Little Village Nrsg & Rhb Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 2320 South Lawndale, Chicago, Illinois 60623
- CMS Provider Number
- 146018
- Inspections on file
- 38
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Little Village Nrsg & Rhb Ctr during CMS and state inspections, most recent first.
A resident with intact cognition and multiple psychiatric and medical diagnoses became agitated and attempted to leave the unit, prompting involvement from an LPN, other staff, and law enforcement. During this episode, two residents reported hearing the resident and an LPN exchange profane, derogatory language, with the LPN responding to the resident’s insults with similar disparaging remarks, which the facility’s own policy defines as verbal abuse. The resident also reported that, during a physical tussle, the LPN pulled out several braided strands of hair from the crown of her head, later showing a bald area and a bag containing six braids with hair attached to staff and surveyors. While the LPN denied pulling the resident’s hair, another resident heard the resident demand that the nurse let go of her hair, and the physician and administrator acknowledged that such conduct, if it occurred, constitutes physical abuse, demonstrating a failure to ensure the resident was free from abuse.
A resident with moderate cognitive deficits, prior femur fracture, and documented need for maximum to dependent assistance with transfers was care-planned to require a mechanical lift. During a shower, a CNA independently transferred the resident between a wheelchair and shower chair without a gait belt, assistive device, additional staff, or a lift, and placed a towel or blanket on the wet shower floor for the resident to stand on. When the resident stood holding the rail, her foot slipped and she tripped on the shower chair footrest, was lowered to the floor, and later was found by an LPN with right leg pain and abnormal leg positioning. Hospital imaging showed an angulated, foreshortened distal right femoral shaft fracture. Interviews and records confirmed that the transfer was not performed according to the resident’s assessed transfer status, the care plan, or facility safe lifting policies.
A resident with serious mental illness and a documented risk for abuse confronted another resident with a history of physical and verbal aggression after being told that this resident had pulled back a third resident’s bed covers while that resident was in bed. The confronting resident went to the other resident’s room, refused to leave when asked, and a verbal altercation ensued, during which the resident with an aggression history struck the other in the face, causing brief facial redness. Multiple staff, including an RN, LPN, social services staff, the DON, and the administrator, as well as the residents involved, confirmed that the incident was a physical and verbal altercation arising from this confrontation, demonstrating that the facility did not prevent resident-to-resident physical abuse despite known behavioral risk factors.
Two residents with histories of behavioral and psychiatric issues were involved in a physical altercation after one took the other's belongings and engaged in inappropriate behaviors, such as blowing kisses and placing a profile picture on the roommate's television. Despite documented risks and prior behavioral incidents, the facility did not prevent the altercation, resulting in one resident being punched and sent for medical evaluation.
A resident's allegation of being bullied by a roommate was communicated to an LPN by a hospital social worker and subsequently reported to the facility administrator. Although an internal investigation was conducted and the residents were separated, the administrator did not report the mental abuse allegation to the state survey agency as required by facility policy.
A resident reported ongoing verbal and mental abuse by two peers, including being called derogatory names. Despite being notified by a hospital social worker and an LPN, the administrator only interviewed the resident's roommate—who was not named as a perpetrator—and did not interview the resident or the accused individuals. No comprehensive investigation or documentation was completed, contrary to facility policy.
A facility failed to protect residents from abuse, resulting in injuries after altercations. Staff did not separate or supervise residents, leading to physical violence. Residents with complex medical conditions were involved, and the facility's abuse policy was not followed.
Two residents in a facility were involved in a physical altercation due to inadequate supervision and failure to implement preventive measures. Despite being informed of the potential for abuse, an LPN did not separate the residents or provide necessary supervision, resulting in one resident being injured. The facility's policy on abuse was not followed, and the staff involved were unreachable for further clarification.
A resident with a history of substance abuse was transferred to a hospital after returning to the facility intoxicated. The facility's administrator incorrectly documented the reason for the involuntary discharge, marking that the safety of individuals was endangered instead of stating that the facility could not meet the resident's needs. Staff interviews confirmed the resident had not exhibited violent behavior, and the administrator admitted to being unfamiliar with the discharge process.
A resident was discharged from a facility without receiving the required 30-day notice for involuntary discharge. The resident, with a history of depression and intoxication, was taken to the hospital after aggressive behavior. The facility issued an immediate discharge due to non-compliance with an alcohol program, but failed to inform the resident of her right to appeal the decision.
A facility failed to follow its bed hold policy, leading to a resident's discharge to the community instead of readmission. The resident, with a history of depression and anxiety, was transferred to a hospital after an incident of aggression and intoxication. Despite plans to return, the facility issued an involuntary discharge without informing the resident of their right to appeal. The administrator admitted unfamiliarity with the discharge process, resulting in the resident's inability to return.
A resident was not allowed to return to the facility after hospitalization due to intoxication and aggressive behavior. The Administrator issued an involuntary discharge without informing the resident of their right to appeal, citing non-compliance with facility rules. The facility's policy on re-admission was not followed, and staff were not informed of the discharge decision.
The facility failed to provide consistent RN coverage for 8 consecutive hours daily, as required by policy, over a three-month period. Observations and records showed sporadic RN presence, with staffing not aligned with resident acuity or census. Interviews revealed that the DON and ADON only worked the floor when short-staffed, and the facility's assessment and staffing records confirmed the deficiency.
The facility failed to follow its infection prevention and control program by leaving soiled clothing bags on the floor, contrary to policy, affecting several residents. Additionally, the facility did not implement its Water Management Program, as the Maintenance Director was unaware of the requirements for water testing and risk assessment, posing a potential risk to all residents.
The facility failed to educate and document influenza and pneumococcal vaccinations for several residents, violating their immunization policy. Two residents were not educated on influenza vaccination, and four were not educated on pneumococcal immunization. Documentation was missing for residents who requested or declined vaccinations, and the Assistant Director of Nursing acknowledged the oversight.
The facility failed to properly manage and store medications, with loose pills found in Medication Cart B and insulin pens lacking open or discard dates. The medication refrigerator was not maintained, containing sticky streaks, ice build-up, and food items, despite policies requiring proper storage. Night shift nurses were responsible for cleaning and temperature checks, but logs showed missing entries.
The facility failed to provide timely and accurate medication administration for three residents, leading to deficiencies in pharmaceutical services. A resident with seizures had a discrepancy in Phenobarbital records, while another with mental health disorders did not receive Sertraline on time. A third resident with heart disease experienced delays in receiving Amlodipine and Metoprolol. Nurses failed to reorder medications timely and lacked access to the electronic dispensing system, contributing to the issues.
The facility failed to obtain informed consent before administering psychotropic medications to three residents. One resident with schizophrenia and COPD was given Aripiprazole, Depakote, and Trazodone without prior consent. Another resident with dementia and depressive episodes received Aripiprazole, Sertraline, and Trazodone without being informed of the side effects. A third resident, who refused Aripiprazole and Lexapro due to adverse effects, continued to receive them without consent. The facility's policies on informed consent and residents' rights to refuse treatment were not followed.
The facility failed to educate two residents on COVID-19 vaccination, as required by their policy, and did not document informed consent or vaccination status. The Assistant Director of Nursing acknowledged the lack of documentation, which is necessary for residents to make informed decisions about their vaccinations.
A resident with multiple medical conditions, including Parkinson's and dementia, was at risk due to detached vinyl flooring at the entrance to their restroom. The resident, who had recently started using a walker, frequently used this path, creating a slipping hazard. The issue was recognized by a CNA, but it was unclear if it was reported to maintenance. The facility's safety policy requires staff to report such hazards, but this was not effectively followed.
The facility failed to document advance directives for two residents, R90 and R250, as per policy. The absence of POLST forms means the residents would be considered full code in emergencies, potentially leading to unwanted resuscitation. This oversight could result in legal issues if residents' wishes are not respected.
A facility failed to include urinary catheter use in a resident's care plan and did not have catheter care orders documented. The resident had a urinary catheter due to medical conditions, but the care plan lacked focus on catheter use, goals, or interventions. Additionally, the facility did not maintain the resident's dignity by failing to provide a privacy bag for the catheter, leaving it in plain sight. The DON confirmed the expectation for staff to provide a privacy bag and ensure catheter care, which was not documented.
A resident with a history of seizures and other conditions was not provided with prescribed Magnesium Oxide upon admission to the facility. The medication was omitted from the treatment plan despite hospital discharge instructions. The facility's DON was initially unaware of the issue, which was later addressed by contacting the resident's physician.
A resident receiving oxygen therapy was found with the oxygen tank set incorrectly, unlabeled tubing, and tubing not stored properly, risking contamination. The LPN and DON acknowledged the lapses in following procedures for labeling and storing oxygen equipment.
A resident in an LTC facility reported being physically and verbally abused by a CNA during a nighttime incident. The resident, who is cognitively intact, stated that the CNA hit him on the cheek after a verbal altercation. Witnesses, including staff and another resident, corroborated the incident. Despite the resident not sustaining physical injuries, the facility failed to protect him from abuse, leading to a deficiency finding.
The facility failed to provide privacy curtains for four residents, compromising their privacy. A surveyor observed the absence of curtains on two occasions, and a CNA confirmed that curtains are usually provided. The Maintenance Director initially claimed all residents had curtains but later confirmed their absence, stating they would be installed when available. This failure contradicts the facility's policy on maintaining resident privacy.
The facility failed to maintain functional call lights for several residents, as observed by a surveyor. Despite the Maintenance Director's acknowledgment of the issue, there was no documentation in the maintenance logbook. Facility policy requires call lights to be within reach and defects reported promptly.
The facility failed to maintain the A-Wing community shower room in a sanitary condition, affecting 13 residents and others who use it. Observations revealed wet towels, blankets on the floor, and patches of a black substance on the ceiling. The ceiling air vent was broken and dusty, and an air vent behind the ice machine was also dusty. The Maintenance Director acknowledged these issues, indicating a need for cleaning. These conditions violate the facility's housekeeping and maintenance policies.
A resident with multiple health conditions was verbally abused by a former floor technician, who used derogatory language during an altercation over wet floors. The incident was reported by the resident and confirmed by a witness. The facility's investigation led to the termination of the staff member involved, and the incident was reported to the health department.
A resident involved in a verbal abuse incident did not have their care plan revised to reflect the risk for abuse, despite facility policy requiring updates as conditions change. The incident was documented by the DON, and the staff member involved was terminated. However, the care plan remained unchanged over a month later.
The facility failed to protect residents from physical abuse, resulting in multiple incidents where residents were hit or pushed by other residents, causing physical and psychosocial harm. The abuse investigations confirmed the occurrences, but the lack of proper documentation and immediate intervention highlights significant deficiencies in ensuring resident safety and well-being.
The facility failed to supervise residents on the smoking patio, leading to an altercation where one resident hit another with a chair, causing injury. The incident occurred during a smoke break, and the smoke monitor was not present. The facility's investigation confirmed the abuse, but there were discrepancies in the documentation of the injured resident's medical records.
Failure to Protect Resident From Verbal and Alleged Physical Abuse During Behavioral Episode
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from physical and verbal abuse by staff. The resident had multiple diagnoses including COPD, bipolar disorder, suicidal ideations, hypertensive heart disease without heart failure, hepatitis C, schizoaffective disorder, and alcohol abuse, and had a BIMS score of 15 indicating intact cognition. On a night shift, the resident exhibited escalating behaviors, including agitation, attempts to elope, and calling police about people on the roof with guns. Staff, including an LPN not assigned to the resident, became involved in managing these behaviors, and police and emergency services were called to the facility. During this episode, multiple witnesses described a verbal altercation between the resident and an LPN. Two other residents reported hearing the resident call the nurse a derogatory term and hearing the LPN respond with similarly derogatory language, including statements such as “Calm your a** down. Your momma’s a B*” and “Your momma B*.” The resident herself reported that she called the nurse a B* and that the nurse called her a B* back. The facility’s own investigation substantiated that the LPN used foul and inappropriate language toward the resident, and the DON and Administrator acknowledged that such language constitutes verbal abuse under the facility’s abuse policy, which prohibits disparaging and derogatory terms directed at residents. The resident also alleged that during the physical tussle associated with attempts to control her behavior and arrange transport to the hospital, the LPN pulled her braided hair, resulting in several braids being forcibly removed from the crown of her scalp. The resident showed surveyors a bald area on the crown of her head and a plastic bag containing six individual braided strands with hair attached, stating these were pulled out by the LPN during the incident. Another resident reported hearing the resident say, “Let my hair go, B*,” directed at the nurse, and hearing the nurse respond with a derogatory remark, though this witness did not visually confirm the hair pulling. The LPN denied pulling the resident’s hair but acknowledged that if staff pull a resident’s hair it is physical abuse, and the facility’s physician stated he agreed with termination when informed of the hair-pulling allegation and that such an act can cause pain and injury. The facility’s abuse policy affirms residents’ rights to be free from physical and verbal abuse, including physical acts such as hitting and controlling behavior, and verbal abuse defined as disparaging or derogatory language, and the events described demonstrate a failure to uphold these protections for this resident. The facility’s documentation and interviews show that the resident reported head pain and described a fight with the nurse before being sent to the hospital, specifically stating that the nurse pulled her hair out from the top of her head and that her head remained sore. The resident reported feeling disrespected, humiliated, and embarrassed by the incident. Staff interviews confirmed that the resident reported hair pulling and showed staff the bag of braids she said were pulled out. The Administrator, acting as abuse coordinator, acknowledged that if a resident’s hair is pulled by staff, it is considered physical abuse, and that the resident showed her the top of her head and a braid said to have been removed. Despite some conflicting accounts about the exact sequence of events and whether hair pulling was directly observed, the combination of the resident’s consistent statements, physical evidence presented (bald spot and braids), and corroborating witness accounts of the verbal exchange establish that the resident was not kept free from verbal and alleged physical abuse as required by the facility’s abuse policy and regulatory standards.
Failure to Follow Assessed Transfer Status and Use Required Lift During Shower Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed a resident’s assessed transfer status, which required the use of a mechanical lift for transfers. The resident had diagnoses including a prior right femur fracture and had a BIMS score of 5, indicating moderate cognitive deficits. The MDS documented that the resident required maximum to dependent assistance with ADLs, transfers, and bed mobility, and the care plan specified that the resident had limited ability to transfer and required a mechanical lift, being dependent on staff for transfers. On the day of the incident, a CNA assigned to the resident for the evening shift wheeled the resident into the shower room in a wheelchair and independently transferred the resident from the wheelchair to the shower chair without a gait belt, assistive device, or staff assistance. After the shower, the CNA placed a towel or bath blanket on the shower floor to keep a foot dressing dry, then asked the resident to stand and hold the rail so she could transfer the resident back to the wheelchair. When the resident stood, her foot slipped and she tripped on the shower chair footrest; the CNA reported catching the resident and then lowering her to the floor as the resident yelled about leg pain. The LPN responding to the incident found the resident on the shower floor, wet and in a gown, with the right leg appearing more contracted than usual and the resident complaining of right knee/leg pain on range of motion. The resident was sent to the local hospital, where imaging showed an angulated, foreshortened fracture of the distal right femoral shaft distal to existing right femoral hardware. The resident later recalled losing her balance and that the CNA could not catch her. The DON stated that the resident’s transfer status at the time required one-person assistance with a pivot transfer and that residents requiring one-person assistance should be transferred using a gait belt, while residents needing two-person assistance should be transferred using a gait belt and mechanical lift. The facility’s Safe Lifting and Movement of Residents policy required mechanical lifting devices for any resident needing two-person assistance and prohibited manual lifting except in emergencies, and the CNA job description required that all transfers and lifts be performed safely and according to facility policy. Staff interviews and record review showed that the resident’s assessed and care-planned need for mechanical lift assistance was not followed during the shower transfer, resulting in the fall and subsequent femur fracture.
Failure to Prevent Resident-to-Resident Physical Abuse Following Room Confrontation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical resident‑to‑resident abuse in accordance with its abuse prevention policy. On the date of the incident, one resident (R4) reported to another resident (R1) that a third resident (R2) had come into R4’s room and flipped or pulled back R4’s bed covers while R4 was lying in bed, which R4 did not like. R4 did not report this interaction to staff but instead told R1, described as a good friend. R4 later stated being surprised by R2 uncovering R4, and did not witness what occurred afterward between R1 and R2. After hearing R4’s account, R1 went to R2’s room to confront R2 about R4. Multiple staff and resident interviews consistently indicated that R1 went to or stood in the doorway of R2’s room, told R2 to leave R4 alone, and refused to leave when R2 asked R1 to go. R2, who has diagnoses including schizophrenia, bipolar disorder, major depressive disorder, and a history of physical and verbal aggression related to hallucinations and serious mental illness, became agitated and struck R1 in the face. R1, who has multiple medical and psychiatric diagnoses including schizoaffective disorder, unspecified psychosis, bipolar disorder, and is care planned as being at risk for abuse related to serious mental illness and impulse control issues, reported that R2 punched the right side of R1’s face. Staff, including an LPN and an RN, described the contact as a slap or hit to the face. The incident resulted in a brief red mark on R1’s face, which staff described as slight redness that resolved after a few minutes. R1, R2, R4, and multiple staff (including the DON, Administrator, Social Services Director, Social Service Aide, LPN, and RN) all confirmed that there was a verbal and physical altercation initiated when R1 confronted R2 about R4 and refused to leave R2’s room, and that R2 responded by hitting or punching R1 in the face. R1’s care plan and abuse risk reviews documented pre‑existing risk factors such as serious mental illness, impulse control issues, verbally threatening behavior, and exposure to trauma, and R2’s care plan and abuse risk review documented a history of physical and verbal aggression, serious mental illness, impulse control issues, and aggression/combative behavior. Despite these identified risks, the facility did not prevent the resident‑to‑resident physical abuse that occurred when R2 struck R1, resulting in the cited failure to protect R1 from abuse.
Failure to Prevent Resident-to-Resident Abuse Following Behavioral Escalation
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a physical altercation between them. One resident, who is cognitively intact and has a history of schizoaffective disorder and bipolar disorder, admitted to taking personal belongings (Kool-Aid) from his roommate, who has moderate cognitive impairment and diagnoses of bipolar disorder and schizophrenia. The incident escalated when the cognitively impaired resident discovered his belongings had been taken, leading to a verbal and physical confrontation in which he punched the other resident in the stomach. The assaulted resident was subsequently sent to the hospital for evaluation, though no injuries were found. Prior to the incident, there were documented behavioral concerns for both residents. The resident who took the Kool-Aid had a care plan noting a risk for abuse and a history of inappropriate sexual behaviors, including making advances and entering other residents' rooms without permission. The roommate, who rarely left his room, reported ongoing issues with his roommate going through his belongings and making him uncomfortable by blowing kisses and placing a profile picture on his television. Despite these documented risks and behaviors, the facility did not prevent the altercation from occurring. The facility's abuse policy affirms residents' rights to be free from abuse and outlines that residents who allegedly abuse others should be immediately evaluated for appropriate therapy, care approaches, and placement. However, the events indicate that the facility did not adequately protect the residents from abuse or prevent the escalation of known behavioral issues, resulting in a physical altercation and the need for medical evaluation and police involvement.
Failure to Report Allegation of Mental Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of mental abuse (bullying) involving a resident to the state survey agency as required. The incident began when a hospital social worker informed a facility LPN that a resident had reported being bullied by their roommate. The LPN immediately notified the facility administrator, who is also the abuse prevention coordinator. The administrator conducted an internal investigation by interviewing staff and the accused roommate but was unable to substantiate the bullying allegation. Despite this, the residents were separated following the allegation. The administrator acknowledged that bullying constitutes mental abuse and confirmed that the allegation should have been reported to the state survey agency, but it was not. Facility policy requires immediate notification of the Department of Public Health's regional office when any allegation of abuse is made, regardless of substantiation. Documentation reviewed included a witness statement from the accused roommate referencing the bullying accusation. The failure to report the allegation as required constitutes the deficiency.
Failure to Investigate Alleged Verbal and Mental Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of verbal and mental abuse after a resident reported being bullied by two other residents. The resident, who was cognitively intact as indicated by a BIMS score of 15, stated that two peers repeatedly called him derogatory names and that this harassment had persisted for over a year. The resident reported the bullying to hospital staff during a recent hospitalization, which prompted a call from the hospital social worker to the facility. The facility administrator was notified of the allegation by an LPN, but the administrator only interviewed the resident's roommate, who was not named by the resident as a perpetrator, and did not interview the resident or the two residents accused of bullying. No documentation of a comprehensive investigation was provided, aside from a single witness statement from the roommate. The administrator confirmed that no further interviews or written records were made regarding the incident, and was unaware that the allegation involved residents other than the roommate. The facility's abuse policy requires prompt and aggressive investigation of all abuse allegations, including interviews with the person reporting the incident, the resident, and anyone likely to have direct knowledge, as well as documentation of all incidents. These procedures were not followed in this case.
Failure to Prevent Resident Abuse Leads to Injuries
Penalty
Summary
The facility failed to protect four residents from physical abuse, resulting in injuries to two of them. The incidents involved verbal altercations that escalated into physical violence. One resident was injured and bleeding from the mouth after being punched by another resident, while another resident required stitches to the eyebrow and had a forehead injury following a fight. These incidents were not adequately addressed by the staff, as the residents were not separated or supervised to prevent the escalation of violence. The report details that the staff did not take appropriate action when informed of the potential for abuse. One resident reported to the nurse's station about a conflict with another resident, but no action was taken to separate them, leading to a physical altercation. Similarly, another resident expressed concerns about a shared bathroom being left in an unsanitary condition, which led to a physical fight when the issue was not resolved by the staff. The facility's policy on abuse was not followed, as the staff failed to prevent the willful infliction of injury among residents. The medical records of the involved residents indicate that they have complex medical and psychological conditions, including schizoaffective disorder, bipolar type, and alcohol abuse, which may have contributed to the incidents. The facility's administrator and a staff member acknowledged that the residents should have been separated and placed under supervision to prevent the altercations. The facility's policy clearly states that residents have the right to be free from abuse, and the staff's inaction violated this policy.
Failure to Prevent Resident Altercation and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate measures to prevent an altercation between two residents, R1 and R2, which resulted in physical abuse and injury. R1, who had a history of schizoaffective disorder, bipolar type, and alcohol abuse, was involved in a physical altercation with R2, who had a diagnosis of Type 2 diabetes mellitus and a chronic ulcer. The incident occurred after R2 reported to the receptionist, V18, that R1 was stealing food and appeared intoxicated. Despite being informed of the situation, the nurse, V17, did not separate the residents or provide adequate supervision, leading to R1 being hit in the face and sustaining a mouth injury. The facility's investigation revealed that V17 was notified of the potential for abuse but failed to take appropriate action to separate the residents or place them under supervision. The facility's policy on abuse, which affirms residents' rights to be free from abuse, was not adhered to, as the altercation was not prevented. The administrator, V1, and the Director of Nursing, V2, acknowledged that the nurse should have separated the residents and placed them on 1:1 supervision. The facility did not provide a supervision policy, and both V17 and V18 were unreachable for further clarification during the investigation.
Improper Documentation of Resident Transfer and Discharge
Penalty
Summary
The facility failed to properly document the reason for a resident's transfer and discharge to the hospital. The resident, who had a history of substance abuse and non-compliance with her care plan, was transferred after returning to the facility intoxicated. The facility's administrator incorrectly filled out the involuntary discharge form, marking that the safety of individuals in the facility was endangered, rather than indicating that the facility could not meet the resident's needs. This error was acknowledged by the administrator, who admitted to being unfamiliar with the involuntary discharge process and the resident's right to appeal. Interviews with staff, including the Director of Nursing, Social Worker Director, and Licensed Practical Nurses, revealed that the resident had not exhibited suicidal or homicidal ideations and had not attacked other residents or staff. The resident had refused to attend a substance abuse program and declined a transfer to a specialized mental health rehab facility. Despite these issues, the facility's documentation did not accurately reflect the situation, leading to a deficiency in the handling of the resident's transfer and discharge.
Failure to Provide Timely Involuntary Discharge Notice
Penalty
Summary
The facility failed to provide a resident with an involuntary discharge notice 30 days prior to the discharge, as required. The resident, who had a history of depression and intoxication, was taken to the hospital after becoming aggressive and intoxicated while on a pass. Upon arrival at the hospital, the resident was calm and cooperative. The facility decided to issue an immediate discharge due to the resident's non-compliance with attending an alcohol program and not following some facility rules. The resident was given the involuntary discharge notice at the hospital, but it was not explained that she had the right to appeal the process. The Director of Business Office, following instructions from the Administrator, delivered the involuntary discharge paperwork to the resident at the hospital. However, the resident was not informed of her right to appeal the discharge. The Administrator admitted to not being familiar with the involuntary discharge process, time frames, or the resident's right to appeal. The facility's policy requires that residents and their representatives be given timely written notice of transfer and the reasons for it, 30 days prior to relocation, which was not adhered to in this case.
Failure to Follow Bed Hold Policy Results in Resident Discharge
Penalty
Summary
The facility failed to adhere to its bed hold policy for a resident who was transferred to a hospital, resulting in the resident not being able to return to the facility. The facility's policy states that a specific bed may be held for ten days for Medicaid recipients unless the resident indicates a desire not to return or if the services provided by the facility are no longer appropriate. However, the facility did not hold the resident's bed for the required period, leading to the resident being discharged to the community instead of being readmitted to the facility. The resident, who had a history of major depressive disorder and anxiety disorder, was transferred to the hospital after becoming aggressive and intoxicated. Despite the resident's initial plan to return to the facility, the facility issued an involuntary discharge notice without informing the resident of their right to appeal the decision. The Director of Business Office delivered the discharge paperwork at the hospital, and the facility's administrator admitted to not being familiar with the involuntary discharge process or the residents' rights to appeal. This lack of adherence to policy and procedure resulted in the resident being unable to return to the facility.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, resulting in the resident being discharged to the community. The resident, who had a history of intoxication and aggressive behavior, was sent to the hospital after returning to the facility intoxicated. The Director of Business Office was instructed by the Administrator to deliver involuntary discharge paperwork to the resident at the hospital, without informing the resident of their right to appeal the discharge. The resident was not allowed to return to the facility, despite the lack of documented incidents of aggression towards other residents or staff. The Administrator cited the resident's refusal to attend an outpatient substance abuse program and non-compliance with facility rules as reasons for the involuntary discharge. However, the Administrator admitted to being unfamiliar with the involuntary discharge process, including the time frames and the resident's right to appeal. The facility's policy states that residents should be allowed to return to the facility when a bed becomes available, but this was not followed in this case. The Director of Nursing and other staff members were not informed of the decision to involuntarily discharge the resident.
Inadequate RN Coverage in Facility
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours in a 24-hour period on multiple days throughout the week, including Mondays, Wednesdays, Thursdays, Fridays, and every other weekend, over a span of three months. This deficiency was identified through observations, interviews, and record reviews. During a facility tour from December 3 to December 5, 2024, it was noted that no RN was assigned to provide care to the residents. The Payroll Based Journal (PBJ) records for the third quarter showed sporadic RN coverage, with specific RNs working only on certain days, and no documented hours for one RN during the entire quarter. The facility's staffing policy mandates that an RN be scheduled for at least one continuous 8-hour shift every day, which was not adhered to. Interviews with the facility's Director of Nursing (DON) and Administrator revealed that the facility did not staff according to resident acuity or census, and the DON and Assistant Director of Nursing (ADON), both RNs, only worked the floor when short-staffed. The facility had a total of four RNs, including the DON, ADON, a Nurse Manager, and another RN, but their schedules did not ensure daily 8-hour RN coverage. The facility's assessment tool and staffing records further confirmed the lack of consistent RN presence, with RNs only assigned to the floor on specific days. The facility's policy requires adequate staffing to meet resident needs and compliance with applicable regulations, which was not met in this case.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by improperly handling soiled clothing. Observations revealed that net-like bags containing residents' clothing were left on the floor in several rooms, contrary to the facility's policy that requires these bags to be placed in bins to prevent contamination. Certified Nursing Assistants (CNAs) acknowledged that the bags should not be on the floor, yet they were found in this state for residents R17, R10, R73, R22, and R100. The facility's policy, dated August 2008, mandates that soiled laundry be handled in a manner that prevents microbial contamination, which was not followed in these instances. Additionally, the facility failed to implement its Water Management Program, which is crucial for preventing waterborne diseases such as Legionella. The Maintenance Director, V10, was unaware of the requirements for water testing and risk assessment, despite the presence of a testing kit in his office. The facility's policy, dated October 2017, requires a risk assessment of the water system to identify potential growth and spread of pathogens, but this was not conducted. The Director of Nursing confirmed that the risk assessment was overdue and should have been completed by V10, who is new to long-term care. The Centers for Medicare and Medicaid Services (CMS) requires healthcare facilities to have water management policies to reduce the risk of Legionella and other pathogens. The facility's failure to conduct a risk assessment and maintain documentation of water system management poses a potential risk to all 105 residents. The Administrator acknowledged the need for annual water testing and monthly temperature checks, which were not being performed, highlighting a significant oversight in the facility's infection control measures.
Failure to Document and Educate on Vaccinations
Penalty
Summary
The facility failed to educate and document the influenza and pneumococcal vaccination status for four residents, leading to a deficiency in compliance with their own immunization policy. Specifically, two residents were not educated on influenza vaccination, and four residents were not educated on pneumococcal immunization. The facility's policy requires that each resident, or their representative, be educated on the benefits and potential side effects of these vaccinations, and that informed consent be documented. However, the records for residents R45, R73, R90, and R250 showed a lack of documentation regarding education and informed consent for these vaccinations. Resident R45 had no record of receiving the pneumococcal vaccination despite a request for it, and R90 was in a similar situation. Resident R73 declined both influenza and pneumococcal vaccinations, but the reasons for the declination were not documented. Resident R250 had no records related to immunization, including informed consent and preventative health care. The Assistant Director of Nursing/Infection Control Preventionist acknowledged the failure to document immunizations and education in the residents' records, which is a requirement under the facility's policy dated November 2016.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications, as observed during a survey. Medications were found loose and not in their original packaging in Medication Cart B, which contained medications for approximately 48 residents. The nurse responsible for the cart, V4, was unable to identify the loose pills and stated that night nurses were supposed to clean the medication carts. Additionally, insulin pens for residents R72 and R31 were not labeled with open or discard dates, and some pens were not stored in the medication refrigerator as required. Further inspection of the medication storage room revealed that the medication refrigerator was not maintained properly. The refrigerator contained sticky streaks, a thick layer of ice build-up in the freezer, and insulin pens stored underneath the ice. A brown paper bag with food items for a resident was also found inside the refrigerator, despite a sign indicating that only medications should be stored there. The night shift nurses were supposed to clean the refrigerator and check its temperature daily, but there were multiple missing entries in the temperature logs for several months. The Director of Nursing, V2, confirmed that night shift nurses were responsible for receiving pharmacy deliveries and maintaining the medication carts and refrigerator. However, all nurses were expected to ensure the cleanliness and proper storage of medications. The facility's policies required medications to be stored securely and properly, with specific guidelines for refrigerated medications. Despite these policies, the facility failed to adhere to them, leading to the observed deficiencies.
Medication Availability and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the availability and timely administration of medications for three residents, leading to deficiencies in pharmaceutical services. One resident, diagnosed with seizures and other mental health disorders, had a discrepancy in the controlled medication records for Phenobarbital, a Schedule IV controlled substance. The nurse was unable to locate the blister packet containing the remaining tablet, and the discrepancy between the record and the physical count could not be explained. Another resident, with diagnoses including major depressive disorder and schizophrenia, did not receive their prescribed Sertraline medication on time due to its unavailability in the medication cart and storage room. The nurse had to order the medication STAT, resulting in a delay in administration. Similarly, a third resident with hypertensive heart disease did not have their prescribed Amlodipine and Metoprolol Succinate available, leading to a delay in administration. The nurse had to retrieve an alternative medication from the electronic dispensing system and obtain a one-time order for a different form of Metoprolol. The facility's policies require medications to be administered within one hour of the scheduled time and for controlled substances to be accurately reconciled. However, the nurses failed to reorder medications in a timely manner and did not have access to the electronic medication dispensing system, contributing to the delays. The Director of Nursing acknowledged the pharmacy's delivery schedule and the responsibility of nurses to manage medication supplies, but could not explain the discrepancies in controlled medication records.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain written informed consent prior to prescribing and administering psychotropic medications for three residents, identified as R15, R90, and R96. R15, who has a primary medical diagnosis of COPD and schizophrenia disorder, was administered Aripiprazole, Depakote, and Trazodone without prior informed consent. Similarly, R90, diagnosed with osteoarthritis, malignant neoplasm, dementia, and depressive episodes, was given Aripiprazole, Sertraline, and Trazodone without informed consent. Both residents were found to have signed consent forms dated after the medications were already being administered, and interviews revealed that they were not informed about the side effects or benefits of the medications. R96, who has diagnoses including unspecified psychosis and mood disorder, expressed a desire not to take Aripiprazole and Lexapro due to adverse effects but continued to receive these medications without having signed a consent form. The facility's staff, including V4 and V15, were aware of R96's refusal but continued to administer the medications. It was only during the survey that a consent form was completed, which R96 signed under the impression it was for a different medication. The facility's policy requires informed consent before administering psychotropic medications, which was not adhered to in these cases. The Assistant Director of Nursing, V3, acknowledged the oversight in obtaining informed consent and admitted to sending other staff to collect signatures without ensuring residents were fully informed. The Director of Nursing, V2, was unaware of R96's refusal and stated that the expectation is for the admitting nurse to educate residents and obtain consent prior to medication administration. The facility's policies emphasize the necessity of informed consent and the right of residents to refuse treatment, which were not followed in these instances.
Failure to Educate and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to educate two residents, R73 and R250, on COVID-19 vaccination as per their policy on documentation of COVID-19 immunization. This failure was identified during a review of records and interviews, which revealed that these residents were not provided with informed consent regarding the risks and benefits of COVID-19 vaccinations. The Assistant Director of Nursing/Infection Control Preventionist (V3) acknowledged the lack of documentation under preventative health care and progress notes for these residents, despite the facility's policy requiring such documentation. The facility's policy, dated March 2022, mandates that all residents be educated and offered COVID-19 vaccinations, with documentation of acceptance or declination entered into the Electronic Health Record under preventative health care. However, V3 admitted to failing to document the immunization education and informed consent for residents R73 and R250. This oversight has the potential to affect the residents' ability to make informed decisions about their COVID-19 vaccinations.
Failure to Maintain Safe Environment Due to Detached Flooring
Penalty
Summary
The facility failed to maintain a safe environment for a resident with multiple medical conditions, including Parkinson's disease, schizoaffective disorder, bipolar type, difficulty in walking, lack of coordination, and dementia. The deficiency was identified when a detached vinyl flooring tile was observed at the entrance to the resident's restroom, posing a slipping hazard. The resident, who had recently transitioned from using a wheelchair to a walker, frequently used this path to access the restroom. The issue was acknowledged by a Certified Nursing Assistant (CNA) who recognized the potential risk of slipping and falling for the resident. The Maintenance Director indicated that maintenance issues should be reported through a ticketing system, but it was unclear if this had been done. The Director of Nursing and the Administrator both emphasized the need for cooperation among departments, including CNAs and housekeeping, to identify and report hazards. The facility's safety policy requires staff to observe and report potential risks to ensure a safe living environment, but this protocol was not effectively followed in this instance, leading to the deficiency.
Failure to Document Advance Directives for Two Residents
Penalty
Summary
The facility failed to uphold the rights of two residents, R90 and R250, to formulate advance directives as per their policy. During a review of the residents' records, it was found that there was no documentation related to advance directives. The Director of Social Service, V8, confirmed that there was no documentation on file for these residents regarding discussions about advance directives. According to the facility's policy, advance directives should be discussed upon admission and followed up within a 72-hour period. However, this procedure was not adhered to for R90 and R250. The absence of a POLST form, which is a legally binding document that communicates a patient's advance decisions about CPR and life-sustaining treatment, poses a significant issue. Without this form, the facility staff would default to considering the residents as full code in case of an emergency, which could lead to unwanted resuscitation if the resident had chosen otherwise. This oversight in documentation and planning of care could potentially lead to legal problems if a resident's wishes are not respected during a medical emergency. The facility's policy mandates that written information on advance directives be provided and documented in the resident's clinical record, which was not done in these cases.
Failure to Include Urinary Catheter Use in Care Plan and Maintain Resident Dignity
Penalty
Summary
The facility failed to include urinary catheter use in a resident's comprehensive care plan, as well as to have urinary catheter care orders documented. The resident, identified as R85, had diagnoses including infection in the urine and the presence of urogenital implants, which necessitated the use of a urinary catheter. However, the resident's Physician Order Report did not document any urinary catheter care orders, and the Care Plan lacked a focus on urinary catheter use, goals, or interventions. Additionally, the facility did not maintain the resident's dignity by failing to provide a urinary catheter privacy bag. Observations noted that the urinary catheter tubing and bag were in plain sight in the resident's room, which was located in front of the main entrance to the facility. The Director of Nursing acknowledged that the expectation was for staff to provide a privacy bag to maintain dignity and ensure the catheter tubing and bag were clean and patent. These interventions were not listed in the resident's Physician Order Report or Care Plan.
Failure to Transcribe Hospital Orders for Resident
Penalty
Summary
The facility failed to transcribe hospital orders upon the initial admission of a resident, identified as R96, who was part of a sample of 46 residents. R96 had a documented medical history that included seizures, hypertensive heart disease, neuralgia and neuritis, alcohol dependence, insomnia, and mood disorder. Upon discharge from the hospital, R96 was instructed to take Magnesium Oxide 250 mg, two tablets daily for 30 days, as a supplement. However, during the admission process at the facility, the Magnesium pills were taken from R96, and the medication was not added to R96's treatment plan. The deficiency was identified when R96 reported the issue to the surveyor, stating that the facility staff had not included the Magnesium Oxide in their treatment despite having a prescription. The facility's Director of Nursing (V2) was initially unaware of the issue but later confirmed that the facility contacted R96's physician to receive the necessary orders for Magnesium Oxide and blood work. The facility's policies require that medication orders be provided by the attending physician at the time of admission and that drugs be administered according to licensed medical practitioners' orders, which was not adhered to in this case.
Deficiency in Oxygen Therapy Management
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident, identified as R37, who was receiving oxygen therapy. The deficiencies observed included the portable oxygen tank being set at an incorrect rate, oxygen tubing not being stored properly to prevent contamination, and the tubing not being labeled and dated as required. R37, who has a history of respiratory failure, chronic kidney disease, and other health issues, was observed with oxygen set at 2 liters per minute instead of the prescribed 3 liters. Additionally, the oxygen tubing was found undated and not stored in a bag, which could lead to contamination. During interviews, a Licensed Practical Nurse (LPN) acknowledged that the oxygen tubing should be labeled and stored in a bag when not in use to maintain cleanliness. The Director of Nursing (DON) confirmed that oxygen equipment is supposed to be changed weekly, labeled, and applied according to the physician's orders. However, there was no separate policy for oxygen labeling, and the tubing was not consistently labeled or stored properly, leading to potential risks for the resident's respiratory care.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by a staff member, specifically a Certified Nurse Assistant (CNA). The incident involved a resident, identified as R3, who reported that the CNA, referred to as V11, yelled at him and physically hit him on the cheek during a nighttime encounter. R3, who is cognitively intact with a BIMS score of 14, stated that the altercation occurred when he requested ice from V11. The resident reported feeling safe afterward as the staff member was immediately terminated and did not return to work. The incident was corroborated by witness statements from other staff and residents. A Restorative Nurse and an LPN reported that R3 immediately informed them of the incident, and another CNA witnessed R3 running away from V11, asking him to keep his hands off. Additionally, another resident with mild cognitive impairment observed the CNA hitting R3 and threatening him. Despite the lack of physical injuries noted in R3's body assessment, the resident was visibly upset and required redirection. The facility's records show that V11 had a history of discourteous behavior, having been previously suspended for such conduct. Despite attending multiple in-services on abuse prevention, V11 denied the allegations in a written statement. The facility's abuse policy, which affirms residents' rights to be free from abuse, was not upheld in this instance, leading to the deficiency noted in the report.
Privacy Curtain Deficiency
Penalty
Summary
The facility failed to ensure that privacy curtains were available and extended around the beds of four residents, compromising their privacy. On two separate occasions, a surveyor observed that the privacy curtains for these residents were missing. During the first observation, the surveyor noted the absence of privacy curtains around the beds of the residents. On a subsequent visit, the surveyor again found that the curtains were still not in place. A Certified Nurse Assistant (CNA) acknowledged that each resident usually has a curtain for privacy, while the Maintenance Director initially claimed that all residents had privacy curtains. However, upon further inspection with the surveyor, the Maintenance Director confirmed the absence of the curtains and stated they would be installed when available. The facility's policy on Quality of Life - Dignity emphasizes the importance of maintaining and protecting resident privacy, which was not adhered to in this instance.
Deficiency in Call Light Functionality
Penalty
Summary
The facility failed to ensure that residents' call lights were functional and in good working order, affecting five residents. On two separate occasions, the surveyor observed that the rooms of these residents did not have functioning call lights, preventing them from requesting assistance from staff. The Maintenance Director, upon being shown the issue, acknowledged the problem but the facility's maintenance logbook did not document any call light issues. The facility's policy requires that call lights be within easy reach of residents and that any defects be promptly reported to the maintenance department. The Maintenance Job Description also mandates the proper operation of all call lights.
Sanitation Deficiency in A-Wing Shower Room
Penalty
Summary
The facility failed to maintain the A-Wing community shower room in a sanitary condition, which has the potential to affect all 13 residents on the A-Wing and others who use this shower room. During an observation, the surveyor noted wet towels and blankets on the floor and patches of a black substance on most areas of the ceiling. Additionally, there was an open area in the ceiling, and the ceiling air vent was broken and covered in accumulated dust. When questioned, the Director of Nursing was unable to identify the black substance, and the Maintenance Director attributed it to moisture on the ceiling, indicating a need for cleaning. Further inspection revealed an air vent behind the ice machine also covered in accumulated dust. The Maintenance Director acknowledged the issue and stated an intention to clean it promptly. The facility's housekeeping and maintenance policies emphasize the importance of maintaining a clean, safe, and sanitary environment, including regular cleaning and preventative maintenance. However, the observed conditions in the shower room and around the ice machine indicate a failure to adhere to these policies, compromising the facility's environment of care.
Verbal Abuse Incident Involving Resident and Staff
Penalty
Summary
The facility failed to protect a resident from verbal abuse, which is a violation of their right to be free from such treatment. The incident involved a former floor technician, V4, who was reported to have verbally abused a resident, R1, by using derogatory language. This altercation occurred when R1 walked on wet floors that V4 was mopping, leading to a confrontation where V4 allegedly used inappropriate language towards R1. The Maintenance Director, V6, was informed of the incident and initiated an investigation after V4 admitted to the verbal abuse during a phone call with V6 and the Administrator, V1. R1, a male resident with multiple diagnoses including Chronic Obstructive Pulmonary Disease, Paranoid Schizophrenia, and Anxiety, reported the verbal altercation to several staff members. The facility's records indicate that R1 was assessed for injuries following the incident, with none noted, and his family and physician were notified. The facility's investigation included witness statements, one of which confirmed that V4 had used derogatory terms towards R1. V4's employee file showed no prior records of abuse, and he had participated in an in-service on abuse, indicating awareness of the facility's policies. The facility's policy affirms the residents' right to be free from abuse, including verbal abuse, which is defined as the use of disparaging and derogatory terms. Despite this, V4 admitted to being verbally inappropriate with R1, which was corroborated by a witness. The facility's documentation and interviews with staff, including the Administrator and Maintenance Director, confirmed the occurrence of verbal abuse, leading to V4's termination. The incident was reported to the health department, and the facility's policy and training on abuse were reviewed as part of the investigation.
Failure to Revise Care Plan After Abuse Incident
Penalty
Summary
The facility failed to revise a care plan for a resident who was involved in an incident of verbal abuse. The Licensed Practical Nurse and former Care Plan Coordinator acknowledged that the social services department is responsible for entering abuse care plans for residents at risk or who have experienced abuse. However, upon reviewing the resident's electronic medical record, it was found that there was no documented abuse care plan for the resident, despite an altercation involving allegations of abuse. The Director of Nursing had documented the incident in a nursing progress note, indicating that the resident reported being spoken to inappropriately by a staff member, but no injuries were noted. The resident's family and physician were informed of the incident. The facility's report indicated that the resident's care plan and assessments were reviewed and updated following the incident. However, the care plan dated over a month later still did not include any documentation of the risk for abuse or the incident that occurred. A witness statement confirmed that a former floor technician admitted to being verbally inappropriate with the resident and was subsequently terminated. The facility's policy requires that care plans be revised as changes in the resident's condition dictate, but this was not adhered to in this case.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure that residents were free from physical abuse, affecting multiple residents. One incident involved a resident who was hit in the head with a chair by another resident, resulting in a facial laceration and pain. Another resident, who is legally blind and wheelchair-dependent, was hit in the face by another resident, causing psychosocial harm and feelings of unsafety. Additionally, a resident was pushed by another, resulting in a scratch on the hand, and another resident was hit in the face by a fellow resident. Lastly, a resident was hit on the head and had their wrists grabbed by another resident, leading to feelings of unsafety in the facility. The incidents were substantiated through interviews and record reviews. In the first case, the resident who was hit with a chair had a moderate cognitive impairment and multiple medical conditions, while the perpetrator was cognitively intact but had severe psychotic symptoms. The second case involved a resident with severe cognitive impairment and blindness, who was hit by a resident with severe cognitive impairment and multiple psychiatric diagnoses. The third case involved a cognitively intact resident who was pushed by a resident with severe cognitive impairment. The fourth case involved a resident with severe cognitive impairment who was hit by another resident with moderate cognitive impairment. The fifth case involved a resident with moderate cognitive impairment who was hit and had their wrists grabbed by another resident with severe cognitive impairment. The facility's abuse policy and resident rights policy were not upheld, as residents were subjected to physical abuse by other residents. The facility's failure to document pain assessments, injuries, and incidents in the residents' medical records further exacerbated the issue. The facility's abuse investigations confirmed the occurrences of physical abuse, but the lack of proper documentation and immediate intervention highlights significant deficiencies in ensuring resident safety and well-being.
Failure to Supervise Residents on Smoking Patio
Penalty
Summary
The facility failed to supervise residents on the smoking patio, leading to an altercation between two residents, R1 and R2. R1 physically hit R2 in the head with a chair, causing R2 pain and a facial laceration near the right eye. The incident occurred during the first smoke break of the day, and the smoke monitor, V11, was not present at the time of the altercation. R1 and R2 both provided accounts of the incident, with R1 admitting to hitting R2 with the chair after a struggle over seating. R2 confirmed the altercation and the resulting injury. R2's medical records indicate a history of paranoid schizophrenia, type 2 diabetes mellitus, chronic obstructive pulmonary disease, emphysema, cardiac pacemaker, cardiomegaly, atherosclerotic heart disease, idiopathic epilepsy, and auditory hallucinations. R2's Minimum Data Set (MDS) showed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. R1's medical records include diagnoses of hereditary and idiopathic neuropathies, major depressive disorder, hypothyroidism, bipolar disorder, anxiety disorder, schizophrenia, hypo-osmolality, and hyponatremia. R1's MDS showed a BIMS score of 15, indicating cognitive intactness. The facility's investigation confirmed the physical abuse incident, with the Administrator, V1, substantiating the abuse. However, there were discrepancies in the documentation of R2's injury and pain assessment. The Director of Nursing, V2, could not explain the lack of documentation in R2's electronic medical record and medication administration record. The facility's policies on abuse and resident rights emphasize the importance of a safe and dignified environment, which was not upheld in this incident. The job description for the Smoke Monitor also highlights the responsibility to ensure a safe smoking environment, which was not met during the altercation between R1 and R2.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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