Disease and Hypertension, and the facility's policies for accurate blood pressure readings and catheter care were not adhered to.
A resident with a history of pressure ulcers and multiple health conditions was found on a low air loss mattress set incorrectly for their weight, posing a risk for skin breakdown. The mattress was set at 350 pounds, while the resident weighed 79.6 pounds, contrary to facility policy requiring settings based on weight.
A facility failed to apply a splint as ordered for a resident with limited range of motion, leading to a contracted right hand. The resident's care plan incorrectly indicated a splint for the left wrist, while the order specified the right hand. The discrepancy and absence of a restorative nurse contributed to the oversight.
The facility failed to prevent the storage and administration of expired dialysis nutritional supplements to two residents. An inspection revealed an opened box of expired Nova Source Renal 19% in the medication room, which was used for dialysis residents. Two residents with end-stage renal disease received the expired supplements, despite facility policy requiring proper storage and expiration checks. The oversight was acknowledged by the ADON, who initiated staff education on checking expiration dates.
A facility failed to reassess the appropriateness of a PRN antipsychotic medication for a resident with Schizoaffective Disorder and other mental health diagnoses. Despite no documented negative behaviors, the PRN order for Haloperidol was not reevaluated or discontinued after 14 days, contrary to facility policy. Staff interviews confirmed that non-pharmacological interventions should precede medication use, and PRN orders should be reassessed within 14 days.
A resident with left-sided weakness fell from their wheelchair due to the absence of a footrest, causing their foot to drag on the floor. The resident, who is cognitively intact, was being pushed by a CNA when the incident occurred. Staff interviews revealed the resident had not been assessed for a footrest after returning from the hospital. The care plan indicated a risk for falls, and the facility's policy assigns therapy the responsibility for ensuring proper wheelchair fit.
The facility failed to maintain a pest-free environment, with residents reporting mice and roaches in their rooms. Despite weekly exterminator visits and the use of traps and bait, pest issues persisted, indicating insufficient measures. The Housekeeping Director acknowledged complaints over several months, and pest control reports highlighted ongoing treatments and sanitation recommendations. The deficiency potentially affected all 229 residents, as pests were reported in multiple areas.
A resident in an LTC facility was found with long, dirty fingernails, indicating a failure in providing adequate nail care. The LPN confirmed the need for trimming and cleaning, while the CNA admitted to not checking the nails during her shift. The ADON emphasized the importance of regular nail care as part of ADL, which was not followed for this resident.
A facility failed to maintain hot food temperatures during meal service, affecting a resident and potentially impacting 60 others. A resident reported receiving cold food, confirmed by surveyor observations. The steam table was not plugged in, leading to inadequate food temperatures. The dietary director acknowledged the oversight, which violated facility policy requiring hot foods to be held at a minimum of 135°F and served at no less than 125°F.
A resident with multiple health conditions, including dementia and pressure ulcers, did not receive timely incontinence care as required by the facility's policy. The resident's incontinence brief was not checked or changed every two hours, resulting in the resident being found with a soiled brief. The CNA responsible for the resident had last changed the brief at 7:00 am, and it was not checked again until nearly five hours later, leading to a deficiency in care.
A resident with multiple pressure ulcers did not receive proper aseptic wound care or timely repositioning in a facility. The resident's low air loss mattress was set incorrectly for their weight, and the wound care nurse failed to perform hand hygiene between glove changes. The facility's policies on pressure ulcer prevention and infection control were not adhered to, leading to deficiencies in care.
The facility failed to provide the prescribed pureed diet to two residents, serving a whole banana instead of a pureed one, contrary to physician orders. This oversight was observed during a meal, with the Dietary Manager acknowledging the error and the need for staff training.
A resident with mental illness was physically assaulted by another resident, resulting in a facial injury requiring sutures. Despite a history of inappropriate behavior, the supervising psychiatric technician failed to prevent the escalation of an argument on the smoking patio, leading to the incident. The facility's abuse prevention policy was not effectively implemented to protect the resident.
A facility failed to monitor residents on the patio, leading to safety risks, especially for those in wheelchairs and at high risk for falls. During an observation, no staff were present to supervise residents, including one who had previously fallen and sustained injuries. The facility's policy requires supervision while smoking, but this was not adhered to, posing a risk to residents with severe cognitive impairments and other conditions.
The facility failed to follow provider orders for Hepatitis C treatment for three residents, leading to significant health consequences. One resident developed hepatocellular carcinoma due to untreated Hepatitis C, while two others did not receive necessary laboratory tests. The facility did not document any attempts to follow through with the orders, despite multiple directives from physicians and a nurse practitioner.
A resident with a history of substance abuse eloped from the facility by climbing over the smoking patio fence due to inadequate supervision and monitoring. The game room and patio doors were left open and unsupervised, and the alarm system failed to sound. The facility did not report the elopement to the state agency, believing it was only necessary for residents with altered mental status.
Failure to Report Resident’s Fear and Possible Abuse by Spouse to Administrator
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse Prevention Program policy requiring that any alleged violations involving mistreatment, abuse, neglect, exploitation, or reasonable suspicion of a crime against a resident be immediately reported to the Administrator. One cognitively intact resident (R1), a 48‑year‑old with major depressive disorder, depression, and schizophrenia, was married to and shared a room with another cognitively intact resident (R2), a 42‑year‑old with schizoaffective bipolar disorder and alcohol abuse. R1 reported a history of several physical altercations with R2 prior to admission, though her trauma screening at admission indicated she denied any prior abuse history. While in the facility, R1 described escalating concerning behavior by R2, including renewed alcohol and marijuana use, increased aggression, and reports of hearing voices, which she did not report to nursing. R1 stated that on one occasion R2 became angry, grabbed her wallet, dumped all her cards into the toilet, urinated on them, forced her to retrieve the cards from the toilet, tore up her Social Security card, and called her derogatory names. R1 also reported that on another day, which she identified as a Monday, she went to the social worker (V4) and told her that R2 was scaring her and making her feel nervous, and that R2 had dumped her wallet into the toilet. R1 stated that V4 told her that R2 was her spouse and that they needed to work it out as a married couple. R1 did not tell V4 at that time that R2 had physically abused her in the past. R1 later reported that on a subsequent day, in their room with the door closed, R2 punched her in the cheek/face after telling her not to talk about him to anyone. She did not yell for help, did not report this incident to facility staff, and stated that her face did not bruise or swell. V4 confirmed that R1 came to her office earlier in the week and reported that R2 sometimes drank alcohol. V4 observed that R1 kept looking out the door and stopped talking when someone walked past, and that R1 said she felt afraid and nervous with R2 and that R2 did not want her to say anything. V4 stated that R1 then ended the conversation and left the office, and that later that same day R1 and R2 together requested and were granted a community pass, appearing calm and peaceful before and after the pass. V4 stated she was confused by the information and intended to report it to the Administrator but wanted to gather her facts first. She did not immediately report R1’s expressed fear and nervousness about R2 to the Administrator, despite having received abuse training and knowing the Administrator was the abuse coordinator. The Administrator later stated she had not been made aware that R1 felt afraid or nervous being in the room with R2 or that R1 was being abused by R2, and that her expectation was that any staff member who learned a resident was afraid or nervous around another resident or staff member would notify her immediately. The facility’s written Abuse Prevention Program policy requires that any alleged or suspected incident of resident abuse be promptly reported to the Administrator, which did not occur in this case.
Failure to Maintain a Safe, Clean, and Homelike Resident Bathroom Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment for one cognitively intact resident. During an observation of the resident’s bathroom, surveyors noted a hole in the lower left wall, a baseboard hanging off the same wall, a black substance between the floor and the lower left wall, and an area of wall covered with white plaster that was not painted to match the rest of the bathroom. The resident, who was alert, oriented, and had an intact BIMS score, stated that their room was not clean. When the Maintenance Director was brought to the bathroom, he confirmed the presence of the hole, the loose baseboard, the black substance, and the unpainted plastered wall, and acknowledged that this did not represent a homelike environment. Facility documents, including the Resident Rights policy, stated that the environment must be safe, clean, comfortable, and home-like. The job descriptions for the Maintenance Staff and Maintenance Director specified responsibilities for maintaining the building and residents’ rooms in a safe, comfortable, and attractive manner, underscoring that maintenance staff were responsible for repairs such as fixing holes in walls and ensuring baseboards were properly attached.
Failure to Inventory and Return a Resident’s Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy for inventorying and tracking a resident’s personal belongings. The facility’s policy titled “Resident Personal Clothes and Belongings Handling” states that upon admission and annually, personal belongings such as clothing and items like TV, recliner, and bookcase are to be listed, with the CNA submitting the list to the charge nurse so it becomes part of the resident’s chart. During interviews, the DON stated there was no inventory list for resident R4’s belongings, and the Administrator confirmed that inventory sheets are supposed to be completed, uploaded to the system, and used to track what residents bring into the facility. However, the Administrator acknowledged that there was no inventory sheet for R4. A CNA explained that for new admissions, a staff member, usually a CNA, is supposed to record the resident’s belongings on a form, have the resident sign it, and then give it to the nurse, but also stated that new items brought in after admission are not logged. The CNA further described that upon discharge, belongings should be bagged by the CNA and taken to a storage area by housekeeping. The Administrator stated that belongings are packed up when residents leave, stored, and either returned when they come back or held for 30 days while the facility contacts family if the resident does not return. During the survey, the Administrator located a bag of R4’s personal belongings, including a Bible, on the third floor with no name on it, still in the facility and not returned to R4, demonstrating that the facility did not implement its inventory and tracking procedures for this resident’s personal property.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to assert residents’ rights and prevent resident-to-resident abuse when one resident physically struck another. Resident 1 had multiple psychiatric and substance use diagnoses, including schizoaffective disorder, bipolar disorder (current manic episode), schizophrenia, anxiety disorder, depression, and psychoactive substance abuse, and had been assessed as at moderate risk for aggression with a documented need for re-evaluation of services due to recent behavior. Resident 1’s care plan noted persistent anger toward self and others related to feelings of abandonment and psychotic symptoms. On the day of the incident, progress notes documented that Resident 1 became physically aggressive toward a peer without provocation, exhibited increased agitation, and was unable to be redirected. The Administrator (who also served as abuse coordinator) reported that during a morning meeting staff heard a noise, came out, and observed Resident 1 in a behavioral episode; the Administrator personally witnessed Resident 1 slap Resident 2 across the back of the head. The Nursing Supervisor stated he was aware that Resident 1 hit Resident 2 and that he had previously observed Resident 1 upset and aggressive on other occasions. Resident 2’s progress notes documented that Resident 2 received physical contact from a peer, that the residents were immediately separated, and that a head-to-toe assessment revealed no visible bruises or injuries, with Resident 2 denying pain or discomfort and vital signs stable. Resident 2’s care plan stated that the resident would remain safe, be treated with respect and dignity, and reside free from mistreatment, including abuse and neglect, and that a safe environment and emotional support would be provided, especially during investigations. During interview, Resident 2 did not recall the incident but confirmed that Resident 1 had been a girlfriend and was no longer in the facility. The Administrator stated she believed Resident 1 did not hit Resident 2 willfully and was just having an episode, despite the facility’s abuse policy defining abuse as the willful infliction of injury and clarifying that “willful” means the individual acted deliberately, not that they intended to inflict harm. The facility’s own Facility Reported Incident documented that Resident 1 made physical contact with Resident 2, and the abuse prevention policy identified physical abuse as including hitting and slapping, underscoring that the resident-to-resident physical contact met the facility’s definition of abuse that should have been prevented.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect residents from abuse, resulting in a physical altercation between two residents. One resident, who had a history of TIA, cerebral infarction, osteoarthritis, COPD, heart disease, schizophrenia, and bipolar disorder, and was moderately cognitively impaired, was physically assaulted by another resident who was cognitively intact and had multiple chronic conditions. The incident occurred when the assaulted resident was walking toward the nursing station and became involved in a verbal altercation with the other resident. Despite attempts by a CNA to separate them, the aggressor pushed the other resident, causing a fall and a laceration to the head that required stitches and hospital evaluation. Staff interviews and documentation confirmed that the residents were engaged in a verbal dispute, and staff intervention was insufficient to prevent the physical assault. The facility's abuse prevention policy requires residents to be free from abuse, neglect, and mistreatment, but this policy was not effectively implemented in this instance. The incident was captured on camera, and statements from staff and residents corroborated that the physical contact led to injury. The event was reported to the police, and the injured resident received medical attention for the head wound.
Failure to Immediately Report Alleged Abuse to Administrator
Penalty
Summary
Facility staff failed to immediately report an allegation of abuse involving a resident to the administrator as required by facility policy. On the date of the incident, two residents were involved in an altercation, and a CNA intervened. Subsequently, one resident alleged that the CNA hit him in the face. The CNA denied the allegation and stated that the incident was reported to the nurse. However, interviews and record reviews revealed that the administrator was not informed of the allegation until two days later, despite the facility's policy requiring immediate reporting of any suspected abuse to the administrator or, in their absence, the DON. Multiple staff members, including the charge nurse, social service director, and nurse supervisor, confirmed that they either did not report the incident immediately or were unaware of the physical abuse allegation until after the fact. The initial incident report documented that the CNA made contact with the resident, but an addendum later concluded the allegation was unsubstantiated. Both initial reports were faxed to the state health department two days after the incident. The facility's abuse prevention policy clearly outlines the requirement for immediate reporting of any abuse allegations, which was not followed in this case.
Failure to Maintain Clean and Odor-Free Resident Room
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in the shared room of three residents, all of whom had significant medical conditions including urostomy, overactive bladder, and mobility issues. On multiple occasions, a strong odor of urine was noted both inside and outside the residents' room. Direct observation revealed one resident with urine leaking from a urostomy site and a puddle of yellow fluid on the floor next to the bed. Despite staff acknowledging the presence of urine and the odor, the issue persisted over several days, with repeated observations of urine on the floor and ongoing odor. Interviews with staff confirmed that both nursing and housekeeping were aware of the urine spills and the associated odor, but the spills were not consistently or promptly addressed. The Housekeeping Director stated that cleaning urine spills is a shared responsibility between housekeeping and nursing staff, depending on availability. The Director of Nursing and Administrator acknowledged the ongoing problem, noting the resident's behaviors and the difficulty in maintaining cleanliness. Facility policies and job descriptions require maintaining a clean and safe environment, but these standards were not met in this instance.
Failure to Provide Urostomy Supplies Resulting in Urine Leakage
Penalty
Summary
The facility failed to ensure the availability of appropriate urostomy supplies for a resident with a history of bladder cancer, dementia, and other urinary tract conditions. The resident, who was cognitively impaired and required assistance with activities of daily living, was observed multiple times with urine leaking from the urostomy site and a strong odor of urine present in and around the room. On several occasions, the resident was found without a functioning urostomy bag, resulting in urine saturation of the lower abdomen and the bedroom floor. Staff confirmed that the resident was completely out of urostomy bags and that attempts to use a colostomy bag as a substitute were unsuccessful, as it was not compatible with the resident's needs. Interviews with nursing and supply staff revealed a breakdown in communication and supply management. The nurse supervisor acknowledged that the resident had requested a new bag, but the correct supplies were not ordered in a timely manner. Central supply staff indicated they were not informed of the shortage until after supplies had run out, and there was difficulty obtaining the correct size. Facility documentation and policies required maintaining adequate stock of medical supplies and providing regular urostomy care, but these were not followed, resulting in the resident's needs not being met.
Failure to Provide Physician-Ordered Diabetic Diet During Special Occasion Meal
Penalty
Summary
A resident with multiple diagnoses, including diabetes mellitus, was not provided with the physician-ordered diabetic diet during a special occasion meal. The resident, who is cognitively intact, reported not receiving a diabetic diet. Observation of the resident's lunch tray revealed items inconsistent with a controlled carbohydrate or no concentrated sweets diet, such as a large sugar cookie with frosting and a slice of lemon meringue pie. The resident's diet order specified a low concentrated sweets diet, and the care plan indicated the need to prepare and serve the prescribed diet due to the risk of hyper/hypoglycemia. Interviews with facility staff, including the Dietary Director, Administrator, DON, and Dietitian, confirmed that the physician's order for the therapeutic diet was not followed during the special occasion meal. The Dietary Director stated that all residents received the same meal on special occasions, regardless of dietary restrictions, and could not confirm if there was a physician's order to alter therapeutic diets for such events. Facility policies and job descriptions reviewed indicated that residents without physician approval should follow their normal diet restrictions, and staff are responsible for serving food according to dietary orders.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation protocols, as observed during a kitchen tour. In the walk-in refrigerator, there were open and uncovered food items, such as chopped lettuce and turkey slices, without any labels or expiration dates. This lack of labeling and covering of food items poses a risk of foodborne illness to residents. The Dietary Cook acknowledged that food should be covered, dated, and labeled with an expiration date once opened, and prepared food must be stored at the appropriate temperature to prevent cross-contamination. Additionally, the facility's food preparation area was found to be unsanitary. There were uncovered garbage cans filled with trash, a mop bucket with dirty water left in the dishwashing area, and garbage bags tied to food preparation tables. Personal items, such as a cell phone, were also found on a food preparation table. The Dietary Manager confirmed that these practices could lead to cross-contamination and foodborne illness. The facility's policy documents emphasize the importance of using food before expiration dates, proper labeling, and maintaining cleanliness in food preparation areas.
Improper Garbage Disposal and Unsanitary Dumpster Area
Penalty
Summary
The facility failed to properly dispose of kitchen garbage in contained dumpsters and maintain the dumpster area in a sanitary condition. During an observation, the dumpsters were found uncovered, surrounded by food garbage packages, papers, Styrofoam plates, food bones, cigarette butts, and emitting foul odors. Squirrels were observed eating the debris around the dumpsters. The Dietary Manager was unaware of why the dumpsters lacked lids and stated that dietary and housekeeping staff are responsible for closing the lids and cleaning the area. A housekeeping staff member confirmed that the garbage and dumpster area are a shared responsibility between housekeeping and kitchen staff, but noted there is no cleaning schedule or logbook. The open lids attract squirrels, raccoons, and rodents, which tear open garbage bags, creating a mess around the dumpsters. The facility's policy requires keeping the dumpster and surrounding area clean and free of debris, and contacting the garbage service for removal when dumpsters are full.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to provide an effective pest control program, as evidenced by multiple resident reports and observations of pest infestations. On January 28, 2025, several residents reported seeing cockroaches and mice in their rooms and common areas. One resident mentioned asking family members to bring bug spray to manage the infestation in their room, where sticky traps with bugs and droppings were observed. Another resident reported a mouse sighting in their bedroom and occasional sightings of roaches, despite the facility's efforts to spray for pests. Additional residents confirmed the presence of mice and roaches in various locations, including hallways and dining areas, with sticky traps capturing multiple bugs. The facility's Pest Control Sighting Logs documented numerous instances of roach and mouse sightings across different floors, with specific reports dating back to December 2024. Housekeeping staff confirmed resident complaints about pests and personal observations of roaches and a trapped mouse on the third floor. The Assistant Director of Nursing acknowledged the ongoing pest problem, despite weekly visits from a pest control company. The facility's undated Pest Control Policy mandates keeping the facility free of insects and rodents, yet the persistent pest issues indicate a failure to adhere to this policy effectively.
Infection Control Deficiencies in Equipment Disinfection and EBP Implementation
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for a resident with a surgical wound and a peripherally inserted central catheter (PICC) line. The resident, who was admitted with a right foot wound infection and receiving intravenous antibiotics, was not placed on Enhanced Barrier Precautions (EBP) as required. There was no EBP signage or isolation cart set up outside the resident's room, which is necessary to inform staff and visitors of the need for protective personal equipment. The infection preventionist acknowledged the oversight and confirmed that residents with open wounds or indwelling medical devices should be on EBP. Additionally, the facility did not ensure the disinfection of blood pressure equipment between use for three residents. A Licensed Practical Nurse (LPN) was observed using a wrist blood pressure monitor on multiple residents without disinfecting it between uses, despite the presence of EBP signage indicating the need for such precautions. The LPN admitted that the equipment should be sanitized between residents to prevent the transfer of infectious diseases, and the Assistant Director of Nursing confirmed the requirement for cleaning the equipment between uses. The facility's policies on cleaning durable medical equipment and blood pressure measurement procedures were not followed, contributing to the deficiencies observed. The lack of adherence to these policies and procedures resulted in potential exposure to infectious microorganisms for residents, staff, and visitors, as the necessary precautions and disinfection protocols were not consistently implemented.
Deficiency in Timely Vaccination and Consent Procedures
Penalty
Summary
The facility failed to provide timely pneumonia vaccinations to five residents, as evidenced by the consents obtained on 12/16/24, but the vaccines were not administered. The Infection Preventionist (V16) acknowledged that the pneumonia clinic planned for December did not occur due to the Director of Nursing (V27) taking an early leave. Additionally, the facility had not completed obtaining consents from all eligible residents, particularly those on the second floor. One resident, R486, was discharged before receiving the vaccine, despite having consented to it. Furthermore, the facility did not offer the influenza vaccine to one resident, R24, and failed to obtain written consent before administering the influenza vaccine to another resident, R486. The facility's records showed that R24 refused the vaccine in March 2024, but there was no recent consent for the current flu season. R486 received the flu vaccine on 9/11/24, but the consent form lacked the resident's signature. The facility's guidelines require that consent and education about the risks and benefits of the vaccines be documented, which was not adhered to in these cases.
Failure to Accommodate Resident Preferences in Daily Care
Penalty
Summary
The facility failed to accommodate the preferences of two residents, R65 and R194, regarding their daily care routines. R65, who has medical diagnoses including end-stage renal disease, weakness, and obesity, expressed a desire to be out of bed every day. Despite being alert and oriented, R65 reported that staff only assisted with getting out of bed during shower times and did not offer daily assistance as preferred. On multiple occasions, R65 requested to be helped out of bed, but staff delayed or ignored these requests, leaving R65 in bed for extended periods. R194, diagnosed with chronic systolic heart failure, dementia, and other conditions, expressed a preference for a shower due to feeling itchy. Despite this request, staff did not provide a shower, citing that R194 was not scheduled for one until later in the week. Instead, R194 received a bed bath, which did not meet the resident's expressed needs and preferences. R194's care plan indicated a need for extensive assistance with bathing, yet the staff did not accommodate the resident's request for a shower. The facility's policies on Activities of Daily Living and Resident Rights emphasize the importance of accommodating resident preferences and providing care that enhances quality of life. However, the actions and inactions of the staff in these instances did not align with these policies, resulting in a failure to meet the residents' needs and preferences as documented in their care plans.
Deficiencies in Blood Pressure Monitoring and Permacath Care
Penalty
Summary
The facility failed to notify the physician when a resident's blood pressure was not within the ordered parameters. A Licensed Practical Nurse (LPN) recorded a blood pressure reading of 99/56 for a resident diagnosed with End Stage Renal Disease and Hypertension, but did not notify the physician as required by the resident's care plan. The care plan specified that the physician should be notified if the systolic blood pressure was less than 100 or the diastolic was less than 60, which was not adhered to in this instance. Another deficiency was observed when an LPN took a resident's blood pressure while the resident was standing, contrary to the facility's policy that requires blood pressure to be measured with the resident sitting and the arm at heart level. This resident had a history of elevated D-dimer and was at risk for cardiac distress, making accurate blood pressure readings crucial. The Assistant Director of Nursing confirmed that the proper procedure was not followed, which could affect the accuracy of the blood pressure reading. Additionally, the facility failed to maintain a dressing on a resident's permacath, which was left open to air without a dressing for an extended period. The resident, who was on hospice and had refused dialysis, reported that the dressing had been removed due to it being filthy, and staff did not replace it. The facility's policy required that central venous catheter dressings be changed at specific intervals to prevent infection, but this was not done. The Assistant Director of Nursing acknowledged that there was no ongoing plan for the permacath's removal, despite it being a potential entry point for infection.
Incorrect Mattress Setting for Resident with Skin Integrity Risk
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set correctly for a resident with a history of skin integrity issues. The resident, who has multiple diagnoses including Type 2 Diabetes Mellitus, Peripheral Vascular Disease, and impaired mobility, was observed lying on a low air loss mattress set at 350 pounds, despite weighing only 79.6 pounds. This discrepancy in the mattress setting was identified during an observation by a surveyor and confirmed by a registered nurse and the Assistant Director of Nursing. The incorrect setting could potentially lead to skin breakdown, as the mattress was too firm for the resident's weight. The resident had a history of pressure ulcers, which had healed, but remained at high risk for skin integrity issues due to factors such as incontinence, impaired mobility, and comorbidities. The facility's policy requires that low air loss mattresses be set according to the manufacturer's recommendations, primarily based on the resident's weight. Despite this policy, the mattress setting was not adjusted to match the resident's current weight, posing a risk for the recurrence of pressure ulcers.
Failure to Apply Splint as Ordered for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure that anti-contracture devices were applied as ordered and did not update the care plan to reflect the correct area of splint application for a resident with limited range of motion. The resident, who has a history of multiple medical conditions including psychosis, epilepsy, hemiplegia, and cerebral infarction, was observed without the necessary splint on their right hand, which was contracted. The resident reported that the splint had been missing for about four months, indicating a significant lapse in care. The care plan for the resident indicated the need for a splint on the left wrist due to monoarthritis, but the order summary specified that the splint should be applied to the right hand. This discrepancy in documentation contributed to the failure to apply the splint correctly. The Assistant Director of Nursing confirmed that the splint was supposed to be on the right hand and acknowledged the potential for increased contracture and weakness if the splint was not worn as ordered. The Restorative Nurse Consultant recognized the error in the care plan and intended to correct it. The facility's policy requires a comprehensive assessment and care plan updates to address residents' range of motion needs, but these procedures were not followed adequately in this case. The lack of a restorative nurse at the time may have contributed to the oversight, as the facility was actively seeking to fill this position.
Expired Dialysis Supplements Administered to Residents
Penalty
Summary
The facility failed to ensure that expired dialysis nutritional supplements were not stored and administered to residents, specifically affecting two residents who were part of a sample reviewed for nutrition. During an inspection of the second-floor medication room, an opened box containing twenty 8-ounce cartons of Nova Source Renal 19% with an expired use-by date was found. A registered nurse confirmed that this was the only box available for the dialysis residents on the floor, which included three or four individuals. Two residents, identified as receiving the expired supplements, were R177 and R183. R177, who has multiple health conditions including end-stage renal disease and dependence on renal dialysis, confirmed consuming the expired supplement. Similarly, R183, who also has end-stage renal disease and other health issues, was documented to have received the expired supplement. The facility's policy requires that medications and biologicals be stored safely and properly, following manufacturer recommendations. However, the expired supplements were not discarded or returned to central supply as they should have been. The Assistant Director of Nursing acknowledged the oversight and mentioned that staff education was being conducted to ensure expiration dates are checked before administration. The failure to adhere to these protocols resulted in the administration of expired nutritional supplements to residents, which could potentially lead to adverse effects.
Failure to Reassess PRN Antipsychotic Medication
Penalty
Summary
The facility failed to evaluate the appropriateness of antipsychotic medication for a resident and did not ensure that PRN orders for antipsychotic medications were limited to 14 days. The resident, who was admitted with diagnoses including Schizoaffective Disorder Bipolar type, Generalized Anxiety Disorder, and Major Depressive Disorder, had moderately impaired cognition. The resident's physician orders included Haloperidol to be administered as needed for agitation, but there was no documentation of negative behaviors from the resident during the month of January. Despite this, the PRN order for Haloperidol was not reassessed or discontinued after 14 days, as required. Interviews with facility staff revealed that non-pharmacological interventions should be attempted before resorting to psychotropic medications, and any PRN psychotropic medication should be discontinued after 14 days if not used. The facility's policy required that the rationale for extending a PRN order beyond 14 days be documented, but this was not done in the resident's case. The lack of documentation and reassessment of the PRN order for antipsychotic medication led to the deficiency identified by the surveyors.
Failure to Provide Wheelchair Footrest Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a footrest was placed on the wheelchair of a resident with left-sided weakness, resulting in the resident's left foot dragging on the floor and causing a fall. The resident, who is cognitively intact with a BIMS score of 13, has a medical history including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. During an observation, the resident was being pushed by a CNA when the left foot was noted on the floor, leading to the resident falling forward out of the wheelchair. At the time of the incident, no footrests were visible on the wheelchair. Interviews with staff revealed that the resident had just returned from the hospital and had not been assessed for a footrest. The LPN acknowledged the purpose of the leg rest was to support the resident's leg and prevent falls. The DON stated that residents with left-sided weakness should have a leg rest to prevent dragging. The resident's care plan indicated a risk for falls due to muscle wasting and atrophy in the lower extremities, and the MDS documented the need for substantial assistance with wheelchair use. The facility's policy on wheelchair usage assigns therapy the responsibility to ensure appropriate fit and appliance application.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain a pest and rodent-free environment, as evidenced by multiple reports and observations of mice and roaches in resident rooms and common areas. Residents reported sightings of mice and roaches, with one resident describing mice as being the size of hamsters and appearing at night. Another resident reported seeing mice in his room and informed the nursing staff. The Housekeeping Director acknowledged receiving complaints about mice and roaches over the past three to four months, and the Maintenance Director confirmed sightings of roaches in common areas. Despite weekly visits from an exterminator and the use of glue traps and bait, residents continued to report pest issues, indicating that the measures taken were insufficient to resolve the problem. The pest control reports documented ongoing treatments and recommendations for improving sanitation and addressing structural issues that could contribute to pest infestations. However, the persistence of pest sightings and resident complaints suggests that these efforts were not effectively implemented or monitored. The facility's policy to keep the environment free of insects and rodents was not adequately enforced, as evidenced by the continued presence of pests and the lack of effective communication and follow-up on resident complaints. The deficiency potentially affected all 229 residents in the facility, as the pest issues were reported in multiple rooms and common areas.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as R2, who was dependent on staff for activities of daily living (ADL). On December 22, 2024, R2 was observed in the dining room with long fingernails that had a thick build-up of black debris. Despite being awake and alert, R2 did not comment on the state of his nails. A Licensed Practical Nurse (LPN), identified as V9, confirmed that R2's nails were long and dirty, acknowledging that they needed to be trimmed and cleaned. The LPN noted that since R2 was not diabetic, a Certified Nursing Assistant (CNA) could perform the nail care. The CNA assigned to R2, identified as V10, admitted to not checking R2's nails during her shift, which began at 7:00 AM. The Assistant Director of Nursing (ADON), identified as V11, stated that residents' nails should be clipped weekly and cleaned during ADL care, with staff expected to check residents' hands before meals and during care. R2's medical record indicated a moderate cognitive impairment and a need for assistance with ADL care. The facility's policy on routine care emphasized the importance of personal care, including nail care, to promote hygiene and comfort, which was not adhered to in this instance for R2.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to maintain hot foods at the required temperatures during meal service, affecting a resident and potentially impacting 60 others on the same floor. On the specified date, a resident reported receiving cold food in their room, which was confirmed by the surveyor's observations. The resident, who is cognitively intact and on a renal with dialysis diet, expressed that CNAs had to reheat the food, which should not have been necessary. During the survey, it was observed that the steam table used for meal tray assembly was not plugged in, leading to inadequate food temperatures. The dietary aide did not ensure the steam table was connected to maintain the required heat. Temperature checks revealed that some food items, such as sliced turkey and pureed broccoli, were below the acceptable serving temperature of 125 degrees Fahrenheit. The dietary director acknowledged that hot foods should be held at a minimum of 135 degrees Fahrenheit and served at a palatable temperature, but this was not achieved. The facility's policy mandates that hot foods be held at a minimum of 135 degrees Fahrenheit during tray assembly and served at temperatures not less than 125 degrees Fahrenheit. However, the failure to plug in the steam table and maintain proper food temperatures during service led to a deficiency in food service standards. The dietary director admitted that the steam table should have been plugged in to retain heat, and the oversight could potentially lead to foodborne illness if not addressed.
Failure in Timely Incontinence Care for a Resident
Penalty
Summary
The facility failed to perform timely incontinence checks and care for a resident (R2) who was unable to manage their own toileting hygiene due to multiple health conditions, including dementia and pressure ulcers. R2's care plan indicated a need for extensive assistance with activities of daily living, including toileting, as R2 was totally dependent on staff and non-ambulatory. On the day of observation, R2 was found in bed with a soiled incontinence brief, indicating that the brief had not been checked or changed every two hours as required by the facility's policy. R2 confirmed that the incontinence brief was not checked every two hours by staff. The observation revealed that the CNA responsible for R2 had last changed the incontinence brief at 7:00 am, and it was not until 11:57 am that the CNA returned to check and change the brief, which was found to be soaked with urine and soiled with a bowel movement. The CNA required assistance from another staff member to turn R2 for cleaning, and during the process, R2's bandage came off, necessitating intervention from the wound care nurse. The Director of Nursing confirmed that CNAs are expected to perform incontinence checks every two hours, which was not adhered to in this instance, leading to the deficiency in care for R2.
Improper Wound Care and Repositioning for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide aseptic wound care treatments for a resident with pressure ulcers, failed to ensure timely repositioning, and did not set the low air loss mattress to the appropriate weight setting. The resident, who has multiple medical conditions including dementia and pressure ulcers, was observed with a low air loss mattress set for a weight over 400 pounds, despite the resident's actual weight being significantly lower. The resident reported having sores and discomfort, and it was noted that the resident was not being repositioned with pillows or wedges as required. During an observation, a Certified Nursing Assistant (CNA) was seen providing incontinence care to the resident, but the resident was not properly turned or repositioned, and the CNA had to seek additional help. The wound care nurse, identified as V5, was observed performing wound care without proper hand hygiene between glove changes, and using a bedside table for treatment supplies without sanitizing it. The nurse also failed to perform hand hygiene between treating different wounds, which could lead to cross-contamination. The Director of Nursing (DON) confirmed that residents with pressure ulcers should be repositioned every hour and that a low air loss mattress should be set according to the resident's weight. The DON also stated that hand hygiene is necessary between glove changes during wound care. The facility's policies on pressure ulcer prevention and infection control were not followed, as evidenced by the improper wound care and lack of repositioning for the resident.
Failure to Provide Prescribed Pureed Diet
Penalty
Summary
The facility failed to provide the diet prescribed by the physician to residents, specifically affecting two residents who were supposed to be on a pureed diet. During a meal observation, it was noted that one resident was served a whole banana instead of a pureed banana, which was not in accordance with their prescribed pureed diet. This resident, along with others on the same diet, did not receive the pureed banana as indicated in the facility's Menu Spreadsheet. The dietary aide confirmed the number of residents on a pureed diet, and the LPN acknowledged the error and removed the banana from the resident's tray, later replacing it with yogurt. The facility's policies require that diets ordered by the physician be followed, and pureed foods be served as ordered to reduce the risk of aspiration. The Dietary Manager confirmed that a whole banana should not have been served to a resident on a pureed diet and acknowledged the need for CNAs to be in-serviced to check tray contents. The deficiency was observed to potentially affect additional residents who also had orders for a pureed diet, as per the facility's undated list of residents on such diets.
Failure to Prevent Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in an incident where a resident sustained a physical injury. The incident involved a female resident with a history of mental illness, including bipolar disorder and schizoaffective disorder, who was physically assaulted by a male resident with schizophrenia and other mental health issues. Both residents were alert and oriented, with a BIMS score of 15/15. The altercation occurred on the smoking patio, where the male resident struck the female resident in the face, causing a laceration that required three sutures. The male resident had a documented history of inappropriate behaviors and was on a 'Red pass' due to previous offenses. Despite this, the psychiatric technician supervising the area did not effectively intervene to prevent the escalation of the argument between the two residents. The technician initially attempted to stop the argument but walked away, allowing the situation to escalate to physical violence. The male resident's actions resulted in the female resident being transferred to the hospital for treatment of her injuries. The facility's final incident report and progress notes indicate that staff intervened after the altercation began, separating the residents and providing immediate medical attention. The female resident was assessed and treated for her injuries, which included a laceration on her cheek and superficial scratches on her neck. The facility's policy on abuse prevention, revised in 2019, emphasizes the prohibition and prevention of resident abuse, yet this incident highlights a failure in effectively implementing these measures to protect residents from harm.
Lack of Supervision on Patio Leads to Safety Risks
Penalty
Summary
The facility failed to adequately monitor residents on the outside patio, which posed a risk for falls and other unsafe conditions. During an observation, a surveyor noted that several residents, including those using wheelchairs and at risk for falls, were on the patio without staff supervision. This lack of supervision was confirmed by a psychiatric technician who was unsure of who was supposed to be monitoring the residents. The facility's policy requires that residents be supervised while smoking, with staff maintaining a close distance to ensure safety. The deficiency was highlighted by a previous incident where a resident, identified as R8, fell from his wheelchair on the patio, resulting in a laceration that required hospital treatment. R8, along with other residents such as R16, R17, and R18, were identified as being at high risk for falls due to their medical conditions, which include severe cognitive impairment and other diagnoses. Despite the facility's policy and the residents' care plans indicating the need for supervision, the lack of staff presence on the patio during the surveyor's visit and the previous fall incident demonstrate a failure to adhere to these guidelines.
Failure to Follow Hepatitis C Treatment Orders
Penalty
Summary
The facility failed to follow provider orders for Hepatitis C treatment for three residents, leading to significant health consequences. Resident R2 was diagnosed with Hepatitis C, but the facility did not carry out the necessary laboratory tests or arrange for an infectious disease consultation as ordered by the physicians. This oversight resulted in R2 developing hepatocellular carcinoma, which progressed to carcinomatosis, ultimately leading to the election of hospice care due to the advanced state of the disease. The facility's records did not document any attempts to follow through with the orders for Hepatitis C treatment, despite multiple orders from the physicians and nurse practitioner. Resident R3, who had a diagnosis of chronic viral Hepatitis C, also did not receive the necessary laboratory testing for Hepatitis C genotype and viral load as ordered by the physician. Despite being aware of the diagnosis and expressing a desire for treatment, R3 did not receive the appropriate care, and the facility had no documentation of the required tests being completed. The physician confirmed that orders were given but not carried out, which could lead to severe health complications if left untreated. Similarly, Resident R4, with a diagnosis of chronic viral Hepatitis C, did not receive the ordered laboratory work for Hepatitis C genotype and viral load. The resident was unaware of the diagnosis and treatment, and the facility failed to document any follow-up on the physician's orders. The Director of Nursing confirmed the lack of documentation and affirmed that the facility's expectation is to follow and carry out provider orders, which was not met in these cases.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to supervise and monitor a resident, resulting in the resident eloping from the facility by climbing over the fence surrounding the smoking patio. The resident, who had a history of substance abuse and was admitted for wound care, was not eligible for an independent community pass due to the short duration of their stay. Despite this, the resident managed to leave the facility without staff noticing, indicating a lapse in supervision and monitoring protocols. On the day of the incident, the smoking monitor/psych tech locked the game room door leading to the smoking patio during meal times, as per protocol. However, the surveyor observed that the game room door and the door to the smoking patio were left wide open and unsupervised multiple times during the inspection. Additionally, the alarm system on the patio door did not sound when the door was opened, further compromising the security measures in place. Interviews with staff revealed that the facility did not report the elopement to the state agency, as they believed it was only necessary to report elopements involving residents with altered mental status. The interim director of nursing and other staff members confirmed that the resident was cognitively intact and capable of signing an AMA form. However, the lack of adequate supervision and failure to secure the smoking patio area allowed the resident to elope, highlighting deficiencies in the facility's monitoring and reporting procedures.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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