Loft Rehabilitation & Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Eureka, Illinois.
- Location
- 700 North Main Street, Eureka, Illinois 61530
- CMS Provider Number
- 145431
- Inspections on file
- 49
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Loft Rehabilitation & Nursing during CMS and state inspections, most recent first.
A confused, intermittently agitated resident with Parkinson’s disease, repeated falls, gait abnormalities, and other serious conditions was not identified as an elopement risk and did not have a wander-alert bracelet or enhanced supervision, despite documented exit-seeking behavior and attempts to leave. On an evening when the resident was noted to be very agitated, an LPN administered lorazepam but left the resident in the lobby in a wheelchair without 1:1 monitoring or instructing the CNA to increase supervision. The resident then exited through the alarmed front doors after a visitor used the keypad code to silence the alarm; staff did not respond to the alarm, did not initiate a Code Yellow, and did not perform a head count. A police officer later found the resident outside in the parking lot next to an overturned wheelchair, in cold weather, with lacerations and contusions, while facility staff were unaware the resident had left the building. The facility had a practice of giving door codes to family members and visitors, allowing them to silence alarms and enter or exit without staff oversight, contributing to the failure to prevent and promptly detect the elopement.
A resident with significant physical limitations was physically abused by two CNAs, who forcefully transferred her from a wheelchair to a recliner despite her protests and inability to comply, resulting in multiple finger-shaped bruises on her upper arms. The incident was reported by another CNA, confirmed by medical documentation and a police investigation, and the resident expressed pain and distress as a result.
A resident with COPD and respiratory failure was taken to an activity without ensuring their portable oxygen tank was filled, leading to a drop in oxygen saturation to 64%. The RN did not check the tank's fullness, and the resident was sent to the ED. The facility failed to follow its Oxygen Administration Policy, which required monitoring and documentation of oxygen levels.
A resident with an indwelling urinary catheter was hospitalized with severe septic shock, acute kidney injury, and hyperkalemia due to inadequate catheter care. The facility's policy required monitoring every shift, but staff failed to document or perform necessary checks, leading to a twisted and blocked catheter. This resulted in a severe infection and the resident's admission to intensive care.
A resident with severe cognitive impairment and a history of exit-seeking behavior eloped from the facility due to inadequate door alarms and supervision. The resident exited the facility unnoticed, walked over 1635 feet, and fell, sustaining fractures and abrasions. The facility's failure to ensure loud enough door alarms and prompt staff response contributed to the incident.
A resident with severe cognitive impairment was physically abused by another cognitively intact resident in an LTC facility. The incident involved the aggressor entering the victim's room, yelling, and striking the victim multiple times, resulting in facial scratches. The abuse was reported by a CNA who observed the aftermath and reviewed video footage confirming the aggressor's actions.
Two residents in a long-term care facility experienced significant medication errors. One resident with Type 2 Diabetes Mellitus missed a scheduled insulin dose, leading to elevated blood sugar levels and fatigue. The nurse failed to administer insulin timely, and the nurse practitioner was not informed of the missed dose. Another resident with Parkinson's Disease missed 25 days of Sinemet due to the facility's failure to reorder the medication and update the neurology office. The resident experienced increased tremors and unsteady gait. The facility did not follow its medication administration and error reporting policies, resulting in these deficiencies.
A resident with dementia and other medical conditions was verbally and mentally abused by an agency CNA, causing extreme fear and mental anguish. The CNA screamed at the resident, threatened her with jail, and used a phone to intimidate her. The facility lacked proper abuse training for the CNA and did not provide psychosocial support to the resident after the incident.
The facility failed to properly cool and document potentially hazardous foods, maintain a clean kitchen, and label and discard outdated food items, affecting all 64 residents. The Dietary Manager acknowledged incomplete logs and unclean conditions, including rusted shelving and improperly stored food.
The facility failed to ensure required members attended QA meetings, affecting all 64 residents. The QAA committee lacked an Infection Preventionist, and the DON was absent from a July meeting. Only three members attended a March meeting, and the Medical Director missed a November meeting. The Administrator confirmed these absences and the lack of a designated ICP.
The facility failed to designate a qualified Infection Preventionist, affecting all 64 residents. The Interim DON admitted to not completing the necessary training before the surveyors' entrance and could not locate the certificate of completion. The Administrator in Training was also unable to find the Infection Preventionist certificate.
The facility did not provide the mandated eight hours of RN coverage daily, affecting all 64 residents. The nursing schedule for July showed no RN coverage on several days, confirmed by the Administrator in Training, who cited challenges in securing weekend coverage. The daily nurse posting was also missing for these dates.
The facility failed to provide adequate oversight, resulting in deficiencies affecting resident care and safety. The Administrator in Training did not ensure the implementation of policies related to abuse prevention, medication administration, and resident supervision. Incidents of verbal abuse by staff were not properly documented or investigated, and medication errors were prevalent, with significant lapses in administration. The facility also failed to inform residents of the bed hold policy during hospital transfers and lacked a designated Infection Control Preventionist.
The facility failed to maintain accurate Advanced Directive information for two residents. One resident had a Full Code status in the Order Summary Report, while the POLST form indicated Do Not Attempt Resuscitation and Comfort-Focused Treatment. Another resident had similar discrepancies. The Administrator in Training acknowledged the issue, citing the absence of a Social Service Director to ensure document alignment.
A resident with dementia and other health issues did not receive scheduled physician-ordered showers, as confirmed by both the resident and her family. Documentation showed the last shower was recorded days before the scheduled ones, and staff confirmed the oversight. The facility's policy requires documentation of such care, which was not adhered to.
A resident with an indwelling urinary catheter was observed with the catheter drainage bag uncovered and the tubing lying on the floor, contrary to the facility's Catheter Care Policy. Staff confirmed the deficiency, acknowledging that the catheter bag should have been covered and the tubing should not have been dragging on the floor.
A facility exceeded the acceptable medication error rate with a 6.9% error rate due to two errors in a sample of 29. A resident with Type Two Diabetes Mellitus did not receive Metformin at the scheduled time, and sliding scale insulin was not administered before breakfast. The errors were attributed to a new RN unfamiliar with the floor.
The facility failed to report and investigate incidents of abuse and injuries of unknown origin for two residents. One resident with multiple diagnoses was found with a large bruise on her wrist, which was not reported to the abuse coordinator. Another resident reported verbal abuse by an LPN, which was not documented or investigated. The Administrator in Training was aware of the incidents but did not ensure proper documentation or reporting.
A resident on hospice care reported verbal abuse by a nurse after a delay in receiving morphine. The resident felt mistreated and isolated, with no documented investigation or protective measures taken by the facility. The Administrator was aware but deferred to the DON, resulting in no recorded actions.
A facility failed to update a resident's care plan after a status change, which included specific instructions prohibiting a friend from taking the resident off the property. Despite these instructions, the resident left the facility with the friend and did not return for several hours, causing concern for the resident's family. The Interim DON confirmed the care plan was not updated to reflect these instructions.
A mentally ill resident with a history of alcohol abuse left the facility unsupervised with a friend, against family wishes. The staff was unaware of the restriction due to inadequate communication and documentation, leading to a police report. The resident returned without signs of alcohol consumption.
The facility failed to notify residents, their representatives, and the Ombudsman of hospital transfers, as confirmed by the Administrator in Training. Medical records for several residents lacked evidence of written transfer notices, potentially affecting all 64 residents in the facility.
The facility failed to provide written notice of the bed hold policy to residents or their representatives upon hospital transfer, affecting multiple residents. The Administrator in Training confirmed the lack of documentation and cited the absence of a Social Service Director and only having an Interim-DON as potential reasons for the oversight.
The facility did not consistently post the required Daily Posting of Nurse and Certified Nurse Assistant information on several days in July 2024. The postings were outdated and not available on specific dates, as confirmed by the Administrator in Training. This affected the transparency of staffing information for the 64 residents in the facility.
A facility failed to protect a resident with severe cognitive impairment from sexual abuse by another resident known for sexually inappropriate behavior. Despite a previous incident and an Immediate Jeopardy finding, the aggressive resident was inadequately supervised, leading to a repeated incident. The facility's lack of effective monitoring and clear policy contributed to the deficiency.
The facility failed to provide sufficient nursing staff, resulting in inadequate care for all 62 residents. Residents reported missed showers, long call light wait times, and unsafe mechanical lift transfers due to CNA shortages. Staff confirmed these issues, and the administrator acknowledged the negative impact on resident care.
The facility did not provide the required eight consecutive hours of RN coverage on six days, affecting all 62 residents. This deficiency was confirmed by the administrator and documented in the facility's assessment and nurse schedule.
The facility failed to provide scheduled showers to residents dependent on staff assistance, affecting four residents. Despite the facility's policy to maintain personal hygiene, documentation and interviews revealed missed showers. One resident with Multiple Sclerosis missed five showers, while another with Depression missed five, with one refusal. A resident with Rheumatoid Arthritis received no showers post-hospitalization, and another with Congestive Heart Failure received only one shower weekly. The administrator confirmed showers should be twice weekly, but this was not consistently documented.
Two residents requiring mechanical lift transfers reported that staff often use only one person for transfers, despite the facility's policy requiring two staff members for safety. A CNA confirmed that staffing shortages lead to this unsafe practice, which was acknowledged by the facility's Administrator.
The facility failed to ensure RN services for a minimum of eight consecutive hours a day, seven days a week, affecting all 67 residents. The nursing schedule for April 2024 showed no RN hours on four specific dates. The Administrator confirmed the lack of RN services on those dates and acknowledged the requirement for a minimum of eight hours of RN services per day. The facility employs only one full-time RN for floor duties, while other RNs are administrative and not scheduled for weekends.
The facility failed to notify a resident's representative of a new roommate assignment, despite policy requirements for advanced notice. The resident, who has severe cognitive impairment and multiple diagnoses, was not informed, and the representative discovered the change during a visit.
A resident with a history of major depressive disorder, anxiety, and PTSD exhibited hyper-arousal and hypersexuality, leading to repeated inappropriate sexual advances towards another resident with severe cognitive impairment. Despite interventions and care plans, the facility failed to prevent multiple episodes of sexual abuse. The facility's policies on abuse prevention and reporting were not effectively implemented, resulting in the failure to protect the vulnerable resident and ensure a safe environment.
Failure to Supervise Confused Resident and Respond to Exit Alarms Resulting in Elopement and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent an intermittently confused resident from exiting the building through alarmed doors without staff knowledge. The resident had multiple diagnoses including Parkinson’s disease, polyneuropathy, repeated falls, weakness, gait and mobility abnormalities, heart failure, sepsis, pneumonia, and type 2 diabetes. Clinical documentation at admission and shortly thereafter described the resident as confused or chronically confused, and a nurse practitioner note documented disorientation to time. Nursing staff and the resident’s spouse reported that the resident had periods of confusion, agitation, restlessness, wandering in a wheelchair, and repeated statements about wanting to go home. On the day of the incident, staff documented that the resident was exit seeking and upset, and the spouse reported that the resident had tried to get out the door and frequently stated he wanted to go home. Despite these behaviors and documented intermittent confusion, the resident was not identified as an elopement risk on admission, did not have a wandering alert bracelet in place at the time of the incident, and was not placed on 1:1 supervision or increased monitoring. The ADON stated that the resident’s BIMS score indicated cognitive intactness and that he was therefore determined not to be at risk for elopement, even though licensed staff notes documented confusion. The day-shift LPN reported that during shift change she had to turn the resident’s wheelchair around at the front door because he was trying to leave, and she passed on to the oncoming nurse that the resident was agitated. The evening LPN acknowledged knowing the resident was intermittently confused, very agitated, fixated on needing to be somewhere, and repeatedly going to the front door. He administered lorazepam for agitation but left the resident in the lobby in a wheelchair, did not initiate 1:1 supervision, and did not instruct the assigned CNA to increase supervision. The facility also failed to effectively monitor and control its door alarm system. The front entrance had two doors with alarms and a keypad code, and multiple staff, including the administrator, ADON, CNA, maintenance director, and social services director, confirmed that most family members and visitors had been given the door code so they could enter and exit freely. The administrator’s review of camera footage showed the resident opening the inner and outer front doors, triggering the alarm, which sounded for several minutes until a visitor entered the code and silenced it; no staff responded to the alarm, no Code Yellow was called, and no head count was performed. A police officer on patrol later found the resident outside in the facility parking lot next to an overturned wheelchair, in cold, snowy conditions, wearing only a thin T‑shirt and sweatpants, with bleeding lacerations and contusions. Facility staff confirmed they were unaware the resident had left the building until alerted by the CNA who encountered the police officer and the injured resident outside. The facility administrator stated she did not consider the resident’s leaving the building to be an elopement and did not report the incident to the state regional office. These failures resulted in an Immediate Jeopardy determination beginning on the date of the elopement. The survey findings further documented that staff practices and visitor access to door codes undermined the facility’s elopement prevention systems. A CNA stated that when the front door alarm sounded, she turned off the alarm, and during the survey a visitor was observed entering the sounding front door alarm by using the keypad code. The ADON and maintenance director confirmed that family members were routinely given the code, and that entering the code when an alarm was sounding would both unlock the door and silence the alarm. The administrator acknowledged that on the night of the incident, no staff responded to the alarm that sounded for several minutes, and that a CNA was seen on video leaving through the same front door shortly after the alarm was silenced. The resident’s spouse reported that she had informed staff of the resident’s confusion and need for close supervision, had observed him trying to get out the door, and was told the facility could not provide one‑to‑one care. She also stated that when she later asked why the resident did not have a wandering alert bracelet before he left the facility unattended, the administrator responded that in hindsight he should have had an alarm on. The combination of not recognizing the resident’s elopement risk, not implementing appropriate interventions, and allowing visitors to silence exit alarms without staff verification led directly to the resident’s unsupervised exit and subsequent injury.
Removal Plan
- Resident was placed on facility's elopement program with placement of a wander alert bracelet.
- Elopement assessment and care plan were updated to reflect the resident's risk for wandering/elopement by social service director/DON/designee.
- A facility-wide elopement audit using the elopement assessment in PCC was conducted by the Social Service Director.
- All exterior door codes were changed by the facility Maintenance Director.
- All employees were in-serviced by all department managers on the elopement and wandering residents and accidents and supervision policy, including that only employees are to have door codes.
- Care plans were reviewed and updated as needed for residents at risk for elopement by social service director/DON/designee.
- The elopement policy was reviewed by administrator/regional nurse consultant/DON.
- DON will review all new admissions to monitor that all interventions are in place for residents at risk for elopement.
- As part of orientation, new hires will receive education on wandering, elopement, and safety by social service director/DON/designee.
- All department managers were in-serviced by the administrator on the elopement and wandering residents and accidents and supervision policy.
- All employees were in-serviced by their department managers on the elopement and wandering residents and accidents and supervision policy, including that only employees are to have door codes.
- Employees are to assist all visitors in and out of the facility to ensure resident safety.
- Wander alert bracelets were placed in the narcotic drawer and nurses were in-serviced by the DON.
- Nurses were educated on how to place wander alert bracelets on residents.
- The DON/designee will be informed regarding wander alert bracelet placement and use.
- QAPI policy and improvement processes will be used to review and interpret all audit findings.
- All findings will be discussed at monthly QAA for a minimum of 3 months or until the facility is compliant.
- DON/designee will audit 3 times a week for 1 month then weekly for 2 months using the elopement assessment.
- Residents at risk for elopement will be reviewed and a wander alert bracelet applied, care plan updated, doctor orders obtained, and placed in the elopement binder by social service director/DON/designee.
- IDT will review high risk residents who are at risk for wandering and/or elopement during morning meeting.
- All new admissions and readmissions will be reassessed for wandering and risk for elopement and the plan of care updated as needed by social service director/DON/designee.
- Social Service Director will maintain the elopement binder and update care plan with all new interventions.
- Monitoring of all residents for statements such as 'I want to go home' or other expressions indicating a desire or need to leave will be conducted by nurses/social service director/DON/designee.
Failure to Protect Resident from Physical Abuse by CNAs
Penalty
Summary
A cognitively intact resident with multiple medical conditions, including acute pyelonephritis, cerebral infarction, rheumatoid arthritis, osteoporosis, and mobility deficits, was subjected to physical abuse by two certified nursing assistants (CNAs) during care. After returning from physical therapy, the resident was wheeled to her room by the CNAs, who became verbally forceful and demanding when she was unable to transfer herself from her wheelchair to a recliner due to her physical limitations. Despite the resident's attempts to explain her inability to comply, the CNAs yelled at her, accused her of being uncooperative, and proceeded to physically grab her under her arms, squeeze her, and forcefully throw her into the recliner. The incident resulted in the resident sustaining multiple bruises on both upper arms, with the bruising described as being in the shape of finger pads and purplish in color. The injuries were documented in the resident's medical record and confirmed during a skin check, which noted several bruises of varying sizes on the resident's arms and axillae. The resident reported pain and distress during the incident and expressed a desire not to have the involved CNAs provide her care in the future. The abuse was reported by another CNA to the Director of Nursing, who then notified the local police. The police officer interviewed the resident, who recounted the details of the incident and allowed photographs of her injuries to be taken. The resident declined to press criminal charges but requested that the CNAs be disciplined by the facility. The facility's policy on abuse, neglect, and exploitation defines such actions as willful infliction of injury and includes staff-to-resident abuse, which was substantiated by the findings in this case.
Failure to Ensure Oxygen Availability for Resident with COPD
Penalty
Summary
The facility failed to adhere to its Oxygen Administration Policy, resulting in a deficiency in providing appropriate respiratory care for a resident with Chronic Obstructive Pulmonary Disease (COPD) and a history of acute and chronic respiratory failure with hypoxia. The resident's care plan required oxygen administration at 6 liters per minute via nasal cannula to maintain oxygen saturation levels above 90%. However, on the day of the incident, the resident was taken to an activity without ensuring the portable oxygen tank was filled. The Registered Nurse (RN) responsible for the resident did not check the tank's fullness before the activity, leading to the resident's oxygen saturation dropping to 64% during the activity. The Director of Nursing (DON) and the RN acknowledged that the portable oxygen tank was not checked for fullness before the resident was taken to the activity. The Licensed Practical Nurse (LPN) also noted that the resident's oxygen levels were known to drop below the baseline when sleeping, indicating a need for careful monitoring. The oversight in checking the oxygen tank resulted in the resident being sent to the Emergency Department due to significantly low oxygen saturation levels. The facility's policy required staff to document assessments and ensure oxygen availability, which was not followed in this instance.
Failure in Catheter Care Leads to Severe Health Decline
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, resulting in the resident being admitted to the hospital with severe septic shock, acute kidney injury, and hyperkalemia. The facility's catheter care policy required monitoring of the catheter every shift for color and clarity, ensuring the catheter was free of kinks, and maintaining freely flowing urine. However, these procedures were not followed for the resident, who had a history of dementia, chronic kidney disease, and obstructive uropathy. The resident's care plan included specific interventions for catheter care, such as checking tubing for kinks and monitoring for signs of urinary tract infection. Despite these instructions, there was no documentation of catheter monitoring from 9/26/24 through 10/2/24. Staff interviews revealed that licensed nurses did not perform or document catheter care, assuming that CNAs were responsible for these tasks. This lack of monitoring and communication led to the resident's catheter becoming twisted and blocked, causing a severe infection. Upon the resident's admission to the emergency department, the catheter was found to be severely twisted and dirty, with thick pus and exudate preventing drainage. The resident's bladder was distended with over 1200 cc of urine, leading to kidney shutdown and the need for intensive care. The facility's failure to adhere to its catheter care policy and adequately monitor the resident's condition contributed to the resident's severe health decline.
Resident Elopement Due to Inadequate Door Alarms and Supervision
Penalty
Summary
The facility failed to ensure that all door alarms were loud enough for immediate staff response and did not promptly search the premises when a door alarm was heard. This lack of adequate supervision led to a severely cognitively impaired resident, diagnosed with Dementia, exiting the facility without staff knowledge or supervision. The resident, who had a history of exit-seeking behavior, managed to leave the facility and walk over 1635 feet down a hill, where they fell by a tree approximately 25 feet from a main street. This incident resulted in the resident sustaining two fractures to the end of the forearm, excruciating pain, abrasions to the chin and right arm, and required hospitalization for treatment. The resident's medical history included Parkinsonism, Dementia, Neurocognitive Disorder with Lewy Bodies, and a history of falling, which placed them at high risk for elopement and falls. The resident was equipped with an electronic monitoring bracelet, which was supposed to be checked daily for function and placement. Despite these precautions, the resident's care plan, which noted their wandering behavior and risk for elopement, was not effectively implemented, as evidenced by the resident's ability to leave the facility unnoticed. Interviews with staff revealed that the door alarm sounded muted, similar to a phone alarm, and was not immediately identified as an elopement alert. Staff initially searched the facility and surrounding area but did not locate the resident until they were found injured by a tree. The facility's failure to provide adequate supervision and timely response to the door alarm directly contributed to the resident's elopement and subsequent injuries.
Removal Plan
- V1 (Administrator) in-serviced all staff in the facility regarding policies and procedures on elopement and wandering residents, prompt response to door alarms, utilization of facility protocol internal alert code alerts code yellow for elopement wandering residents, head count, and notifications. All staff not in the facility were in-serviced prior to their next scheduled shift.
- V24 (Social Service Director/SSD) and V13 (MDS Coordinator) conducted an audit to ensure all current residents at high risk for wandering and elopement had a care plan in place and interventions in place to ensure their safety.
- V1 and V25 (Vice President of Clinical Services) ensured the communication book was updated with all residents at high risk of wandering.
- V25 completed new elopement assessments for all residents.
- V23 is continuing audits of door function daily for six weeks.
- V1 is continuing to audit the communication book daily for 6 weeks to ensure the elopement procedure is fully implemented.
- V25 provided in-service to the Interdisciplinary Team (IDT) regarding assessing all residents quarterly who wander/exit seek and with any changes in behavior. IDT continues to review the 24/72-hour notes to assess for changes in behavior and possible completion of a current wandering risk assessment.
- V6 (R1's Family Member) and V7 (R1's Physician) were notified of R1's elopement with injuries and an order was given to send R1 to the emergency department for evaluation and treatment.
- A tour was done, and all exit doors were checked for enunciators. The front entrance door and the basement service doors were not alarmed with an enunciator as stated by the abatement plan. V1 revised the abatement plan to include applying an enunciator to the basement service doors by V26 (Corporate [NAME] President of Plant Operations) and assuring the front entrance door was double alarmed. The basement service door was alarmed with an enunciator and the front entrance door was double alarmed.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident, identified as R5, from physical abuse by another resident, R4. R5, who is severely cognitively impaired, was physically assaulted by R4, who is cognitively intact. The incident occurred when R4 entered R5's room, yelled at him, and struck him multiple times in the face, resulting in scratches and redness. This incident was observed by a Certified Nursing Assistant (CNA), who reported the abuse to the facility's abuse coordinator. The CNA also reviewed hallway video footage, which confirmed R4's entry into R5's room during the time of the incident. The facility's policy on Abuse, Neglect, and Exploitation mandates that residents must be free from abuse by anyone, including other residents. Despite this policy, the incident was substantiated, as documented in the facility's Final State Report and the local police officer's incident report. The reports detail the physical evidence of abuse, including scratches on R5's face, and statements from both residents and staff. R4 admitted to being frustrated with R5's behavior but did not explicitly admit to the assault, while R5 consistently reported being hit by R4.
Medication Errors and Missed Doses in LTC Facility
Penalty
Summary
The facility failed to monitor blood sugar glucose levels and administer physician-ordered sliding scale insulin timely for a resident with Type 2 Diabetes Mellitus. The resident missed a scheduled insulin dose before breakfast, resulting in fatigue, drowsiness, confusion, and an elevated blood sugar level of 487. The nurse responsible for the morning medication pass did not check the resident's blood glucose or administer insulin at the scheduled time, leading to the resident eating breakfast without insulin. The nurse practitioner was not informed of the missed insulin dose, which affected the treatment plan, as the resident received a high dose of insulin followed by another large dose shortly after, without holding the subsequent dose as should have been done. Another resident with Parkinson's Disease did not receive the prescribed medication, Sinemet, for 25 days due to the facility's failure to reorder the medication and update the neurology office as required. The resident's medication administration record showed no administration of Sinemet for a total of 19 missed days initially, and then another 5 missed days after a new order was written. The resident experienced increased tiredness, unsteady gait, and increased tremors due to the lack of medication, which was supposed to be titrated over four weeks. The facility did not notify the neurology office or the primary physician about the expired order or the missed doses, leading to a lapse in the resident's treatment. The facility's policies on medication administration, error reporting, and timely insulin administration were not followed, resulting in significant medication errors for both residents. The facility did not complete medication error reports for the incidents, and the staff involved were unaware of the procedures to follow when medication errors occurred. The lack of communication and adherence to policies contributed to the residents' adverse conditions, highlighting deficiencies in the facility's medication management practices.
Resident Subjected to Verbal and Mental Abuse by Agency CNA
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by a staff member, specifically an agency Certified Nursing Assistant (CNA), which resulted in the resident experiencing extreme fear and mental anguish. The resident, an elderly female with diagnoses including dementia, major depressive disorder, and other medical conditions, was subjected to aggressive and threatening behavior by the agency CNA. The incident was witnessed by two other CNAs who reported that the agency CNA screamed at the resident, called her a nuisance, and threatened her with jail, causing the resident to become terrified and cry. The incident occurred when the resident was already in a state of distress, screaming for help and stating she couldn't breathe. Despite attempts by other CNAs to comfort her, the agency CNA escalated the situation by yelling at the resident and using her phone to intimidate her further. The resident was left feeling unsafe and expressed her fear to the surveyors, stating she was afraid of some of the staff and did not feel secure in the facility. The facility's failure to provide adequate abuse training to the agency CNA and the absence of a Social Service Director to offer psychosocial support to the resident after the incident contributed to the deficiency. The Administrator in Training acknowledged the lack of abuse training records for the agency CNA and confirmed that the abuse policy was not included in the binder that agency staff were required to read and sign off on. This oversight in training and support left the resident vulnerable to abuse and without necessary follow-up care after the incident.
Deficiencies in Food Safety and Kitchen Cleanliness
Penalty
Summary
The facility failed to properly cool down and document potentially hazardous foods, maintain a clean kitchen, label food items, discard outdated food items, and replace rusted shelving, potentially affecting all 64 residents. The facility's Cooling Cooked Potentially Hazardous Foods/Time Temperature Controlled for Safety document outlines specific cooling procedures, but the logs provided were inconsistently filled, with missing records for several months. The Dietary Manager, who had been in the position for six weeks, acknowledged the incomplete logs and lack of documentation. The kitchen was observed to be unclean, with visible grime, grease, and dirt accumulation. The ice machine had visible wet and slimy spots, and food splashes were noted on the walls. The kitchen's cleaning schedule was not adequately followed, as confirmed by the Dietary Manager. Rusted shelving and unclean equipment were also noted, with the Dietary Manager unaware of the rust issue. Food storage practices were inadequate, with improperly labeled and outdated items found in the cooler and storage areas. The Dietary Manager confirmed these deficiencies, including unlabeled and undated food items, and acknowledged the need for new storage containers. The facility's application for Medicare and Medicaid documented 64 residents residing within the facility at the time of the survey.
Failure to Ensure Required Members Attend QA Meetings
Penalty
Summary
The facility failed to ensure that the required members attended the scheduled Quality Assurance (QA) meetings, which has the potential to affect all 64 residents residing in the facility. The facility's Quality Assessment and Assurance (QAA) committee is required to include key members such as the Medical Director, Administrator, Director of Nursing (DON), Regional Nurse Consultant, Regional Operations Consultant, and Infection Preventionist (ICP). However, the facility's Quality Assurance Committee list did not include an ICP, and the duties of the ICP were being completed by the DON, which is not in compliance with the requirement for separate roles. The QA sign-in sheets for various meetings revealed that not all required members were present. Specifically, the Interim DON was absent from the July 2024 meeting, only three members attended the March 2024 meeting, and the Medical Director was not present at the November 2023 meeting. The Administrator in Training confirmed these absences and acknowledged the lack of a designated ICP. This lack of attendance by required members at the QA meetings indicates a failure to adhere to the facility's QAPI plan, which mandates regular review and monitoring to maintain the highest level of quality.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to ensure that they had a qualified Infection Preventionist, which has the potential to affect all 64 residents residing in the facility. The Facility Assessment dated July 24, 2024, outlined the requirement for an effective training program for all staff, including the need for a qualified Infection Preventionist. However, the Interim Director of Nurses (DON) admitted on July 30, 2024, that they had not completed all the necessary training prior to the surveyors' entrance on July 29, 2024. The Interim DON stated that they had completed most of the training late in the evening on July 29, 2024, but could not locate the certificate of completion. Additionally, the Administrator in Training was unable to find the Infection Preventionist certificate, as documented on July 31, 2024.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required eight hours of Registered Nurse (RN) coverage seven days a week, which has the potential to affect all 64 residents living in the facility. The nursing schedule for July indicated that there was no RN coverage on several specific days: 7/06/24, 7/07/24, 7/13/24, 7/20/24, 7/21/24, 7/26/24, 7/27/24, and 7/28/24. This lack of coverage was confirmed by the Administrator in Training, who acknowledged the difficulty in securing RN coverage on weekends. Additionally, the facility's daily posting of nurse and certified nurse assistant coverage was checked and found to be missing for the same dates, further confirming the deficiency.
Deficiencies in Oversight and Care at LTC Facility
Penalty
Summary
The facility failed to provide adequate oversight and leadership, resulting in multiple deficiencies affecting the care and safety of its residents. The Administrator in Training (V1) did not ensure the implementation of policies and procedures related to abuse prevention, medication administration, and resident supervision. This lack of oversight led to incidents of verbal abuse and intimidation by staff members, such as a Certified Nursing Assistant (V17) and a Licensed Practical Nurse (V7), which were not properly documented or investigated. Additionally, the facility did not have a Social Service Director to provide psychosocial support to residents affected by these incidents. Medication administration errors were also prevalent, with significant lapses in the administration of medications to residents. For instance, a Registered Nurse (V14) failed to administer insulin to a resident (R5) before breakfast, resulting in elevated blood glucose levels. Furthermore, another resident (R52) missed five days of Sinemet medication due to an expired physician order, which was not updated or communicated to the Neurology department. The Interim Director of Nursing (V2) was unaware of these errors and did not have a clear understanding of the medication policy, indicating a lack of proper training and communication among the nursing staff. The facility also failed to ensure that residents or their representatives were informed of the bed hold policy during hospital transfers. The Administrator in Training (V1) admitted to not having conducted audits to verify the accuracy of advance directives and POLST forms, leading to discrepancies in residents' code status. Additionally, the facility lacked a designated Infection Control Preventionist, with the Interim Director of Nursing (V2) temporarily filling this role without the necessary certification. These deficiencies highlight a systemic failure in leadership and oversight, affecting the quality of care provided to all 64 residents in the facility.
Inconsistent Advanced Directive Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate Advanced Directive information for two residents, R15 and R60, as identified during a survey. R15 was admitted with diagnoses including Frontal Lobe and Executive Function Deficit Following Cerebral Infarction, Vascular Dementia, and Cardiac Murmur. The Order Summary Report indicated a Full Code status, while the POLST form documented a Do Not Attempt Resuscitation order and a Comfort-Focused Treatment plan. Similarly, R60, who was admitted with diagnoses such as Malignant Neoplasm of Prostate and Atrial Fibrillation, had a Full Code status in the Order Summary Report, but the POLST form indicated a Do Not Attempt Resuscitation order and a Comfort-Focused Treatment plan. The discrepancy between the physician orders and the POLST forms was verified by the Administrator in Training, who acknowledged the lack of a Social Service Director to ensure the alignment of these documents. The facility's policy mandates that advance directives be included in physician orders and scanned into the resident's record after being signed by the physician. However, due to the absence of a Social Service Director, the Administrator in Training had been attempting to manage the advance directives without conducting an audit to ensure consistency between the orders and the POLST forms.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide a resident with scheduled physician-ordered showers, as observed in the case of a resident with a self-care performance deficit due to dementia, spinal stenosis, depression, and altered mental status. The resident's care plan indicated a preference for a bath at least once weekly, and physician orders required daily antibacterial soap baths or showers prior to surgery. However, the resident expressed dissatisfaction, stating that she had not received the necessary showers, which was corroborated by her family member who reported that the resident had gone weeks without a shower. Documentation revealed that the resident's last recorded shower was on 7/23/24, missing the scheduled showers on 7/29 and 7/30/24. The facility's staff, including a Certified Nursing Assistant and the Vice President of Clinical Operations, confirmed the lack of documentation for the missed showers. The administrator in training acknowledged that staff should document when residents receive baths or showers, highlighting a lapse in adherence to the facility's policy on activities of daily living.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter. The resident, identified as R15, had an indwelling urinary catheter due to obstructive uropathy and urinary strictures. During observations, it was noted that the catheter drainage bag was uncovered and the catheter tubing was lying on the floor. These observations were made while the resident was sitting in her wheelchair both in the hallway and in her room. The facility's Catheter Care Policy mandates that catheter drainage bags should be covered with privacy bags at all times and that catheter tubing should not be in contact with the floor. Despite this policy, the staff, including a Licensed Practical Nurse and a Regional Nurse Consultant, confirmed the deficiency, acknowledging that the catheter bag should have been covered and the tubing should not have been dragging on the floor. The staff were aware of the policy requirements, yet the deficiency occurred.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two medication errors in a sample of 29, resulting in a 6.9% error rate. This deficiency was identified during a review of medication administration for one of five residents. The resident involved had orders for blood glucose monitoring followed by a sliding scale Insulin Aspart Injection and Metformin for Type Two Diabetes Mellitus. The Medication Administration Record (MAR) specified administration times for these medications, which were not adhered to. On the day of the incident, a registered nurse, who was new to the facility, administered the resident's Metformin at 10:30 AM instead of the scheduled 8:00 AM. Additionally, the nurse failed to administer the sliding scale insulin before the resident's breakfast, as required. The facility's medication administration policy mandates that medications be administered within 60 minutes of the scheduled time unless otherwise ordered by a physician. The nurse acknowledged the error, attributing it to being new and unfamiliar with the floor.
Failure to Report Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to immediately report and investigate incidents of abuse and injuries of unknown origin for two residents. One resident, a female with multiple diagnoses including dementia and diabetes, was found with a large bruise on her wrist, which was not reported to the abuse coordinator as required by the facility's policy. The Licensed Practical Nurse who observed the bruise did not report it, and the Administrator in Training confirmed that no report had been made. This lack of reporting is a violation of the facility's policy, which mandates immediate notification of the administrator for any injuries of unknown origin. Another resident reported an incident of verbal abuse by a Licensed Practical Nurse, which was not documented in the resident's medical record. The resident stated that the nurse made derogatory comments about her medication needs, and when reported to the former Director of Nursing, the resident was moved to another hallway without any formal documentation or investigation of the abuse allegation. The Administrator in Training was aware of the verbal abuse allegation but did not have any documentation to support that the incident was handled according to the facility's abuse policy.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of verbal abuse involving a resident who was on hospice care and required morphine. The resident reported that after waiting for an hour and a half for her medication, she approached her nurse, who responded negatively and later accused her of being a 'pain seeker and pill popper.' The resident, who has significant medical issues and experiences constant pain, reported feeling mistreated and subsequently isolated herself in her room, feeling lonely and unsupported by the facility. The resident's electronic medical record did not document any allegations or investigations of verbal abuse for the past year. The Administrator in training acknowledged awareness of the verbal abuse allegation but deferred the matter to the Director of Nursing, who reportedly handled it. However, there was no documentation of any investigation, measures to prevent further abuse, or actions taken to address the resident's feelings of intimidation and fear following the incident.
Failure to Update Care Plan Following Resident's Status Change
Penalty
Summary
The facility failed to update the care plan for one resident, identified as R17, following a significant status change. According to the facility's policy, care plans must be reviewed and revised when a resident experiences a status change. R17's face sheet included special instructions prohibiting a friend, V21, from taking R17 off the property, although visits and outdoor activities on the premises were allowed. Despite these instructions, R17 left the facility with V21 and did not return for several hours, causing concern for R17's family member. The Interim Director of Nurses confirmed that R17's care plan had not been updated to reflect these special instructions, indicating a lapse in adherence to the facility's policy on care plan revisions.
Failure to Supervise Mentally Ill Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a mentally ill resident, identified as R17, who left the building unsupervised. R17 has a complex medical history, including cerebral infarction, alcohol-induced dementia, schizoaffective disorder, and other mental health conditions. On the day of the incident, R17 left the facility with a friend, V21, who is also an alcoholic. This was against the wishes of R17's family member, V22, who is the Health Care Power of Attorney (HCPOA) and had previously informed the facility that R17 should not leave with V21 due to their history of alcohol abuse when together. The incident occurred because the staff, including the LPN on duty, were not informed or aware of the restriction against R17 leaving with V21. The LPN allowed R17 to sign out and leave, believing R17 was alert and oriented. The facility's policy on accidents and supervision was not effectively communicated or implemented, as the restriction was not flagged in R17's chart, and the staff did not receive adequate information during the report. As a result, R17 was gone for over six hours, prompting V22 to contact the police, although R17 returned without signs of alcohol consumption.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely notification to residents, their representatives, and the local Ombudsman regarding transfers to the hospital. This deficiency was identified through interviews and record reviews, revealing that the facility did not document or issue written notices of transfer for several residents. Specifically, the medical records of residents R3, R18, R27, R5, R48, R52, and R315 showed no evidence of such notifications, despite their transfers to local hospitals on various dates. The Administrator in Training, identified as V1, confirmed the absence of documentation for these notifications and acknowledged that the facility had not sent monthly transfer notifications to the Ombudsman. This oversight has the potential to impact all 64 residents currently residing in the facility, as indicated by the facility's CMS Long Term Care Facility Application for Medicare and Medicaid Form 671, signed by V1.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to residents or their representatives upon transfer to a hospital, as required by their own policy dated 12/23/22. This policy mandates that at the time of transfer for hospitalization or therapeutic leave, the facility must provide written notice specifying the duration of the bed-hold policy and information about the resident's return to the next available bed. The deficiency was identified through interviews and record reviews, revealing that multiple residents, including R3, R18, R27, R5, R48, R52, and R315, were hospitalized without receiving the required written notice of the bed hold policy. The Administrator in Training confirmed the lack of documentation for these residents and acknowledged the absence of a Social Service Director and only having an Interim-Director of Nursing, which may have contributed to the nursing staff's unawareness of the requirement to provide the bed hold policy upon discharge to the hospital. This oversight has the potential to affect all 64 residents currently residing in the facility, as documented in the facility's CMS Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 7/29/24.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the Daily Posting of Nurse and Certified Nurse Assistant information on multiple days, which is a requirement for transparency and compliance. The missing postings were specifically noted for several dates in July 2024, including 7/02, 7/04, 7/06, 7/07, 7/13, 7/14, 7/20, 7/21, 7/25, 7/26, 7/27, 7/28, and 7/29. On 7/29/24, the posting available at the Receptionist's desk was outdated, showing the date 7/25/24. This issue was confirmed by V1, the Administrator in Training, who acknowledged that the postings were not consistently available. The facility's documentation indicated that 64 residents were residing in the facility at the time of the survey.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from continued sexual abuse by another resident known to be sexually aggressive. This deficiency was identified when a resident with severe cognitive impairment was found to have been sexually abused by another resident who had a history of sexually inappropriate behavior. The facility had previously identified an Immediate Jeopardy situation involving the same two residents, which led to the implementation of a removal plan that included 1:1 supervision for the aggressive resident. Despite the initial intervention, the facility did not maintain adequate supervision, as the aggressive resident was later found to have engaged in inappropriate sexual contact with the cognitively impaired resident. The aggressive resident had been placed on increased monitoring instead of 1:1 supervision, which proved insufficient to prevent further incidents. Staff interviews revealed that the aggressive resident was able to move independently in a wheelchair and had been left unsupervised, allowing her to approach and abuse the other resident. The facility's failure to maintain effective supervision and monitoring of the aggressive resident, despite being aware of her history and the previous incident, resulted in a repeated occurrence of sexual abuse. The lack of documentation and clear policy on increased monitoring contributed to the deficiency, as staff were not adequately informed or equipped to prevent the recurrence of abuse.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all 62 residents, as evidenced by multiple instances of inadequate care and services. Residents reported not receiving scheduled showers, with documentation missing for several scheduled shower dates. For example, one resident was scheduled for showers twice a week but only received them sporadically, with several instances of no documentation for the showers. This resident also reported that staff often did not have time to provide showers and that mechanical lift transfers were sometimes conducted with only one staff member, contrary to the facility's policy requiring two staff members for safety. Several residents expressed concerns about long wait times for call lights to be answered, sometimes waiting up to an hour. This delay in response was attributed to a shortage of Certified Nursing Assistants (CNAs), as confirmed by both residents and staff members. The CNAs reported that they were often short-staffed, which led to incomplete showers, delayed call light responses, and unsafe transfer practices. The facility's policy mandates that two staff members assist with mechanical lift transfers, but due to staffing shortages, this was not consistently followed, posing a risk to resident safety. The facility's administrator acknowledged the staffing issues, confirming that the facility was aware of the problem and that it often operated with fewer CNAs than required. The administrator confirmed that being short-staffed could significantly negatively impact the quality of care residents receive. This deficiency in staffing and the resulting inadequate care and services have the potential to affect all residents in the facility, compromising their safety and well-being.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide eight consecutive hours of Registered Nurse (RN) coverage per day, which is a requirement for the care and support of residents. This deficiency was identified through interviews and record reviews, revealing that from May 22, 2024, to May 31, 2024, there were six days without the required RN coverage. The facility's assessment indicated the necessity of licensed nursing staff, including RNs, to meet the needs of the residents. The absence of RN coverage was confirmed by the facility's administrator, affecting all 62 residents in the facility at the time of the survey.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers to residents who are dependent on staff assistance for bathing, affecting four out of four residents reviewed for this issue. The facility's Activities of Daily Living (ADL) policy mandates that residents receive necessary services to maintain personal hygiene, including bathing, based on their comprehensive assessment and needs. However, documentation and resident interviews revealed that scheduled showers were frequently missed. For instance, one resident with Multiple Sclerosis and Right Side Hemiplegia, who requires substantial assistance, missed five scheduled showers in May 2024. Another resident with Depression and Congestive Heart Failure, requiring moderate assistance, also missed five scheduled showers, with one refusal documented. Additional residents experienced similar issues. A resident with Rheumatoid Arthritis and other conditions, requiring maximum assistance, did not receive any showers after returning from a hospital stay, despite being scheduled for twice-weekly showers. Another resident with Congestive Heart Failure and mobility issues, requiring moderate assistance, reported receiving only one shower per week instead of the scheduled two. The facility administrator confirmed that showers should be offered twice weekly and documented accordingly, but this was not consistently done, leading to the deficiency.
Unsafe Mechanical Lift Transfers Due to Staffing Shortages
Penalty
Summary
The facility failed to provide safe mechanical lift transfers for residents who are dependent on staff for mobility assistance. This deficiency was identified during interviews and record reviews, affecting two residents who require mechanical lift transfers. One resident, diagnosed with Multiple Sclerosis and Right Side Hemiplegia, reported that staff often use only one person for transfers, despite knowing that two staff members are required for safety. Another resident, diagnosed with Sepsis, Falls, Amnesia, and Lymphedema, also reported similar experiences, indicating that staff frequently complete transfers with only one person due to staffing shortages. A Certified Nurse's Assistant confirmed the issue, stating that the facility does not have enough CNAs to assist with mechanical lift transfers, leading to transfers being conducted with only one staff member. The facility's policy mandates that two staff members must be present for mechanical lift transfers to ensure safety, a requirement that was confirmed by the facility's Administrator. The failure to adhere to this policy resulted in unsafe transfer practices for the residents involved.
Failure to Ensure RN Services for Minimum Required Hours
Penalty
Summary
The facility failed to ensure the services of a Registered Nurse (RN) for a minimum of eight consecutive hours a day, seven days a week, which has the potential to affect all 67 residents residing in the facility. The nursing schedule for April 2024 documented no RN hours were scheduled or worked on four specific dates. The Administrator confirmed that the facility did not have any RN services on those dates and acknowledged that the facility should have a minimum of eight hours of RN services per day. The facility currently employs only one full-time RN who is scheduled to work the floor, while other RNs employed are administrative and not regularly scheduled to work weekend shifts. The CMS 802 form dated 4/29/24 confirmed there are 67 residents in the facility.
Failure to Notify Resident's Representative of Roommate Change
Penalty
Summary
The facility failed to notify a resident's representative of a new roommate assignment. The facility's policy requires that all parties involved in a room change or roommate assignment be given advanced notice. However, the facility did not inform the representative of a resident receiving Hospice Services, who has severe cognitive impairment and multiple diagnoses including Alzheimer's Disease and Major Depressive Disorder, about the new roommate assignment that took place on 4/11/24. The resident's representative discovered the new roommate during a visit on 4/14/24 and confirmed that she had not been notified of the change. The facility's Social Service Director and Administrator both acknowledged that the representative should have been notified in advance of the new roommate assignment. The resident's medical record and the facility's computerized electronic Census Report confirmed the date of the new roommate's move-in, but there was no documentation of notification to the resident or the representative. This oversight was confirmed through interviews and record reviews conducted by the surveyors.
Inadequate Supervision and Protection of Residents with Sexual Aggressive Behaviors
Penalty
Summary
The facility failed to adequately supervise a resident (R4) exhibiting sexually aggressive behaviors and protect another resident (R5) from multiple episodes of sexual abuse. The incident involved R4 attempting to touch R5 in the dining room, with R4 claiming they were in love and doing nothing wrong. R4's behavior escalated over time, with reports of inappropriate sexual advances towards R5, including incidents of lifting her shirt and attempting to touch him inappropriately. R5, who had severe cognitive impairment, was unable to fully comprehend or respond to the situation, leading to concerns about his vulnerability to abuse. R4, who had a history of major depressive disorder, anxiety, and PTSD, exhibited hyper-arousal and hypersexuality, leading to inappropriate behaviors towards other residents. Despite interventions and care plans addressing R4's behavior issues, the facility failed to prevent the repeated incidents of sexual abuse involving R4 and R5. Staff members reported instances of R4's persistent pursuit of R5, with R4 manipulating situations to engage in inappropriate behaviors. The facility's policies on abuse prevention and reporting were not effectively implemented in this case, resulting in the failure to protect R5 from harm and ensure a safe environment for all residents.
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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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