Loft Rehab Of Decatur
Inspection history, citations, penalties and survey trends for this long-term care facility in Decatur, Illinois.
- Location
- 500 West Mckinley Avenue, Decatur, Illinois 62526
- CMS Provider Number
- 145965
- Inspections on file
- 53
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Loft Rehab Of Decatur during CMS and state inspections, most recent first.
A resident with gait abnormalities, muscle weakness, altered mental status, and moderate cognitive impairment had a care plan that included floor mats as a fall prevention intervention. Despite this, an RN reported that the floor mats were not in place when the resident fell from bed and was found on the floor beside the bed, complaining of head and neck pain and bleeding from the head. Hospital evaluation, including CT imaging, confirmed a head laceration and hematoma requiring staple closure. Facility leadership confirmed that fall mats had been implemented previously and should have been in place when the resident was in bed.
Surveyors found that multiple residents did not receive their ordered evening medications during one medication pass. A resident filed a complaint about not receiving evening meds, and the DON later confirmed that residents on one hall missed their scheduled doses. MAR review showed that several medications, including famotidine, potassium chloride, baclofen, gabapentin, atorvastatin, carvedilol, clonidine, doxazosin, Eliquis, fluticasone inhalation, and rosuvastatin, were not administered as ordered. The DON acknowledged that nurses are required to follow physician orders and notify the physician and nursing supervisor when medications are not given.
Two residents reported rough and undignified care by CNAs, including one resident with multiple comorbidities and moderate cognitive impairment who described rough handling during transfers and perineal care with associated bruising, and another cognitively intact resident with an upper extremity impairment who reported that a CNA was on the phone during care, was rude, rough, and belittling. The Social Service Director documented both concerns as grievances about staff approach, observed bruising on one resident, and acknowledged an allegation of rough care but did not ensure that these reports were treated and processed as potential abuse allegations. Instead, she addressed one CNA directly about phone use, did not fully relay the rough-care and belittling allegations to the DON or Administrator, and facility leadership later confirmed they were unaware of one resident’s grievance and that it had not been reported or investigated as possible abuse.
Two residents reported that CNAs provided rough and belittling care, causing bruising, neck pain, and fear of future rough treatment, and that staff were distracted by personal phone use during care. The Social Service Director documented both concerns as grievances related to staff approach, but did not treat the rough and abusive care allegations as potential abuse, relying instead on personal knowledge of the CNAs. An LPN and a PTA were also aware of one resident’s verbal and physical abuse allegations but did not report them to the Administrator or Abuse Prevention Coordinator, and the DON and Administrator later confirmed they were unaware of these abuse reports.
Multiple staff failed to report resident allegations of rough care, bruising, neck pain, and derogatory comments to the Administrator/Abuse Prevention Coordinator as required by the facility’s abuse policy. One resident with moderate cognitive impairment and significant ADL dependence reported that a CNA was rough during transfers, causing bilateral forearm bruising and neck pain, and stated she had informed social services, yet leadership reported no knowledge of the allegation while the CNA continued working. Another resident with no cognitive impairment reported to social services, an LPN, and therapy staff that a CNA was rough and rushed during care, remained on her phone, and belittled him as lazy, but the Social Service Director, who is related to the CNA, handled the matter informally and did not report it as possible abuse. The DON and Administrator stated they were unaware of these allegations, and timecards showed the implicated CNAs continued to work multiple shifts with access to residents without timely removal from duty or documented investigation.
A resident who was cognitively intact and required partial to moderate assistance with toileting reported that a CNA noticed feces from another resident on a toilet seat and told the resident to clean it using sanitary wipes before being allowed to use the bathroom. The CNA stated she would not help the resident until the feces was cleaned, threw the container of wipes toward the resident, and waited for the resident to comply. The resident reported feeling upset, embarrassed, and disrespected by this interaction, and the Administrator later confirmed the CNA did not treat the resident with dignity.
A cognitively intact resident’s right to be free from misappropriation of property was violated when a CNA removed a check from the resident’s personal checkbook kept in the room, wrote it for $975, and forged the resident’s signature to pay the CNA’s rent. The incident was identified through a state investigation and confirmed by the resident and the Administrator, who acknowledged that the CNA had taken and used the resident’s check without permission.
Two residents were transported in a facility van without being properly secured in their wheelchairs due to malfunctioning and missing seatbelts. One resident, who had multiple medical conditions and a history of falls, fell forward during abrupt braking and sustained fractures to the humerus, tibia, and fibula. The securement system was found to be broken and had been previously reported to administration but not repaired, leading to the incident.
A resident's Power of Attorney requested copies of the resident's medical records after the resident was transferred to another facility, but the records were not provided in a timely manner. The request, made through a lawyer, was acknowledged by Medical Records staff and forwarded to corporate, yet the records were not sent until much later, despite repeated follow-up by the family member.
The facility did not ensure a clean and comfortable environment for two residents, as evidenced by unmade beds, soiled linen, dirty dishes left in rooms, and unclean floors. One resident, who is cognitively intact, and another who is severely cognitively impaired and dependent on staff, both experienced lapses in housekeeping and bed-making. Staff and resident council meeting minutes confirmed that these deficiencies were ongoing and not addressed as required.
A resident with an indwelling urinary catheter was observed with unsecured catheter tubing and an uncovered drainage bag exposed to the hallway. Staff confirmed these observations and acknowledged that urinary output was not consistently documented every shift as required by physician orders and facility policy.
The facility did not report allegations of verbal and physical abuse involving a resident to the state survey agency as required by policy. The DON received these allegations from the resident's daughter and a CNA but failed to notify the state agency, and no documentation of such reporting was available.
Two residents experienced significant harm due to the facility's failure to promptly assess, notify physicians, and manage pain or changes in condition. One resident with severe cognitive impairment suffered untreated severe knee pain and swelling for several days before a femur fracture was identified and surgically repaired. Another resident, after an unwitnessed fall, did not receive timely neurological checks or post-fall assessments, leading to delayed recognition of a subdural hematoma and hip dislocation, both requiring hospital intervention. Staff did not follow established policies for assessment, documentation, and physician notification.
A resident with significant medical complexities who required Contact Guard Assist for ambulation fell and suffered a fractured humerus, facial contusion, and abrasions when a physical therapy aide, who was trailing behind with a wheelchair and oxygen tank, stepped away to untangle oxygen tubing and was unable to maintain contact or assist the resident, resulting in inadequate supervision and assistance.
Two residents did not receive timely and appropriate pressure ulcer care, including regular repositioning, incontinence care, wound assessment, and physician or dietitian notification. One resident developed multiple pressure ulcers, including a stage four coccyx wound, due to missed interventions and lack of monitoring, while another had an untreated buttock wound that was not promptly identified or managed by staff.
Two residents experienced verbal and emotional abuse from staff, including an LPN yelling at a resident for requesting pain medication and a CNA removing another resident's call light and treating him roughly. Both residents suffered emotional harm and distress as a result of these actions.
Multiple residents experienced harm due to the facility's failure to assess, monitor, and manage bowel and wound care. One resident with cognitive impairment and a history of bowel obstruction was not properly monitored for bowel movements, leading to hospitalization for bowel obstruction. Another resident with a surgical wound did not receive timely wound care or assessments, and wound care was not performed according to orders, resulting in infection and additional surgery. A third resident suffered from prolonged constipation and was hospitalized for fecal impaction, with no evidence of bowel management prior to the event.
A resident with multiple medical conditions experienced significant unplanned weight loss over several months. Staff did not notify the physician or registered dietician as required, nor did they implement new nutritional interventions, despite clear evidence of ongoing weight loss. The facility's policy for monitoring and responding to weight changes was not followed, and the resident continued to lose weight without appropriate assessment or intervention.
Two residents experienced unmanaged pain due to the facility's failure to accurately assess pain, notify physicians, and implement pain medication orders. One resident with cognitive impairment and a worsening pressure ulcer showed clear signs of pain that were not addressed, while another resident with a history of back surgery and chronic pain conditions suffered severe pain during care activities without timely administration of PRN pain medications. Staff did not follow care plans or pain management protocols, resulting in inadequate pain control.
The facility did not maintain adequate nursing staff to meet resident needs, leading to prolonged call light response times, delayed wound care, missed showers, and cold food service. Multiple residents and staff reported ongoing issues with insufficient staffing, resulting in unmet care needs such as delayed toileting and incomplete scheduled care.
The facility did not update the posted daily nurse staffing information for several days, as confirmed by the Interim Regional DON, with the same outdated staffing sheet remaining visible near the front entrance. This failure potentially affected all 97 residents, and additional concerns were noted regarding staffing, care routines, and call light wait times.
A facility with 150 beds and 97 residents did not employ a qualified full-time social worker as required. The staff member assigned to cover social services lacked the necessary degree in Social Work or Human Services, as confirmed by the administrator.
The facility did not carry out its water management plan, failing to document a risk assessment, establish testing protocols, or define corrective actions for controlling Legionella and other pathogens in the water system. The administrator confirmed there was no documentation or evidence of completed assessments, potentially impacting all residents.
Staff failed to document and manage resident funds according to facility policy, with cash found in medication carts and no sign-out sheets or records of deposits or withdrawals. An LPN reported keeping residents' money in the carts due to the business office being closed, and the business office manager was unaware of this practice.
Four residents who were dependent on staff for activities of daily living did not receive scheduled showers, shaving, nail care, or grooming as required. Observations included unclean hair, long and dirty nails, stained clothing, and missed showers, with documentation and staff interviews confirming the lack of care.
Multiple residents reported that their meals were cold, unappetizing, and not delivered promptly, with observations confirming that food trays remained on holding carts for extended periods and were served below the required temperature. Staff acknowledged delays in tray delivery and inadequate food temperatures, resulting in dissatisfaction among residents.
A resident requiring significant assistance with eating and having physical impairments was repeatedly observed with stained clothing, dirty fingernails, and unshaven facial hair after meals. Staff interviews indicated a lack of awareness and cited staffing shortages, resulting in a failure to uphold the resident's dignity as outlined in facility policy.
Two residents who required staff assistance were found without access to their call lights, with one unable to request help for cold food and the other reporting frequent inability to reach the call light, despite care plans and facility policy requiring call light accessibility.
A resident with a signed DNR order on their POLST form was incorrectly listed as full code in the facility's electronic medical record and physician's orders, despite the care plan reflecting the DNR status. Nursing staff relied on hospital records and the electronic profile, leading to a mismatch between the resident's advance directive and the documented code status.
A resident with mobility limitations due to a femur fracture, infection, and low back pain was left in a broken bed overnight, unable to reposition and experiencing discomfort. Despite staff being notified, no maintenance response occurred, and the bed remained nonfunctional until the issue was later acknowledged by the Regional Maintenance Director.
A resident reported being verbally abused by an LPN, and the administrator was informed of the incident by the resident's family member. Despite facility policy requiring immediate investigation and notification to the state agency within 24 hours, the administrator delayed both the investigation and reporting for several days.
A resident's family member reported to the administrator that an LPN was rude and caused the resident distress. The administrator did not notify the state agency of this verbal abuse allegation until several days after receiving the report, resulting in a failure to meet timely reporting requirements.
A resident's family member reported to the Administrator that an LPN was rude and caused the resident distress, but the Administrator did not begin investigating the alleged verbal abuse until several days after the initial report.
A resident with longstanding diagnoses of Generalized Anxiety Disorder and PTSD was admitted without a required PASARR Level II evaluation, as the initial Level I screening failed to identify any Significant Mental Illness. The DON later confirmed that the evaluation should have been coordinated, but the Level I assessment was not reviewed for accuracy at admission.
A resident with chronic heart failure and kidney disease did not receive daily weights as ordered by the physician, with multiple missed days documented over several months. Despite a significant weight gain, there was no evidence that the medical provider was notified as required. Staff interviews confirmed that daily weights and timely notification were necessary and expected.
A resident receiving both Eliquis and Clopidogrel did not have physician orders in place to monitor for bleeding risks associated with these medications. While the care plan addressed bleeding risk for some medications, it did not include Eliquis, and staff confirmed that required monitoring orders were missing.
A resident developed a stage four pressure ulcer and unstageable pressure areas due to the facility's failure to implement resident-centered interventions and notify medical personnel of new open areas. The resident, who was wheelchair-dependent and frequently incontinent, did not receive timely incontinence care, contributing to the worsening of pressure sores. Delays in care and inadequate documentation further exacerbated the resident's condition.
The facility failed to provide the required eight hours of RN coverage on six occasions between January and February 2025. This deficiency was confirmed by the administrator, affecting the care of 95 residents.
The facility did not maintain an accurate facility-wide assessment, failing to document the interdisciplinary team's review and the necessary direct care staff by shift. The assessment inaccurately recorded zero residents with behavioral symptoms and cognitive issues, despite 29 residents being diagnosed with Alzheimer's or Dementia. The administrator confirmed the assessment's inaccuracy.
Two residents with significant medical conditions reported delays in call light responses, with staff often turning off the call light and not returning to assist. The facility's policy requires prompt response, but residents experienced wait times of 30 minutes or more, leading to discomfort and unmet needs. The DON confirmed the necessity for timely assistance.
The facility failed to follow its policy requiring two staff members for mechanical lift transfers, affecting two residents who were transferred with only one CNA. Both residents, dependent on staff for transfers, reported instances of unsafe practices, which were confirmed by the DON.
The facility failed to maintain clean and safe resident rooms, affecting several residents. Observations included full garbage cans, unclean floors, and debris under beds, even after cleaning was reported. A deceased resident's room was not promptly cleaned, leaving soiled items and odors affecting the roommate. The housekeeping schedule ending at 2:00 PM was cited as a reason for these issues, with nursing staff expected to cover housekeeping duties thereafter.
A resident's room had an unsecured sink, which was not properly attached to the cabinet or wall, making it unstable. The resident avoided using the sink for support due to its instability. A CNA confirmed the issue had been reported, and a corporate maintenance staff member acknowledged the sink's condition, admitting no repairs had been made.
A resident with muscle weakness and Alzheimer's disease, assessed at moderate fall risk, did not have access to a call light in her shared room, leading to multiple unwitnessed falls. Despite the care plan's requirement for a call light, staff confirmed its absence, contributing to the resident's injuries.
The facility failed to provide sufficient RN hours on five days, with zero RN coverage for 24-hour periods on multiple occasions. This affected all 92 residents, as confirmed by the administrator, with the nursing schedule showing no RN coverage on specific days.
The facility failed to ensure timely response to call lights, affecting multiple residents with mobility impairments. Residents reported long waits for assistance, with one resident waiting over an hour and having to walk unassisted to the restroom. The facility's administrator acknowledged the issue, noting that response times of up to 30 minutes were deemed acceptable, despite policy stating response times should be a priority.
A resident was hospitalized after being found with two Fentanyl patches, leading to Narcan administration. The facility failed to follow its policy requiring two nurses to witness the destruction of narcotic patches, as an RN disposed of a patch alone without checking for others, resulting in a medication error.
A facility failed to notify a resident's family of X-ray results, despite policy requiring prompt notification. The resident complained of foot pain, leading to an X-ray ordered by a physician. The facility received the results and informed the physician, but did not notify the family, as confirmed by the DON.
A resident at moderate risk for falls was found on the floor after slipping from a wheelchair, with no documentation confirming the use of a prescribed non-slip material. The DON confirmed the absence of documentation and uncertainty about the intervention's implementation.
Two residents experienced significant delays in receiving incontinence care, with one resident waiting nearly three hours for assistance, leading to a call to the police. Both residents, who require maximum assistance, reported long wait times for call light responses and expressed distress over being left in soiled conditions. The facility's policies on resident dignity and incontinence care were not followed, resulting in a deficiency.
Failure to Maintain Fall Mat Intervention Resulting in Resident Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions as outlined in its Fall Prevention Program for a resident assessed as being at risk for falls. The facility’s policy dated 2/2/26 states that each resident’s fall risk will be assessed and interventions implemented to decrease the risk of falls and injuries. The resident had medical diagnoses including abnormalities of gait and mobility, lack of coordination, muscle weakness, and altered mental status. An MDS documented that the resident was moderately cognitively impaired and required moderate staff assistance for transfers. The resident’s care plan dated 1/7/26 identified risk for falls related to muscle weakness and included an intervention for floor mats to be placed on the side of the bed, implemented on 1/6/26. On 1/25/26, nursing notes documented that the resident was found on the floor on the right side of the bed in a fetal position, reporting that they had fallen from the bed and that their head and neck hurt, with blood noted on the right side of the head. A CT scan from that date showed mild subcutaneous soft tissue swelling and a hematoma in the right posterior parietal region, along with subcutaneous emphysema consistent with a laceration, and emergency room records documented a head laceration requiring five staples. The RN assigned to the resident during the overnight shift confirmed that at the time of the fall, the fall floor mats were not in place at the bedside, despite being a previously implemented intervention. The President of Clinical Services confirmed that fall mats had been put in place as a fall prevention intervention earlier in the month and that they should have been on the floor when the resident was in bed and at the time of the fall.
Multiple Residents Did Not Receive Ordered Evening Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to physician orders, resulting in multiple omitted doses for three residents during one evening medication pass. The facility’s Medication Error Policy dated 2/2/26 requires that medications be administered as ordered and that any medication errors be reported to the physician, documented in the medical record, and reported to the appropriate supervisor. A Resident/Family Complaint Form dated 1/26/26 documents that one resident (R13) reported not receiving her evening medications on 1/23/26. During an interview on 2/5/26 at 11:48 a.m., the DON (V2) stated that residents on the Northeast Hall did not receive their evening medications on 1/23/26 and acknowledged that R13 filed a grievance about the missed medications. Record review of the January 2026 Medication Administration Records (MARs) confirmed that multiple ordered medications were not administered on the evening of 1/23/26. For R13, the MAR showed missed doses of Famotidine 20 mg, Fluticasone Propionate nasal spray, Potassium Chloride 20 mEq, Baclofen 10 mg, Diclofenac Sodium Gel 1%, and Gabapentin 1200 mg. For R14, the MAR showed missed doses of Atorvastatin 40 mg, Carvedilol 25 mg, Clonidine 0.1 mg, Doxazosin 4 mg, and Eliquis 2.5 mg. For R15, the MAR showed missed doses of Fluticasone Furoate inhalation 200-25 mcg and Rosuvastatin 5 mg. During the same 2/5/26 interview, the DON confirmed that nurses are required to administer medications per physician orders and to notify the physician and nurse supervisor when medications are not administered.
Failure to Ensure Dignified Care and Proper Response to Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ rights to dignified care and proper handling of abuse allegations for two residents. One resident (R1), with essential hypertension, COPD, bipolar disorder, muscle wasting, unsteadiness, lack of coordination, a history of falls, moderate cognitive impairment, and limited upper extremity range of motion, was totally dependent for all ADLs except eating and required significant assistance with toileting and wheelchair use. R1 reported to the Social Service Director (V4) and her county case manager (V7) that a night-shift CNA, described by physical characteristics, was rough with her care, including during transfers from bed to standing and perineal care, and that she was afraid the CNA would be rough again. V4 observed bruises on the backs of both of R1’s arms, asked about their origin, and was told by R1 that a night CNA had been rough with her care, while V7 noted small, faded bruises on both forearms and R1’s report of a neck pull during transfer. A second resident (R3), cognitively intact with an upper extremity range of motion impairment and orders for a left arm sling and ongoing occupational therapy, required substantial/maximal assistance with upper and lower body dressing. R3 filed a grievance that a night-shift CNA was on her phone during care, was rude, and rough with care. R3 later stated that the CNA belittled him by calling him lazy and saying he did not need help, and that he reported this to nursing and therapy staff. An LPN (V16) confirmed that R3 reported the CNA was on the phone, belittling him, and rough with care, and stated she immediately informed the Director of Nursing. Despite these reports, the facility did not appropriately treat the allegations as potential abuse. For R1, although V4 acknowledged the allegation of rough care and stated it would be reported to the Administrator and investigated as possible abuse, the report documents that the concern was logged as a grievance related to staff approach and resolved the same day, without further detail of an abuse investigation in the cited findings. For R3, V4 documented the concern as a grievance about staff approach and contacted the CNA directly on her personal cell phone to address phone use, but did not report or investigate the allegation of rough and belittling care as potential abuse. V4 stated she did not consider the situation abuse because she knew the CNA personally and believed she was a good person, and she informed the DON only about phone use. Facility leadership, including the Interim Administrator/Abuse Prevention Coordinator (V1) and the DON (V2), later confirmed they were not aware of R3’s grievance and that the allegation was not reported or investigated as potential abuse.
Failure to Recognize and Report Resident Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to recognize and report resident allegations of abuse, including rough and belittling care, to the Administrator/Abuse Prevention Coordinator as required. One resident (R1), with moderate cognitive impairment, limited upper extremity range of motion, and total dependence for most ADLs, reported that a CNA with a ponytail was rough during care and transfers, causing bruises on both forearms and neck pain. R1 showed the surveyor quarter- and nickel-sized bruises with yellow halos on both forearms and described being grabbed behind the neck during a transfer, which made her cough and feel scared it could happen again. R1 stated she had told a “lady up in the front offices,” later identified as the Social Service Director (V4), who noticed the bruises and was told about the rough care, but no one followed up with R1 afterward. The facility’s January Concern Log documented a grievance from R1 on 01/14/26, recorded by V4 and the Business Office Manager, describing a “mean” CNA on night shift who was rough with care and that R1 wanted to discharge home. The concern was categorized as “Care-Staff Approach,” assigned to the Interim Administrator/Abuse Prevention Coordinator (V1), and marked resolved the same day. However, when the surveyor reported R1’s detailed allegation of rough care, physical abuse, and bruising on 01/16/26, V1, the DON (V2), and the Regional Nurse Consultant (V3) all stated they were not aware of any abuse allegations involving R1. Later, V4 confirmed she had received and logged R1’s grievance, including allegations that the CNA caused bruising and neck pain, and stated she reported it to V1, while a county Community Support Services Manager (V7) corroborated being present when R1 described the rough transfer, bruises, neck pulling, and fear of future rough care. A second resident (R3), cognitively intact and receiving aftercare following joint replacement surgery, also reported concerns about staff conduct that were not properly recognized or reported as possible abuse. The January Concern Log showed a grievance from R3 about a CNA on the phone during care, categorized as “Care-Staff Approach” and assigned to Social Service, with same-day resolution. V4 later stated that R3 had reported the CNA was on her phone, rude, and rough with care, and that she identified the CNA as V11. V4 acknowledged she only addressed the phone use with the CNA, did not consider the situation abuse because she knew the CNA personally, and did not report the rough care allegation to the Administrator. R3 told the surveyor he reported the incident to prevent other residents from receiving rushed or rough care and described the CNA belittling him by calling him lazy and saying he did not need the help. An LPN (V16) and a Physical Therapy Assistant (V14) both confirmed awareness of R3’s allegations of verbal and physical abuse but did not report them to the Administrator, citing uncertainty about who the Interim Administrator was at the time. The DON and Interim Administrator later confirmed they were not informed of R3’s grievance or abuse allegations.
Failure to Report and Act on Allegations of Rough Care and Derogatory Comments
Penalty
Summary
The deficiency involves multiple staff members failing to report allegations of rough care, bruising, neck pain, and derogatory comments to the Administrator/Abuse Prevention Coordinator as required by facility policy, resulting in delayed investigation and failure to remove the alleged staff perpetrators from resident care. One resident, who had moderate cognitive impairment, limited range of motion in both upper extremities, and was dependent for most ADLs, reported that a CNA with a ponytail was rough during transfers and care, causing bruises on both forearms and neck pain that made her cough and feel choked. During an interview, the resident showed bruises on both posterior mid-forearms, described as purple with yellow halo-like fading, and stated she was scared the CNA might hurt her again. The resident reported that she had told the Social Service Director about the rough care and bruising, and that the Social Service Director had noticed the bruises and said she would report the matter to her supervisor, but no one subsequently came to interview the resident about the allegation. The facility’s concern log documented a grievance from this resident indicating she was tired of a mean CNA on night shift who was rough with care, and this concern was assigned to the Administrator. The Social Service Director later confirmed that she had received and recorded this grievance, including the resident’s report that the CNA was rough with care, caused bruising to both forearms, and caused neck pain, and stated she reported the allegation to the Interim Administrator/Abuse Prevention Coordinator. However, the Interim Administrator/Abuse Prevention Coordinator, the DON, and the Regional Nurse Consultant all stated they had no reported allegations of abuse regarding this resident. The CNA identified by the resident continued to work a full shift after the grievance was documented and was not suspended until days later, after the surveyor reported the allegation to facility leadership. A second resident, cognitively intact and receiving care following joint replacement surgery, reported to the Social Service Director that a CNA had been rough with care while on the phone during care, was rude, and did not pay attention to what she was doing. The resident described the CNA’s physical characteristics, stated that the CNA was talking to someone else instead of engaging with him, and reported that she was rough and rushed. The Social Service Director confirmed that the resident reported the CNA was rough with care and on the phone, and that she personally called the CNA, who is her relative, on her own cell phone outside the building and yelled at her about being on the phone during care. The Social Service Director stated she did not view the rough care as abuse because she knew the CNA and believed she was a good person, and therefore did not report the allegation as abuse to the Administrator, despite acknowledging knowledge of the requirement to report abuse immediately. The same resident later told the surveyor that the CNA had belittled him during care by telling someone on the phone that he was lazy and did not need all the help she had to give him, and that he reported this to the Social Service Director, an LPN, and a physical therapy assistant. The LPN confirmed that the resident reported that the CNA was rough with care, called him lazy, and said he could not do anything for himself, and stated she reported the issue to the DON but did not know who the Administrator was. The DON and Interim Administrator/Abuse Prevention Coordinator both stated they were not aware of this resident’s grievance or allegation of rough care. Timecard records showed that the CNA identified in this second allegation continued to work multiple shifts on various halls with full access to residents after the allegation was made and before she was suspended, and there was no investigation documented at the time of the survey. The facility’s Abuse, Neglect, Exploitation policy required immediate protection of residents and immediate reporting of alleged violations to the Administrator and appropriate agencies, but these procedures were not followed in these instances.
Failure to Treat Resident With Dignity During Toileting Assistance
Penalty
Summary
The facility failed to honor a resident’s right to be treated with dignity and respect when a CNA required the resident to clean another resident’s feces from a toilet seat before assisting her with toileting. The resident, who was documented as cognitively intact and requiring partial to moderate assistance with toileting hygiene and transfers, reported that while being helped to the bathroom, the CNA observed feces on the toilet seat that did not belong to the resident. The CNA told the resident to use sanitary wipes to clean the feces off the toilet seat before she could use the bathroom and stated she could not help the resident until this was done. The CNA then threw the container of wipes toward the resident and waited until the resident complied. The resident stated this interaction made her feel upset, embarrassed, and disrespected, and the Administrator confirmed that the CNA did not treat the resident with dignity in this incident.
Misappropriation of Cognitively Intact Resident’s Funds by CNA
Penalty
Summary
The facility failed to protect a resident’s right to be free from misappropriation of property when a certified nurse assistant (CNA) took a check from the resident’s personal checkbook without permission and used it to pay her own rent. The facility’s Abuse, Neglect, and Exploitation policy dated 2/11/25 states the facility will develop and implement policies and procedures that prohibit and prevent abuse and misappropriation of resident property. A State Report Investigation dated 1/12/26 documented that the CNA, later identified as V15, removed a check from resident R4’s checkbook, wrote the check for $975.00, and signed R4’s name. R4’s Minimum Data Set documented that R4 was cognitively intact, and during an interview R4 confirmed that a staff member had stolen a check from her checkbook, which she kept in her room, and used it to pay rent without her knowledge, with the issue first noticed by her son. The Administrator confirmed that V15 CNA had taken the check from R4’s checkbook and used it to pay her rent.
Failure to Secure Residents During Van Transport Results in Serious Injury
Penalty
Summary
The facility failed to ensure that two residents were properly secured in their wheelchairs during van transportation, resulting in one resident sustaining serious injuries. Specifically, one resident with multiple complex medical conditions, including chronic kidney disease, COPD, Parkinson's disease, and a history of falls, was being transported in a facility van when the driver abruptly braked, causing the resident to fall forward from the wheelchair and suffer fractures to the humerus, tibia, and fibula. The investigation revealed that the seatbelt did not properly lock in place, and the shoulder belt was broken and would not tighten. The lap belt was also missing from another seat, and these issues had been previously reported to facility administrators but were not addressed. Interviews and observations confirmed that the van's wheelchair securement system was malfunctioning, with missing and broken belts, and that the van should not have been in service. The maintenance director and a technician from the mobility company verified that the occupant securement system was not fully functioning, and the last inspection had occurred several months prior. Another resident in the van at the time was not injured but reported that neither the lap nor shoulder belt was in use. The failure to maintain the van's securement system and to ensure residents were properly secured directly led to the accident and resulting injuries.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide a copy of a resident's medical records in a timely manner after a request was made by the resident's Power of Attorney. The resident had resided at the facility for a week before being transferred to a hospital and did not return. The family member, acting as Power of Attorney, reported making a formal request and signing for the medical records, but only received evasive responses from the facility. The Medical Records staff confirmed that the request was received months earlier and, because it came from a lawyer, was forwarded to corporate, but the records had not been sent out as of the time of the survey. The Administrator acknowledged that the records had only recently been sent and agreed they should have been provided much earlier.
Failure to Maintain Clean and Comfortable Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by observations, interviews, and record reviews. During an initial tour, several unmade beds were observed, with some lacking linen and others containing soiled linen. One cognitively intact resident reported that staff did not make the bed daily, left dirty dishes in the room, and did not change sheets after providing bed or sponge baths. The resident's family member corroborated these findings, noting trash, used gloves, napkins, dirty dishes with old food, flies, and dirty linen present in the room during a visit. Another resident, who is severely cognitively impaired and dependent on staff for activities of daily living, was found in an unmade bed with the top sheet touching the floor and multiple used glasses and meal covers with thickened liquids left in the room. Staff interviews confirmed that beds should be made in the morning and dirty dishes removed after meals, but these tasks were not completed as required. Resident council meeting minutes from several months documented ongoing complaints about inadequate housekeeping, unclean floors, lack of clean linen after showers, and bedside tables not being cleaned, as well as certified nurse aides not making beds.
Failure to Secure Catheter Tubing, Cover Drainage Bag, and Document Output
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter by not securing the catheter tubing to the lower extremity, not covering the urinary collection bag with a dignity cover, and not consistently documenting urinary output every shift as ordered by the physician. Multiple observations confirmed that the catheter tubing was left dangling from the bedside and the urinary collection bag was uncovered and exposed to the hallway. Staff interviews corroborated these findings, and it was confirmed that the facility's policy requires the use of a securement device for the catheter tubing, covering the drainage bag, and recording urinary output every shift. Record review showed that the resident had physician orders for catheter care, including weekly changes of the securement device and documentation of urinary output every shift. However, the resident's output tracker revealed inconsistent documentation, with only one day showing output recorded for all three shifts. The facility's catheter care policy also mandates the use of privacy bags for drainage bags and proper securement of tubing, which was not followed in this case.
Failure to Timely Report Abuse Allegations to State Agency
Penalty
Summary
The facility failed to report allegations of abuse involving one resident to the state survey agency as required by its Abuse, Neglect and Exploitation policy. The policy mandates that all alleged violations be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes—immediately, but not later than two hours if the allegation involves abuse or results in serious bodily injury, or within 24 hours if not. The Director of Nursing (DON) received an allegation of verbal abuse from the resident's daughter and a separate allegation of physical abuse from a CNA, but did not report either incident to the state agency. The DON admitted to not knowing the abuse policy and acknowledged the failure to report. No documentation was provided to show that any abuse allegations had been reported to the state agency since February.
Failure to Assess, Notify, and Manage Pain and Change in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for two residents, resulting in significant harm. In the first case, a resident with severe cognitive impairment and a diagnosis of dementia experienced sudden, severe pain with redness and swelling in the left knee. Despite multiple staff members observing and reporting the resident's pain and changes in condition over several days, there was no immediate physician notification, no comprehensive pain or physical assessment, and inadequate pain management. The resident continued to experience severe pain for five days before being hospitalized with a left femur fracture requiring surgical repair. Documentation was lacking for pain assessments, nursing assessments, and rationale for obtaining diagnostic imaging, and the resident's pain was not consistently managed or monitored as per facility policy. In the second case, a cognitively intact resident with a history of left femur fracture, hip replacement, diabetes, heart failure, and Alzheimer's disease suffered an unwitnessed fall. The initial assessment documented no complaints of pain or injury, but no neurological checks or post-fall assessments were performed for an extended period. Over the following days, the resident exhibited increasing pain, required more frequent pain medication, and demonstrated significant changes in mobility and function, including inability to bear weight and flaccid extremities. Multiple staff members observed and reported these changes, but there was a failure to recognize the change in condition and notify the physician in a timely manner. The resident was eventually sent to the hospital, where a subdural hematoma with midline shift and a dislocated hip were diagnosed, necessitating neurosurgical and orthopedic intervention. Both cases demonstrate failures to follow the facility's policies on notification of changes, pain management, and assessment following significant changes in condition or falls. Staff did not consistently assess, document, or communicate critical changes, resulting in delayed recognition and treatment of serious medical conditions. These deficiencies were confirmed through interviews, record reviews, and direct observations by surveyors.
Removal Plan
- The facility Nursing Staff was in serviced by Director of Nursing and Regional Nurse Consultant regarding pain management, evaluation and treatment, physician notifications, documentation and follow-up. All nursing staff who have not attended the in-service will be in-serviced prior to their start of next scheduled shift. Nursing staff not in-serviced will not be able to return to work until in-service has been completed.
- All residents were assessed for pain by Assistant Director of Nursing. All residents have a pain scale documented on their Medication Administration Record to be completed every shift. A nonverbal pain scale was added for residents who are not cognitively intact.
- Director of Nursing implemented daily clinical rounds with the nursing staff to ensure all acute/chronic pain is addressed, appropriate assessments are completed, and notification of the physician has been completed appropriately. Reports will be reviewed/addressed during morning clinical meeting each day. Daily morning Clinical sheets were reviewed and Director of Nursing has been completing daily.
- Director of Nursing and Assistant Director of Nursing in-serviced Nursing Staff regarding physician notification of changes by phone with follow up by fax and text message. Random review of progress notes confirm physicians have been notified by phone with condition changes.
- Each nurses station contained a list of hot rack charting for nurses to review daily. Director of Nursing is updating hot rack sheets daily with changes. Facility Nurses will use hot rack charting with their report sheet for shift to shift nursing report to assist with communication and follow up. The report sheets will be reviewed by Director of Nursing and discussed in morning QA (Quality Assurance) meetings.
- Director of Nursing provided a print out of the daily dashboard electronic clinical record. Director of Nursing is reviewing the Point Click Care Dashboard, 24-hour report, pain management, and physician notification of change, daily for four weeks, to ensure effective measures are implemented for quality resident care.
- Director of Nursing provided a pain management weekly audit sheet. This audit documents five residents are being reviewed weekly for pain management.
- The facility Pain, Change in condition, and notification of changes in-service documents Director of Nursing reviewed policies and procedures with all nursing staff. Director of Nursing will discuss pain management policy and procedure and notification of changes at monthly nursing meeting.
- Director of Nursing and Administrator held an interdisciplinary meeting to discuss changes in conditions of residents. Administrator provided quality assurance meeting notes.
Failure to Provide Adequate Supervision During Ambulation Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including congestive heart failure, diabetes with complications, morbid obesity, polyneuropathy, end stage renal disease, cellulitis, muscle wasting, unsteadiness, and lack of coordination, was not provided adequate supervision and assistance during ambulation. The resident required Contact Guard Assist (CGA) for ambulation, meaning a caregiver should maintain physical contact to help with balance. During a physical therapy session, the resident was ambulating with a walker while a physical therapy aide trailed behind with a wheelchair carrying the resident's oxygen tank. The oxygen tubing became tangled around the wheelchair, and the aide bent over to untangle it, leaving a gap and unable to maintain contact or reach the resident. As a result, the resident experienced weakness, lost balance, and fell forward, sustaining a fractured right humerus, facial contusion, multiple abrasions, and right elbow pain. Documentation and interviews confirmed that the aide was not in a position to provide the required level of assistance, and the Director of Rehabilitation acknowledged that two staff members should be used when ambulating residents with multiple pieces of equipment. The incident led to the resident being sent to the hospital for evaluation and surgical repair of the fracture.
Failure to Provide Timely Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for two residents, resulting in significant deficiencies. For one resident with Parkinson's Disease and Alzheimer's Disease, who was dependent on staff for toileting and transfers and at high risk for pressure ulcers, the facility did not implement required repositioning and incontinence care every two hours. Staff did not consistently report refusals of care or dislodged dressings to nursing staff, and there were lapses in maintaining wound dressings. The resident was observed sitting in a wheelchair for extended periods, experienced pain, and was found with a saturated brief and an uncovered, golf ball-sized pressure ulcer on the coccyx. Documentation revealed gaps in weekly skin assessments, lack of timely physician notification, and absence of pressure-relieving interventions for the heels, despite the presence of new wounds and deterioration of existing ones. The same resident developed heel blisters that progressed to stage two and three pressure ulcers, leading to hospitalization for infection and cellulitis. After returning from the hospital, the resident developed a sacral wound that deteriorated into a stage four pressure ulcer with necrosis and slough, requiring debridement. There was no documentation of ongoing wound assessments, timely physician or dietitian notification, or implementation of recommended interventions such as offloading, repositioning, and nutritional support. Staff interviews confirmed that wound care, monitoring, and communication were inconsistent, and that staffing shortages contributed to delays in care. The wound nurse and dietitian were not made aware of the resident's wounds in a timely manner, and treatment orders were not always implemented promptly. A second resident with a history of pressure ulcers was found to have a partial thickness wound on the right buttock that was not being treated or monitored. The wound had been present for more than two days, and there was no treatment order or documentation of physician notification until the wound was identified by staff during the survey. The facility's failure to follow its own policies for wound assessment, treatment, and communication with the interdisciplinary team resulted in unaddressed and deteriorating pressure ulcers for both residents.
Removal Plan
- R52 was assessed and treated by the Wound Care Physician.
- V22 Wound Nurse was hired as the facility's full time wound nurse.
- V2 Director of Nursing and V22 Wound Nurse conducted facility wide skin checks of all residents.
- V22 Wound Nurse initiated audits that included a review of the resident skin checks, provisions of incontinence care, turning and repositioning, notifications to the physician and Registered Dietician, and monitoring of wound treatments.
- V2 Director of Nursing conducted an inservice training for nurses and Certified Nursing Assistants on the topics of skin assessments, wound assessments, identifying and reporting new and deteriorating wounds, implementing and maintaining wound treatments, notification of physician and dietitian, incontinence care, and turning and repositioning. Any remaining staff will receive this training prior to their next scheduled shift.
- V22 was in-serviced by V2 on the facility's skin and wound management programs and notification of registered dietitian and physician. V22 will be responsible for monitoring/tracking/processing of physician orders and dietitian recommendations.
- V22 will bring the audits to the Quality Assurance meetings to be reviewed by the interdisciplinary team weekly, monthly, and quarterly.
Failure to Protect Residents from Verbal and Emotional Abuse by Staff
Penalty
Summary
The facility failed to protect two residents from verbal and mental/emotional abuse by staff members. One resident, who is cognitively intact and has multiple medical diagnoses including COPD, asthma, and depression, reported being yelled at by an LPN after requesting pain medication. The resident expressed fear of retaliation and emotional distress, stating that the nurse was angry about being reported and made comments about being too busy to respond to the resident's needs. The resident's daughter confirmed the incident, and the administrator acknowledged that such behavior constitutes verbal abuse. Another resident, who requires substantial assistance with activities of daily living due to conditions such as cerebral infarction, metabolic encephalopathy, and hemiplegia, reported that a CNA took away his call light during the night shift, preventing him from calling for help. The resident also stated that staff laughed at him and were rough during transfers, causing visible distress and emotional harm. The interim DON confirmed that staff should not remove call lights or treat residents disrespectfully, and that the resident is at risk for abuse due to his level of dependency and medical conditions.
Failure to Assess, Monitor, and Manage Bowel and Wound Care
Penalty
Summary
The facility failed to properly assess, monitor, and manage the care of multiple residents, resulting in significant deficiencies in nursing care. For one resident with a history of bowel obstruction and cognitive impairment, staff did not consistently monitor or document bowel movements, failed to update the care plan with new interventions after a previous obstruction, and did not notify the physician when the resident went several days without a bowel movement. The resident was ultimately hospitalized for a high-grade small bowel obstruction after staff failed to implement bowel management medications or interventions, and there was no evidence of abdominal assessments or physician notification prior to the hospitalization. Another resident with a recent below-knee amputation did not receive timely wound care or assessment upon admission. The wound was not reported to the physician until several days after it was first identified, and no wound treatments were implemented for several days. Documentation of wound assessments and measurements was lacking, and wound care was not administered according to physician orders. During wound care, a nurse failed to change gloves and perform hand hygiene after removing the old dressing and handling the resident's personal items, increasing the risk of cross-contamination. The resident required additional surgery for wound infection and dehiscence. A third resident, who was cognitively intact and had a diagnosis of constipation, experienced prolonged periods without bowel movements while receiving medications known to cause constipation. The resident reported severe pain and difficulty with elimination, and was eventually hospitalized for fecal impaction and pyelonephritis. There was no evidence of bowel management medications being administered prior to hospitalization, and documentation showed multiple days without bowel movements. The care plan for constipation was not initiated until after the hospitalization event.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to identify and respond to significant weight loss in a resident diagnosed with multiple conditions including COPD, chronic respiratory failure, anemia, protein calorie malnutrition, and hypokalemia. Despite a care plan that required monitoring and notification of the physician and registered dietician in the event of further weight loss, staff did not notify the appropriate medical personnel or implement new interventions when the resident experienced a weight loss of over 13% in six months. The resident's weight continued to decline over subsequent months without documented action. Record review and staff interviews confirmed that neither the physician nor the registered dietician were informed of the resident's ongoing and significant unplanned weight loss. The registered dietician had not assessed the resident since several months prior, and the nurse practitioner was also unaware of the weight loss. The facility's own policy required comparison of monthly weights and notification of significant changes, but these steps were not followed, resulting in continued weight loss for the resident.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for two residents by not accurately assessing pain, failing to notify the physician of pain, and not implementing physician orders for pain medications. One resident with cognitive impairment, Parkinson's Disease, and Alzheimer's Disease had a worsening sacral pressure ulcer and exhibited clear signs of pain, including moaning, grimacing, tearfulness, and clenched fists. Despite these symptoms and staff awareness of the resident's pain, there were no active physician orders for pain medication, and pain assessments consistently documented no pain. The resident's care plan included interventions for pain management, but these were not followed, and the physician was not notified of the resident's pain until after significant deterioration of the wound and increased pain were observed. Another resident, cognitively intact and with a history of back surgery, radiculopathy, spinal stenosis, and osteoarthritis, reported frequent pain in the lower back and knees. The resident experienced severe pain during care activities, as evidenced by yelling, moaning, heavy breathing, and tears. Although the resident had PRN orders for pain medications, there were no scheduled pain medications, and pain medication was not administered until later in the day despite the resident's requests and visible distress. Staff interviews indicated that the resident often did not request pain medication until already in pain during therapy or care, and pain assessments documented moderate to severe pain on multiple occasions. Both cases demonstrate a failure to recognize and respond to residents' pain, as required by the facility's pain management policy. Staff did not consistently assess or report pain, and physician notification and intervention were delayed, resulting in unmanaged pain and, in one case, a worsening pressure ulcer that required debridement. The facility's actions and inactions did not align with established care plans or standard pain management practices.
Insufficient Nursing Staff Resulting in Delayed Resident Care and Unmet Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by long call light response times and delays in wound treatments and assessments for eight residents out of 32 reviewed. The facility's own assessment indicated a need for 24 CNAs for a census of 97 residents, but staffing records showed only 19-20 CNAs were present on several days. Resident council minutes and interviews with residents consistently reported call light response times of 30-45 minutes or longer, missed or delayed showers, and cold food due to insufficient staff to deliver trays promptly. Multiple residents stated they often waited extended periods for assistance, including incontinence care, and some had not been cleaned up by late morning. Staff interviews confirmed the ongoing staffing shortages, with one LPN responsible for 32 residents and reporting difficulty completing assessments, treatments, and processing orders, often resulting in tasks being passed to the next shift and sometimes missed. The CNA/scheduler and administrator acknowledged the inability to maintain adequate staffing, with frequent call-ins and no-shows, and confirmed that the facility had stopped taking new admissions due to the staffing crisis. The deficiency directly resulted in unmet resident care needs, including delayed toileting, repositioning, and incomplete scheduled showers.
Failure to Post Up-to-Date Nurse Staffing Information
Penalty
Summary
The facility failed to post daily, up-to-date nurse staffing information as required, with the posted staffing sheet near the front entrance remaining dated 2/28/25 over several days of observation, including 3/3/25 and 3/5/25. This issue was confirmed by the Interim Regional DON, who acknowledged that the posted daily staffing should be updated each day. The deficiency potentially affected all 97 residents in the facility. Additional concerns identified during the survey included issues related to staffing, showers, cold food, turning and repositioning, toileting, incontinence care, infection control, and call light wait times. Resident Council Meeting Minutes from two separate dates also documented resident concerns regarding call light wait times.
Failure to Employ Qualified Full-Time Social Worker
Penalty
Summary
The facility, which has 150 licensed beds and 97 residents, failed to employ a qualified full-time social worker as required by its own facility assessment. During an interview, the administrator confirmed that the current staff member covering both Activities and Social Services does not possess the necessary qualifications to serve as a social worker, specifically lacking a degree in Social Work or Human Services. This deficiency was identified through interviews and record reviews, and it was noted that the lack of a qualified social worker could potentially affect all residents in the facility.
Failure to Implement Water Management Plan and Risk Assessment
Penalty
Summary
The facility failed to implement its water management plan as required, specifically by not conducting a comprehensive risk assessment to identify areas in the water system where Legionella and other pathogens could grow and spread. The water management plan, although revised, did not include documentation of the risk assessment, specific testing protocols, acceptable control measure ranges, or corrective actions for when control limits are not maintained. During an interview, the administrator confirmed a lack of access to or documentation of completed risk assessments or related activities. These failures were identified through interviews and record reviews and have the potential to affect all 97 residents in the facility.
Failure to Properly Record and Manage Resident Funds
Penalty
Summary
The facility failed to properly record and manage resident funds for five out of seven residents reviewed. During observation, surveyors found stapled plastic pill pouches containing cash taped to the underside of the narcotic section of medication carts, with residents' names written on the pouches. The amounts of money varied, and one pouch was labeled as 'lost and found.' Staff, including an LPN, stated that the money belonged to the residents and was kept in the medication carts because the business office was closed on weekends. There was no sign-out sheet or documentation system in place for tracking how much money each resident had or how much was given to them from these pouches. Further interviews with the Assistant Director of Nursing confirmed that there should have been a sign-out sheet at each medication cart, but none were present. The Corporate Business Office Manager stated that all resident money should be entered into the resident fund account and was unaware that nurses were storing residents' money in the medication carts. Review of the residents' trust fund statements showed no documentation of deposits or withdrawals related to the money found in the carts. The facility's policy requires the business office to maintain a record of all financial transactions, including deposits and withdrawals, but this was not followed in these cases.
Failure to Provide Scheduled Showers and Hygiene Assistance
Penalty
Summary
The facility failed to provide scheduled showers and necessary hygiene and grooming assistance for four residents who were unable to perform activities of daily living independently. According to the facility's Activities of Daily Living Policy, residents who cannot carry out these tasks are to receive the required care to maintain grooming and personal care. Observations and record reviews revealed that one resident, who was dependent for personal hygiene due to a history of CVA and left-sided weakness, was noted to have unclean hair, long nails, and food in his beard and on his shirt. Another resident, requiring substantial assistance due to dementia and right hemiplegia, was observed with long and dirty nails. A third resident, with hemiplegia and limited mobility, was seen on two occasions with stained clothing, long and dirty nails, and facial hair in need of shaving. Additionally, a cognitively intact resident who is dependent on staff for bathing reported during a resident council meeting that showers were not being provided as scheduled, citing insufficient staffing. Documentation confirmed that this resident missed several scheduled showers over a two-month period, with gaps in records indicating showers were not offered as required. The Director of Nursing confirmed the accuracy of the provided documentation, which supported the findings of missed care.
Failure to Serve Palatable and Appropriately Heated Meals in a Timely Manner
Penalty
Summary
The facility failed to ensure that food was palatable, served at a satisfactory temperature, and delivered in a timely manner for five residents reviewed for food satisfaction. According to the facility's policy, hot food should be held and served at a temperature no lower than 135 degrees Fahrenheit. Multiple residents reported during interviews and a resident council meeting that their food was often cold, unappetizing, and not delivered promptly, both in the dining room and in their rooms. Several residents stated that there was insufficient staff to pass trays in a timely manner, and some reported that their families brought food from home due to dissatisfaction with the facility's meals. Observations confirmed that food holding carts with resident trays remained in the kitchen for extended periods before being delivered. When food temperatures were checked, items such as fried chicken were found to be significantly below the required 135 degrees Fahrenheit, with readings as low as 100.7 degrees. Staff acknowledged that the delay in passing trays resulted in food being served too cold. The dietary manager confirmed that meals are expected to be served at the appropriate temperature, but this standard was not met during the survey period.
Failure to Maintain Resident Dignity in Activities of Daily Living
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral infarction, metabolic encephalopathy, rhabdomyolysis, and hemiplegia was observed on multiple occasions with stained clothing, long and dirty fingernails, and unshaven facial hair. The resident required substantial to maximum assistance with eating and had impairments on one side of both upper and lower extremities, as documented in the care plan and Minimum Data Set. Despite these needs, the resident was seen after meals with food and drink stains on their shirt and poor personal hygiene. Interviews with staff revealed that the certified nursing assistant was unaware of the resident's soiled condition, attributing it to staffing shortages and not being the one who returned the resident to their room after lunch. The administrator confirmed that staff are expected to follow policies and procedures to maintain resident dignity and meet their needs. The facility's policy emphasizes the importance of treating residents with respect and dignity, but these standards were not met in this instance.
Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to two residents as required by its policy and the residents' care plans. One resident, who was cognitively intact and required partial to moderate assistance for transfers and ambulation, was observed sitting in a wheelchair with his breakfast tray untouched because his call light was attached to the bedrail on the opposite side of the bed, out of his reach. The resident reported being unable to request assistance to have his food reheated due to the inaccessible call light and stated he could not walk on his own. Another resident, who required staff assistance with all personal care, transfers, and bed mobility due to a history of right femur fracture, was found sitting in a wheelchair with the call light lying on the floor behind him, also out of reach. This resident stated that being unable to reach the call light happened frequently, despite a care plan intervention specifying that the call light should be kept within reach at all times.
Failure to Accurately Record and Communicate Resident's Advance Directive
Penalty
Summary
The facility failed to accurately review and record a resident's physician's orders for life-sustaining treatment, resulting in a discrepancy between the resident's documented code status and their signed advance directive. Specifically, a cognitively intact resident stated having a Do Not Resuscitate (DNR) order, and their Physician's Order for Life Sustaining Treatment (POLST), signed by both the resident and a physician, indicated DNR. However, the resident's hospital discharge orders, active profile, and physician's orders in the electronic medical record all listed the resident as full code. The care plan did reflect the DNR status, but nursing staff relied on hospital records and the electronic profile, which did not match the POLST form. This inconsistency was confirmed during interviews and record reviews, demonstrating a failure to ensure that the resident's advance directive was accurately reflected and communicated in all relevant documentation.
Failure to Provide Functional Bed Results in Resident Discomfort
Penalty
Summary
The facility failed to provide a comfortable and functioning bed for a resident who required assistance with bed mobility due to a right femur fracture, infection, and low back pain. The resident was found lying in bed with the head of the bed unevenly elevated and reported that the bed had been broken since 1:00 AM, leaving him unable to change position and causing discomfort. Despite notifying staff, no maintenance personnel responded, and the bed remained nonfunctional when both the resident and a Certified Nursing Assistant attempted to operate it. The Regional Maintenance Director later confirmed that staff should have replaced the bed rather than leaving the resident in the broken bed overnight.
Failure to Timely Investigate and Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse prevention policy by not promptly investigating and reporting an allegation of verbal abuse involving one resident. According to the facility's policy, all allegations of abuse, including verbal abuse, must be immediately investigated and reported to the state agency within 24 hours. However, after a resident reported being verbally abused by an LPN, the administrator received a call from the resident's family member about the incident but did not notify the state agency or begin an investigation until several days later. This delay in response was contrary to the facility's established procedures for handling abuse allegations.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to notify the state agency in a timely manner regarding an allegation of verbal abuse involving one resident. The administrator received a phone call from a family member reporting that a Licensed Practical Nurse was rude to the resident and caused the resident to become upset. Despite receiving this information, the administrator did not notify the state agency until several days later. Documentation confirmed that the state agency was not informed of the verbal abuse allegation until after the delay.
Failure to Immediately Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to immediately investigate an allegation of verbal abuse involving one resident. The Administrator received a phone call from a family member reporting that a Licensed Practical Nurse was rude to the resident and caused the resident to become very upset. Despite receiving this information, the Administrator did not initiate an investigation into the alleged abuse until several days later. The facility's report to the state agency confirmed that the investigation was not started until after the delay.
Failure to Coordinate PASARR Level II Evaluation for Resident with SMI Diagnoses
Penalty
Summary
The facility failed to coordinate a required Pre-Admission Screening and Resident Review (PASARR) Level II evaluation for one resident who was reviewed for PASARR II completion. The resident was admitted with diagnoses of Generalized Anxiety Disorder and Post Traumatic Stress Disorder, both of which had been present since 2016. Despite these diagnoses, the PASARR Level I evaluation completed at admission indicated that no Level II evaluation was necessary, as it did not identify any Significant Mental Illness (SMI) diagnosis. Upon interview, the Regional Interim DON confirmed that if a resident had an SMI diagnosis on admission or was later diagnosed, a PASARR Level II evaluation should have been coordinated. The PASARR Level I evaluation for this resident was not reviewed for accuracy at the time of admission, resulting in the failure to identify the need for a Level II evaluation.
Failure to Follow Physician Orders for Daily Weights and Notification
Penalty
Summary
Staff failed to follow physician orders for a resident diagnosed with Chronic Diastolic Congestive Heart Failure and Chronic Kidney Disease Stage 4. The physician had ordered daily weights to be taken every day shift, with instructions to notify the physician if there was a weight gain greater than three pounds in 24 hours or greater than five pounds in seven days. The resident's care plan also included monitoring and reporting sudden weight gain as an intervention for fluid volume overload. However, review of the Treatment Administration Records (TAR) revealed multiple missed days for daily weights across several months, including 12 missed days in December, 11 in January, 9 in February, and 3 in March. During this period, there was a documented weight gain of 12.9 pounds over two days, with no evidence that the medical provider was notified as required by the physician's order. Interviews with facility staff, including a nurse practitioner and the regional interim DON, confirmed that daily weights were necessary for monitoring the resident's condition and that staff were expected to follow physician orders. Both acknowledged that the daily weights should have been completed and documented, and that the physician should have been notified of significant weight changes as specified in the orders. The failure to consistently obtain and document daily weights, as well as to notify the physician of abnormal weight gain, constituted a failure to provide care according to the resident's written plan of care.
Failure to Monitor Bleeding Risk for Resident on Anticoagulant and Antiplatelet Therapy
Penalty
Summary
The facility failed to adequately monitor a resident's risk of bleeding associated with the use of anticoagulant and antiplatelet medications. The resident had physician orders for Eliquis (an anticoagulant) and Clopidogrel (an antiplatelet), but there were no corresponding physician orders to monitor for bleeding risks or signs of bleeding related to these medications. The resident's care plan addressed the risk of bleeding and bruising related to Aspirin and Clopidogrel, with interventions to administer medications as ordered and monitor for adverse reactions, but did not include Eliquis in the care plan. Interviews with facility staff confirmed awareness of the resident's use of both Eliquis and Clopidogrel and the associated need for close monitoring for bleeding risks. A nurse practitioner stated that the medications were prescribed for different conditions and acknowledged the necessity for monitoring. A licensed practical nurse confirmed that there should be an order for monitoring anticoagulant use and bleeding complications, typically recorded on the Treatment Administration Record, but verified that such an order was missing for this resident.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to implement resident-centered interventions to prevent skin breakdown and worsening of pressure sores for a resident, identified as R2. This failure led to R2 developing a stage four pressure ulcer on the right ischium and unstageable pressure areas on both heels. The facility did not notify the wound physician and dietitian of new open areas, which contributed to the severity of the pressure injuries. R2's condition was exacerbated by inadequate incontinence care and delayed response to call lights, resulting in prolonged exposure to moisture and pressure. R2 was admitted with intact skin and a history of cerebral infarction, obesity, muscle weakness, generalized anxiety disorder, major depression, paralytic gait, and reduced mobility. R2 was wheelchair-dependent and required substantial assistance for transfers and toileting. Despite being frequently incontinent, R2 did not receive timely incontinence care, which contributed to the development and worsening of pressure sores. The facility's failure to provide appropriate skin care and pressure relief measures, such as pressure-relieving boots and a low air loss mattress, further aggravated R2's condition. Observations and interviews revealed that R2 often experienced delays in receiving care, with call lights being turned off without follow-up. The facility's staff did not consistently document or communicate R2's skin condition to the appropriate medical personnel, delaying necessary interventions. The facility's policies on pressure injury prevention and incontinence care were not effectively implemented, leading to avoidable pressure injuries and inadequate treatment of existing wounds.
Removal Plan
- R2's wounds were assessed and treated by wound care consultant staff.
- R2 was educated on benefits of preventative measures and current treatment regimen.
- A facility-wide skin audit was conducted by V2 DON/Designees.
- Facility-wide risk for skin breakdown assessments were initiated by V2DON/Designees.
- An audit was conducted by V2 DON/RNC to ensure completion of risk for skin breakdown assessments and weekly/daily skin checks.
- In-servicing was initiated by V2 DON/Designee for all Licensed Nurses on Pressure Injury Prevention and weekly skin checks. V2 DON/Designee will be responsible for ensuring compliance of the program.
- In-servicing was initiated by V2 DON/Designee of all Licensed Nurses and CNAs on incontinence care and call light response.
- V2DON/designee will review four residents skin checks weekly for four weeks and then four residents skin checks bi-weekly for four weeks to ensure that all skin issues have been identified and properly treated.
- V1 Administrator/Designee will monitor call light response time four times a week for four weeks and then randomly thereafter.
- V2 DON/Designee will in-service Licensed nursing staff and CNAs on call light response time, incontinence care, skin checks, and pressure injury prevention policy once a month for 3 months.
- V2 DON/Designee will be responsible for monitoring/tracking/processing of MD orders.
- CNAs were in-serviced by DON/RNC/ADMINISTRATOR on reporting skin concerns to nurses with skin report sheet.
- If the facility in the future utilizes agency staff DON/Designee will ensure in-serving on all processes prior to start date.
- V2 DON/Designee will be responsible for notification of Registered Dietitian and processing the recommendations.
Insufficient RN Coverage in Facility
Penalty
Summary
The facility failed to provide sufficient Registered Nursing (RN) hours for six specific days within the period from January 1, 2025, to February 24, 2025. On these days, the facility's nursing schedule did not document the required eight hours of RN coverage within a 24-hour period. This deficiency was confirmed by the facility's administrator, who acknowledged the accuracy of the nursing schedule and the absence of the mandated RN coverage on the specified dates. The facility houses 95 residents, all of whom could potentially be affected by this staffing shortfall.
Inaccurate Facility Assessment
Penalty
Summary
The facility failed to maintain an accurate and up-to-date facility-wide assessment, which is required to be reviewed at least annually and updated as needed. This deficiency was identified through interviews and record reviews, revealing that the facility's assessment did not document the date or time when the interdisciplinary team met to review it. Additionally, the assessment failed to address the direct care staff needed to meet the resident population's needs by shift. Notably, the assessment inaccurately recorded zero residents with behavioral symptoms and cognitive performance issues, despite the facility's Matrix indicating that 29 residents were diagnosed with Alzheimer's or Dementia. The facility administrator confirmed the inaccuracy of the assessment and provided a separate signature page dated 12/20/24, which was not part of the assessment.
Delayed Call Light Response Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to respond to call lights in a timely manner for two residents, leading to unmet needs and discomfort. The facility's policy requires all staff to respond to activated call lights and notify appropriate personnel if they cannot fulfill the resident's request. However, residents reported that call lights often took 30 minutes or longer to be answered, and staff would sometimes turn off the call light without returning to assist the resident. This issue was highlighted in the Resident Council Meeting Minutes, where residents expressed dissatisfaction with the delayed response times. Resident 1, who has multiple medical conditions including Ischemic Heart Disease, Congestive Heart Failure, and Chronic Kidney Disease, reported that it often took 25-30 minutes for staff to respond to her call light. She also mentioned being left on a bedpan for extended periods, causing discomfort. Resident 2, diagnosed with Muscle Wasting and Paralytic Gait, also experienced similar issues, with staff turning off the call light and not returning to provide assistance. The Director of Nurses acknowledged the need for prompt response to call lights and emphasized that staff should assist residents immediately or return within a reasonable timeframe if they need to leave the room.
Failure to Ensure Safe Resident Transfers
Penalty
Summary
The facility failed to adhere to its Safe Resident Handling/Transfers policy, which mandates the use of two staff members when transferring residents with a mechanical lift. This deficiency was identified through interviews and record reviews involving two residents, R1 and R2, who were both dependent on staff for transfers and required a full body mechanical lift. R1, diagnosed with multiple conditions including Ischemic Heart Disease and Obesity, reported that staff sometimes transferred her with only one CNA due to the unavailability of additional help. Similarly, R2, who has a history of falls and reduced mobility, also reported being transferred with the assistance of only one CNA on at least two occasions. The Director of Nurses confirmed that both R1 and R2 require a full body mechanical lift for all transfers and that the facility's policy necessitates the assistance of two CNAs for such transfers to ensure the safety of both residents and staff. The failure to consistently follow this policy resulted in unsafe transfer practices for these residents, highlighting a significant lapse in the facility's adherence to its own safety protocols.
Failure to Maintain Clean Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by multiple observations of unclean resident rooms. For instance, a resident's garbage can was observed to be full throughout the day, and the housekeeper admitted to not having cleaned the room yet. Another room shared by two residents had a medical glove and used paper towels on the floor, along with food particles and dirt under the bed, which were not fully cleaned even after the housekeeper had supposedly cleaned the room. In another instance, a resident's room had dirt and debris behind the bed and under the feeding pole, which remained even after the room was cleaned. The housekeeping supervisor confirmed the oversight and acknowledged that the area should have been cleaned. Additionally, a family member reported that a deceased resident's room was not cleaned promptly, leaving soiled items and a strong odor, which affected the surviving roommate. The housekeeping staff's schedule, which ends at 2:00 PM, was cited as a reason for the lack of cleanliness, with nursing staff expected to take over housekeeping duties after that time. The facility's policy on room cleaning and disinfection was not adhered to, as evidenced by the unclean conditions observed in the resident rooms. The policy requires regular cleaning of horizontal surfaces and thorough cleaning upon a resident's discharge, which was not followed in the reported cases. The housekeeping supervisor acknowledged the lapses in cleaning and the need for follow-up with the housekeeping staff to ensure compliance with the facility's cleaning standards.
Unsecured Sink in Resident's Room
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment for a resident, identified as R4, due to an unsecured sink in the resident's room. On August 28, 2024, it was observed that the sink was not properly attached to the cabinet base or the wall, leaving it unstable and wobbly. The resident, R4, mentioned that they avoid using the sink for support due to its instability and recalled that a maintenance worker had acknowledged the issue 2-3 weeks prior but did not fix it. A Certified Nurses Assistant (CNA) confirmed the sink's instability and stated it had been reported. On the following day, a corporate maintenance staff member confirmed the sink's condition and admitted that no repairs had been made before the initial observation date.
Failure to Provide Call Light Access for Resident at Fall Risk
Penalty
Summary
The facility failed to implement a call light intervention for a resident, identified as R6, who had a recent history of falls. R6, diagnosed with muscle weakness and Alzheimer's disease, was assessed to be at moderate risk for falls. Despite this, the resident did not have access to a call light in her shared room, which was a critical intervention outlined in her care plan. This lack of access was confirmed by multiple staff members, including a housekeeper, a CNA, and the Director of Nursing, who all acknowledged the absence of a call light on R6's side of the room. R6 experienced multiple unwitnessed falls, one on 7/25/24 and another on 8/21/24, both times rolling out of bed while attempting to reposition herself. The falls resulted in injuries, including a hematoma on the forehead and a bruise near the eye. The resident's cognitive impairment and poor safety awareness were noted, and it was documented that the bedside call light was not on when the resident was found after the fall on 8/21/24. The facility's policy requires that each resident's fall risk be assessed and appropriate interventions be implemented, including ensuring that call lights and frequently used items are within reach. However, R6's room lacked the necessary equipment to provide her with a call light, as there was only one call light available for her roommate, and no splitter was present to extend the call light to R6's side. This oversight in providing adequate supervision and accident prevention measures contributed to the resident's falls and injuries.
Insufficient RN Coverage Over Multiple Days
Penalty
Summary
The facility failed to provide sufficient Registered Nursing (RN) hours on five out of fourteen days reviewed, which has the potential to affect all 92 residents in the facility. Specifically, the facility's nursing schedule from July 24, 2024, through August 6, 2024, showed zero hours of RN coverage for the entire 24-hour period on July 27, July 29, August 1, August 3, and August 4, 2024. This deficiency was confirmed by the facility's administrator on August 7, 2024, who acknowledged the accuracy of the nursing schedule and the lack of RN coverage on the specified dates. At the time of the deficiency, the facility's resident midnight census documented that 92 residents resided in the facility.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner and were within reach for residents, affecting three of four residents reviewed for call lights. Resident 2, diagnosed with abnormalities of gait and mobility, gout, and morbid obesity, reported that staff did not respond quickly to call lights, resulting in long waits for assistance. Resident 3, with a fracture of the left femur and impaired mobility, also reported long delays in response to call lights. Resident 6, with multiple mobility impairments and a history of falls, experienced significant delays, including an instance where they waited 1 hour and 30 minutes for assistance and had to walk to the restroom unassisted, waiting an additional 45 minutes for help to return to their recliner. The resident council minutes and grievance logs further document ongoing issues with call light response times, with residents consistently voicing complaints about delays and staff turning off call lights without returning. The facility's administrator acknowledged the ongoing issue, stating that a response time of 15 to 30 minutes was considered acceptable, despite the facility's policy emphasizing that response times should be a priority. The administrator also agreed that not all staff adhered to the policy of responding to activated call lights, contributing to the deficiency.
Failure to Follow Narcotic Destruction Policy
Penalty
Summary
The facility failed to adhere to its narcotic destruction policy, which requires that the destruction of unused drugs be witnessed by two nurses. This deficiency was identified during a review of a resident's medication management. The resident, who was transferred to the hospital for hypotension, was found to have two Fentanyl patches on their body, which led to the administration of Narcan and subsequent admission to the Intensive Care Unit (ICU). The resident's Electronic Medication Administration Record (MAR) indicated that a Fentanyl patch was to be applied every 72 hours, with the last recorded application on 7/31/24. A Registered Nurse (RN) admitted to removing a Fentanyl patch from the resident's back and applying a new one to the chest without checking for additional patches. Furthermore, the RN disposed of the patch alone, without a witness, contrary to the facility's policy. This oversight contributed to the resident having two patches applied simultaneously, resulting in the need for emergency medical intervention. The facility's administrator confirmed the policy requirement for two nurses to witness the destruction of narcotic patches, highlighting the procedural lapse in this instance.
Failure to Notify Resident's Family of X-ray Results
Penalty
Summary
The facility failed to notify a patient representative of an X-ray result for a resident who was reviewed for notification of changes. The facility's policy requires prompt notification of the resident, physician, and resident's representative when there is a change requiring notification. On July 1, 2024, a resident complained of pain in the left foot, and an LPN notified the physician, who ordered an X-ray. The X-ray was completed on July 2, 2024, and the result was received by the facility on July 3, 2024, with the physician being notified. However, the resident's family was not informed of the X-ray results, as confirmed by the Director of Nursing on July 11, 2024. There was no documentation of the notification to the patient representative, which was acknowledged as a requirement by the Director of Nursing.
Failure to Implement Fall Prevention Intervention
Penalty
Summary
The facility failed to implement a fall prevention intervention for a resident identified as R2, who was at moderate risk for falls. R2's care plan, initiated on 5/19/24, included a fall intervention of a non-slip rubber-like plastic material to be added to the wheelchair seat. Despite this intervention, R2 was found lying on the floor in the dining room near her wheelchair on 5/29/24. The fall investigation determined that R2 slipped out of the wheelchair while trying to reposition herself, but there was no documentation confirming whether the non-slip material was in place at the time of the fall. R2's medical history includes a history of falling, urinary tract infection, dementia, wedge compression fractures, abnormalities of gait and mobility, and muscle weakness, all contributing to her moderate fall risk. The Director of Nursing confirmed the absence of documentation regarding the presence of the non-slip material during the fall and was unsure who found R2 on the floor. This lack of documentation and uncertainty about the intervention's implementation contributed to the deficiency identified in the facility's fall prevention efforts.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure the dignity of two residents by not providing timely incontinence care. Resident 1, who has multiple medical diagnoses including cerebral infarction and morbid obesity, was found in a fully saturated incontinence brief and linen pads. The resident, who is cognitively intact and requires maximum assistance for toileting, reported that staff took two hours and forty-five minutes to respond to her call light, leading her to call the police for assistance. The facility's Assistant Administrator confirmed that the resident had voiced concerns about delayed responses to call lights, and the Assistant Director of Nurses stated that incontinent residents should be offered care at least every two hours. Resident 2, who has a history of ischemic heart disease and a recent left leg amputation, also reported long wait times for call light responses, typically 30-45 minutes. The resident expressed embarrassment and distress over being told by staff to urinate in her incontinence brief due to delays in assistance. Despite complaints to the Administrator and nursing staff, the resident noted no improvement in response times. The facility's Administrator acknowledged the issue with call light response times and stated that staff had been educated on the matter. The facility's policies on promoting resident dignity and incontinence care emphasize timely responses to requests for assistance and maintaining residents at their highest functioning level. However, the observations and resident reports indicate a failure to adhere to these policies, resulting in prolonged periods of incontinence and distress for the residents involved.
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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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