Marigold Rehabilitation And Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Galesburg, Illinois.
- Location
- 275 East Carl Sandburg Drive, Galesburg, Illinois 61401
- CMS Provider Number
- 145446
- Inspections on file
- 33
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 15 (3 serious)
Citation history
Health deficiencies cited at Marigold Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
A resident with prostate cancer and metastatic disease was admitted with hospital discharge orders for daily Abiraterone 250 mg (four tablets on an empty stomach) without a stop date. Facility policy required accurate documentation of all medication orders and changes, but an LPN transcribed the Abiraterone order onto the MAR with an unwarranted stop date, and another LPN later only adjusted the administration time. The MAR showed that the medication was not given for three consecutive days, and the resident and family reported that staff repeatedly stated there was no order or that the drug was unavailable, despite the resident having brought in a supply from home. The former DON confirmed the order had been improperly stopped, which led to the missed doses.
A resident with complex cardiac and respiratory conditions was admitted with multiple physician‑ordered medications, including diuretics, bronchodilators, steroids, and other maintenance drugs, which were to begin shortly after arrival. Over the next two days, an LPN documented numerous doses as unavailable and did not administer key medications such as diuretics, nebulizer treatments, and prednisone, despite the facility having a STAT safe stocked with several of these drugs and pharmacy deliveries arriving overnight. The LPN did not notify the physician or nursing administration about the missed doses, and no alternative interventions or treatment plan changes were implemented. The resident was later found without respirations or pulse and was pronounced deceased, and the survey determined that the failure to administer ordered medications and to notify the provider constituted neglect and resulted in actual harm and death, rising to Immediate Jeopardy.
A resident with complex cardiac and respiratory conditions was admitted after a prolonged hospitalization with multiple physician‑ordered medications, including diuretics, bronchodilators, steroids, and maintenance drugs. Over the first two days, the MAR shows that numerous scheduled doses were not given and were marked as unavailable, even though many of these medications were stocked in the facility’s STAT Safe and later documented as delivered by pharmacy. The LPN did not obtain medications from the STAT Safe, did not notify the physician or DON about the missed doses, and did not escalate the issue despite the resident’s need for breathing treatments and heart failure medications. The resident, previously documented as alert with intermittent SOB and requiring BiPAP and nebs with O2, was later found without respirations or pulse when the LPN went to administer medications, and the death certificate lists acute on chronic CHF and diastolic heart failure with COPD as contributing conditions. The failure to follow physician orders, secure and administer available medications, and communicate missed doses resulted in actual harm and death and was cited at the Immediate Jeopardy level.
The facility failed to maintain accurate medical records by not obtaining signed physician orders to support nursing documentation that medications were placed on hold for three newly admitted residents when their medications were unavailable. Nursing notes indicated that an APN or physician had been notified and had given orders to hold various medications, including Abilify, Trelegy, Jardiance, and that some PRN Ultram and Lasix were obtained from backup, but the corresponding physician order sheets contained no signed orders authorizing these holds. The interim DON verified the absence of signed orders and acknowledged that, under the facility’s standard of practice, telephone or verbal orders without a physician’s signature are insufficient and void.
A resident with dementia and multiple chronic conditions was pushed by another resident, resulting in a fall, after repeatedly entering the other's personal space despite staff redirection. Staff confirmed that the resident who pushed is known to become aggressive when his space is invaded, and that the incident occurred while the LPN was not present in the immediate area.
The facility did not reasonably accommodate the needs and preferences of residents, as identified during the survey. The report does not specify the particular circumstances or individuals involved.
A resident who was cognitively intact requested a care plan meeting with the ombudsman present to address concerns about inconsistent bathing and hair care. Despite repeated requests and involvement of the ombudsman, facility staff did not schedule or document the meeting, and the resident's concerns remained unaddressed.
The facility failed to prevent and respond to resident-to-resident sexual and physical abuse, including incidents where a cognitively impaired resident was sexually assaulted by another resident and another resident was physically struck by her roommate. Care plans and medical records did not reflect the abuse incidents or necessary interventions, despite staff awareness and direct observation of the events.
The facility did not post grievance procedures in prominent locations and failed to promptly address a resident's grievance regarding care concerns, resulting in residents being unaware of how to file grievances and reports of grievances not being followed up on in a timely manner.
The facility did not promptly report allegations of sexual and physical abuse between residents to the State Agency and local law enforcement as required. In one case, an LPN observed inappropriate sexual contact between two residents, but the incident was reported to the State Agency several days late and not at all to law enforcement. In another case, a resident was struck by another during care, and the incident was not reported within the mandated two-hour window. These reporting failures involved four residents.
A resident with severe dementia was not properly assessed or documented after being found on the floor following a fall. CNAs notified an LPN, who did not assess the resident at the time and instructed staff to return her to bed. The resident was later sent to the ED and diagnosed with rib fractures. There was no documentation of the fall, assessment, or notifications in the nursing notes, contrary to facility policy.
The facility did not ensure that Medicaid residents received their Personal Needs Allowance, failed to assist residents in applying for SSI or disability benefits, and improperly deducted room and board payments from a resident's trust account. Staff interviews revealed a lack of knowledge and action regarding financial assistance processes, resulting in residents not receiving funds for personal expenses.
Several residents did not receive their monthly personal needs allowance (PNA) or assistance with obtaining state-funded payments due to the facility's failure to update payee information, assist with SSI or disability applications, and ensure proper financial arrangements. Staff were unclear about their responsibilities, and there was no documentation of efforts to help residents access entitled benefits.
A resident's personal trust account was improperly charged for room and board, a service covered by Medicaid and social security, resulting in the depletion of her personal funds. The resident did not receive her monthly Personal Needs Allowance due to issues with social security payments, leaving her without money for personal expenses.
A resident's right to privacy in receiving mail was violated when the Business Office Manager opened two envelopes containing life insurance checks addressed solely to the resident. The mail was delivered to the resident already opened, despite facility policy requiring mail to be delivered sealed and only opened at the resident's request. Staff interviews confirmed the breach, and the incident was corroborated by the resident and a family member.
The facility failed to ensure sanitary handling of food during mealtimes, affecting all 75 residents. A CNA was observed preparing food trays without using gloves or washing hands, handling bread with bare hands, and placing it back on the tray. This was against the facility's policy, as confirmed by the CNA and other staff members, including an Activities staff member and an LPN.
The facility failed to respond to call lights in a timely manner for 11 residents, with some waiting over two hours for assistance. Despite the administrator's expectation of a 30-minute response time, there was no formal policy, leading to significant delays and unmet resident needs.
The facility did not provide bedtime snacks to 11 residents, despite a policy requiring snacks to be offered at 8:00 PM. A CNA confirmed that only some residents receive snacks, and the Regional Director of Operations stated that all residents should be offered snacks. Several affected residents have Type II Diabetes Mellitus, which may require regular nutritional intake.
The facility did not implement Enhanced Barrier Precautions for residents with wounds and indwelling medical devices, as required by their infection control policy. Observations showed a lack of personal protective equipment and signage in residents' rooms, and staff confirmed they had not received training on these precautions. The Infection Preventionist acknowledged the oversight, highlighting a gap in adherence to infection control measures.
A facility failed to provide a resident and/or their representative with a written notice of hospital transfer, as required. The resident's Census Profile documented hospital unpaid leave, but there was no evidence of a written notice of transfer or discharge in the resident's chart. This was confirmed by a Social Service Assistant during an interview.
A facility failed to provide a Bed Hold Policy to a resident or their representative during a hospital transfer. The resident, diagnosed with Dementia with Agitation, was admitted to a hospital after attempting self-harm. The facility's policy requires notification of the Bed Hold Policy, but no documentation was found to confirm this was done.
A facility failed to obtain a Level II PASRR screening for a resident newly diagnosed with Disorganized Schizophrenia. Initially, the resident's PASRR Level I indicated no need for further screening. However, after a nurse practitioner documented the new diagnosis, the facility did not conduct the required Level II PASRR. The Regional Director of Operations acknowledged this oversight.
A facility failed to document PTSD triggers and interventions for a resident with PTSD, as required by their Trauma Informed Care Policy. The resident's care plan and Trauma Informed Care form lacked necessary documentation, despite the resident's diagnosis being noted in their Physician Order Sheet and PASRR. The Regional Director of Operations acknowledged the oversight, attributing it to updates made during a receivership transition.
The facility failed to document behaviors justifying the use of antipsychotic medications, obtain consent prior to their use, and perform an annual gradual dose reduction for two residents. One resident was prescribed ABH gel for dementia and anxiety without documented behaviors or consent, while another was given Haldol Decanoate IM monthly without justification or consent. Staff confirmed the absence of behaviors warranting these medications.
A facility failed to prevent multiple incidents of resident-to-resident abuse, involving a resident with severe cognitive impairment who physically assaulted several other residents and was also sexually assaulted by another resident. The facility did not adequately address the aggressive behaviors in the care plans or provide sufficient supervision, leading to Immediate Jeopardy.
A bariatric resident in a LTC facility was unable to be safely transferred due to malfunctioning mechanical lifts. Despite being dependent on staff for transfers, the facility's lifts either failed to lift the resident high enough or stopped working mid-transfer. Staff and the resident reported these issues to the administration, but the problems persisted, leaving the resident feeling unsafe and neglected.
The facility failed to investigate two resident-to-resident altercations involving physical abuse. A resident with severe cognitive impairment and aggressive behavior assaulted another resident, and in a separate incident, threw water on a different resident. Despite these events, the facility did not conduct investigations or report the incidents to the state agency, as required by their policy.
A resident with depression and type 2 diabetes did not receive their prescribed medications, Venlafaxine HCl ER and Victoza, for several days due to unavailability. The nursing staff failed to notify the resident's physician or document any interventions to address the medication shortage. The facility's protocol for handling such situations was not followed, leading to adverse effects for the resident.
Failure to Accurately Transcribe Cancer Medication Order Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and maintain a continuous physician order for an anti-neoplastic medication, resulting in a resident not receiving the drug for three days. The facility’s medication administration policy requires that all medication orders and any changes be accurately documented in the medical record, and that errors or omissions be recorded and reported. The resident was admitted with multiple diagnoses including malignant neoplasm of the prostate, malignant pleural effusion, and secondary malignant neoplasm of bone. Hospital discharge orders dated 2/9/26 directed Abiraterone 250 mg, four tablets orally once daily on an empty stomach, with no stop date. However, the facility’s MAR for the month showed the Abiraterone order entered with a stop date of 2/24/26, and the MAR documented that the resident did not receive the medication on 2/25, 2/26, and 2/27. The resident and family reported that the resident had missed several doses of his cancer medication because nurses told him there was no order for it or that it was not available. The resident stated he had brought a four-day supply from home and had it renewed after admission, and that he was told he could not miss taking it because his prostate cancer had spread to his bones. The LPN who transcribed the admission orders confirmed she entered the Abiraterone order and acknowledged that the hospital discharge orders did not contain a stop date, and she did not know where the 2/24/26 stop date came from. Another LPN stated she only changed the administration time based on the resident’s usual home schedule and that the stop date was already present on the order. The former DON reported that the resident had voiced concerns that a nurse would not administer his cancer medication because there was no order for it, and that the order had been incorrectly stopped, leading to the documented missed doses.
Failure to Provide Ordered Medications and Notify Physician Resulting in Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not providing ordered medications and necessary services to prevent physical harm. A resident with complex cardiopulmonary conditions, including acute on chronic respiratory failure with hypercapnia, COPD, pulmonary hypertension, and acute on chronic diastolic congestive heart failure, was admitted from a hospital with detailed physician orders for multiple medications and treatments. These included oxygen at 5 L via nasal cannula, diuretics (such as spironolactone and torsemide), bronchodilators and nebulizer treatments (including arformoterol, Breztri, ipratropium‑albuterol, and albuterol), steroids (prednisone), and several other maintenance medications and supplements. The facility’s own policies required that physician orders be entered within one hour of admission, that medications be available upon admission using the emergency drug kit or STAT safe if needed, and that pharmacy be contacted for STAT delivery when medications were not on hand. Despite these requirements and the resident’s high‑risk medical status, the Medication Administration Record shows that on multiple days following admission, the resident did not receive numerous ordered medications at scheduled times. Missed medications included aspirin, cyanocobalamin, docusate sodium, ferrous sulfate, fluoxetine, fluticasone, folic acid, prednisone, spironolactone, vitamin D3, acetazolamide, Budeson‑Glycopyrrolate‑Formoterol (Breztri), clonazepam, hydroxychloroquine, torsemide, and ipratropium‑albuterol at various 8:00 a.m., 12:00 p.m., and 4:00 p.m. doses. These omissions were documented by the LPN as “unavailable.” The facility had an electronic STAT safe/automated dispensing cabinet stocked with several of these medications, including albuterol, fluoxetine, prednisone, simvastatin, spironolactone, torsemide, and ipratropium, but the LPN acknowledged that she did not obtain medications for the resident from this machine on the days in question. The LPN further stated that the resident’s medications had not arrived from the pharmacy and that the resident did not receive medications on those days, but she did not notify the physician or nursing management that ordered medications, including breathing treatments, diuretics, heart failure medications, and prednisone, were not being administered. Pharmacy records later showed that many of the resident’s medications were in fact delivered to the facility overnight and early morning, yet the LPN could not explain why certain medications, such as acetazolamide and Breztri, were still not administered after delivery. The primary physician and advanced practice nurse both stated they were not notified that the resident’s medications were unavailable or not being given and indicated that they would have modified the treatment plan or sent the resident back to the hospital if they had been informed. On the day of death, staff last spoke with the resident shortly before noon, and when the LPN went to administer medications late that morning, the resident was found without respirations or pulse and was pronounced expired. The facility and surveyors determined that the failure to administer prescribed medications as ordered, to use available medication resources, and to notify the physician and nursing administration of missed doses constituted neglect and resulted in actual harm and death, rising to the level of Immediate Jeopardy. The facility’s own documentation and staff interviews confirmed that there was no timely escalation when medications were marked as unavailable, no documented physician notification regarding missed doses over multiple days, and no implementation of alternative interventions despite the resident’s complex cardiac and respiratory diagnoses. The DON verified that the resident did not receive multiple ordered medications on the identified days. The death certificate listed acute on chronic congestive heart failure and acute on chronic diastolic heart failure as the cause of death, with COPD as a significant contributing condition. The survey findings concluded that the deprivation of necessary medications and services, in violation of the facility’s abuse prevention and medication availability policies, constituted neglect and led to actual harm and death, resulting in an Immediate Jeopardy determination.
Removal Plan
- Director of Nursing reviewed all residents receiving prescribed medications as ordered.
- Director of Nursing reviewed all residents and identified no residents as having missed any doses of prescribed medications.
- All licensed nurses were educated by the Director of Nursing and provided access and instructions on how to obtain unavailable medications from the facility emergency medication kit (STAT Safe).
- Regional Nurse Consultant educated the Director of Nursing on medication administration and availability.
- Weekly match-back audits are completed for medication availability.
- All new admissions are reviewed to ensure medications are available and orders are in place using a checklist, which is reviewed daily during the clinical QA meeting.
- Licensed nursing staff were educated by the Director of Nursing on adherence to physician orders, timely resident assessment and documentation, physician notification when an ordered dose is missed, immediate notification and escalation to facility nursing administration for medication administration issues, and the facility Abuse and Neglect Policy related to administering prescribed medications to avoid physical harm.
- Director of Nursing created an audit tool to ensure compliance with medication administration and availability, assessment and documentation, physician notification and escalation to nursing administration, and staff knowledge of facility medication administration standards to avoid physical harm to residents.
- Director of Nursing or designee will audit licensed nurses to ensure compliance with medication administration standards.
- Administrator or designee will audit licensed nurses to ensure compliance with medication administration standards to avoid physical harm to residents.
Failure to Administer Ordered Medications and Notify Providers Resulting in Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a newly admitted resident received prescribed medications in accordance with physician orders. The resident was admitted from a local hospital after a prolonged hospitalization for acute on chronic respiratory failure with hypercapnia, acute respiratory distress, COPD, pulmonary hypertension, and acute on chronic diastolic congestive heart failure, among other diagnoses. Hospital discharge instructions and the facility’s October physician order sheet show that the resident was to receive multiple routine medications, including oxygen at 5 L via nasal cannula, diuretics (torsemide, spironolactone, acetazolamide), bronchodilators and nebulizer treatments (albuterol, ipratropium‑albuterol, arformoterol, Breztri), steroids (prednisone, fluticasone), psychotropic medication (clonazepam), and several other maintenance medications and supplements. Facility policy required that physician orders be entered within one hour of admission, that pharmacy be contacted after 4:00 p.m. for new admissions, and that medications be obtained from the emergency drug kit or STAT Safe if not yet delivered. Despite these orders and policies, the resident’s Medication Administration Record shows that on two consecutive days after admission, the resident did not receive a wide range of ordered medications at scheduled times (8:00 a.m., 12:00 p.m., and 4:00 p.m.). Missed medications included aspirin, cyanocobalamin, docusate sodium, ferrous sulfate, fluoxetine, fluticasone, folic acid, prednisone, spironolactone, vitamin D3, acetazolamide, Budeson‑Glycopyrrolate‑Formoterol, clonazepam, hydroxychloroquine, torsemide, and ipratropium‑albuterol. These doses were documented by the LPN as “unavailable,” yet there is no documentation in the medical record that the physician was notified of the missed doses or that nursing management was informed. The facility had an electronic STAT Safe with several of the resident’s ordered medications stocked, including albuterol nebulizer solution, fluoxetine, prednisone, simvastatin, spironolactone, torsemide, and ipratropium, but the LPN later stated she did not obtain medications for the resident from this machine on the days in question. Interviews confirmed that required escalation and communication did not occur. The LPN reported that when new admissions arrive, other staff typically enter orders and that medications are usually delivered between 8:00 p.m. and 10:00 p.m., but she stated the resident’s medications had not arrived and that the resident did not receive medications on the two days prior to death. She acknowledged she did not notify the physician or nursing management that the resident had not received any medications, including breathing treatments, diuretics, heart failure medications, or prednisone, and could not explain why she did not administer certain medications that had been delivered by pharmacy before the resident’s death. The attending physician and an advanced practice nurse both stated they were not notified that the resident’s medications were unavailable or not administered; the physician stated the medications, including multiple diuretics, nebulizer treatments, and steroids, should never have been placed on hold and that he expected medications to be available on the evening of admission or to be notified to modify the treatment plan. Pharmacy records showed that many of the resident’s medications were delivered late in the evening and early morning following admission, but the resident still did not receive them as ordered. The resident was last noted as alert with shortness of breath at times and requiring BiPAP and nebulizer treatments with oxygen; later, staff found the resident without respirations or pulse when attempting to administer medications, and the death certificate lists acute on chronic congestive heart failure and acute on chronic diastolic heart failure with COPD as contributing conditions. The facility’s failure to follow physician orders, obtain and administer available medications, and provide appropriate monitoring and response resulted in actual harm and death and was cited at the Immediate Jeopardy level. The facility’s own policies and available resources underscore the inactions that led to the deficiency. The Medication Availability policy directed staff to enter orders promptly, contact pharmacy after 4:00 p.m. for new admissions, use the emergency drug kit or STAT Safe for needed medications, and obtain STAT or backup pharmacy delivery when medications were not in stock, with all administrations documented in the EMAR. The pharmacy’s posted hours and cutoff times, along with the STAT Safe inventory list, showed that many of the resident’s ordered medications were accessible through the automated dispensing cabinet. Nonetheless, the LPN did not use the STAT Safe to obtain medications, did not document any attempts to secure medications beyond marking them as unavailable, and did not escalate the issue to the DON or physician. The DON later verified that the resident did not receive multiple ordered medications on the days prior to death and that she had not been informed of the unavailability or non‑administration of these medications. These documented failures in medication procurement, administration, and communication formed the basis of the cited deficiency and Immediate Jeopardy determination.
Removal Plan
- Director of Nursing reviewed all residents to confirm they are receiving prescribed medications as ordered.
- All licensed nurses were educated by the Director of Nursing and provided access/instructions on how to obtain unavailable medications from the facility emergency medication kit (STAT Safe).
- Regional Nurse Consultant educated the Director of Nursing on medication administration and medication availability processes.
- As part of QA activities, match-back audits are completed for medication availability.
- All new admissions are reviewed using a checklist to ensure medications are available and orders are in place; this checklist is reviewed during the clinical QA meeting.
- Licensed nursing staff were educated by the Director of Nursing on adherence to physician orders, timely resident assessment and documentation, physician notification when an ordered medication dose is missed, and immediate notification/escalation to facility nursing administration for any medication administration issue.
- An audit tool/process was created by the Director of Nursing to ensure compliance with medication administration and availability, assessment and documentation, physician notification, and escalation to nursing administration.
- Director of Nursing or designee will audit licensed nurses to ensure compliance with medication administration standards.
Failure to Maintain Signed Physician Orders for Held Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and physician orders related to holding medications for three residents. For one resident, the nursing progress note documented that an advanced practice nurse was notified that the resident was a new admission and that medications were not available, and that the practitioner gave an order to hold the unavailable medications. However, a review of the resident’s physician order sheet for that month did not show any signed physician order to hold those medications. For a second resident, nursing progress notes documented receipt of a physician’s order to hold Abilify, Trelegy, and Jardiance until the pharmacy could verify delivery and fill all orders for drop-off that evening, but the corresponding physician order sheet contained no signed physician order to hold these medications. For a third resident, nursing progress notes stated that the resident’s medications were on hold until available, that PRN Ultram and Lasix were obtained from backup, and that the primary care physician was aware that medications were on hold; however, there was no signed physician order in the medical record to support holding the medications. The interim DON confirmed that the electronic medical records for all three residents lacked signed physician orders to hold medications and stated that, per facility standard of practice, telephone or verbal orders must be backed up by a signed physician order and that without such a signature, those orders are insufficient and void.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in one resident pushing another, causing the latter to lose balance and fall to the floor. The incident involved two residents on a locked dementia unit, both of whom were not cognitively intact. The resident who was pushed had a history of dementia with psychotic disturbance and other chronic conditions, and was ambulatory without assistance. The resident who pushed used a wheelchair and had diagnoses including dementia with anxiety and other chronic illnesses. According to staff interviews and documentation, the resident who was pushed had repeatedly entered the personal space of the other resident, requiring redirection on multiple occasions. On the day of the incident, staff observed the ambulatory resident approach the wheelchair-bound resident twice—first in the hallway and then in the day room. After being redirected the first time, the resident again entered the other's personal space, at which point the wheelchair-bound resident pushed, causing a fall. Staff confirmed that the resident who pushed is known to become aggressive when his personal space is invaded, and that the other resident frequently needs redirection for similar behaviors. The incident occurred while the LPN was down the hall, and staff confirmed the sequence of events as described.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of each resident. This deficiency was identified during the survey process, but the report does not provide specific details regarding the actions or inactions that led to the failure, nor does it mention any particular residents or their conditions at the time of the incident.
Failure to Honor Resident's Request for Care Plan Meeting with Ombudsman
Penalty
Summary
The facility failed to honor a cognitively intact resident's request to participate in a care plan meeting with the ombudsman present. The resident had submitted a grievance regarding inconsistent bathing and hair care after a change in CNA assignments and specifically requested a care plan meeting with the ombudsman to discuss these concerns. Despite the resident's repeated verbal and written requests, and the ombudsman's direct communication with the prior administrator and DON about scheduling the meeting, no care plan meeting was arranged or documented in the resident's electronic health record during the review period. Interviews confirmed that the resident continued to express frustration about not being heard and not having the requested meeting, and the ombudsman reported never receiving follow-up from facility leadership after the initial discussion. The Social Service Director, responsible for scheduling care plan meetings, stated they were never informed of the resident's request. At the time of observation, the resident's hair appeared oily and stringy, and the resident expressed ongoing dissatisfaction with care and communication from staff.
Failure to Protect Residents from Abuse and Inadequate Documentation
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident sexual and physical abuse, as evidenced by multiple incidents involving four residents. One cognitively intact resident entered the room of a severely cognitively impaired resident on more than one occasion and engaged in inappropriate sexual contact, including groping and exposing the resident. Staff members witnessed these incidents, and there was evidence that the cognitively impaired resident was unable to recall or report the events due to her condition. Despite these occurrences, the care plan for the cognitively impaired resident did not address her risk for abuse or include interventions to protect her from further harm. Additionally, the facility failed to document the incidents and necessary interventions in the medical records of both the perpetrator and the victim. The cognitively intact resident's record did not reflect the sexual abuse allegations or the rationale for increased supervision, and the cognitively impaired resident's records lacked documentation of the abuse incidents and protective measures. Staff interviews confirmed that the administration was aware of the incidents, but appropriate documentation and care plan updates were not completed at the time of the events. A separate incident involved a resident with a history of physical aggression due to dementia and mood disorders physically striking her roommate during care. The aggressive resident's care plan noted her behavioral issues and triggers, but the incident still occurred, resulting in the roommate being hit on the shoulder. Staff and the roommate confirmed the aggressive behavior, and the facility's records corroborated the event. These failures to prevent and appropriately respond to abuse led to the finding of Immediate Jeopardy.
Failure to Post and Address Grievance Procedures
Penalty
Summary
The facility failed to post grievance and complaint procedures in prominent locations throughout the building and did not promptly address resident grievances, as required by policy. The facility's grievance policy states that forms should be available at all nurse's stations and front desks, and that grievances should be addressed and resolved within five days. However, during a tour, the Administrator confirmed that grievance procedures were not posted in any prominent locations. Additionally, during a resident council meeting, multiple residents stated they did not know where or how to file a grievance, and some reported that grievances were not followed up on promptly or at all. A specific incident involved a resident who filed a grievance with the assistance of the Ombudsman regarding issues with bathing, call light response times, and supply availability. The grievance requested a care plan meeting with the Ombudsman present. The Ombudsman submitted the grievance to the Administrator, but the Administrator did not document any investigation or resolution, and the Activities Director, who received the grievance weeks later, had not started addressing it. The lack of investigation and response to this grievance, along with the absence of posted procedures and resident awareness, demonstrates the facility's failure to honor residents' rights to voice grievances without discrimination or reprisal.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report allegations of resident-to-resident sexual and physical abuse to the appropriate authorities in a timely manner, as required by its own Abuse, Prevention, and Prohibition Policy. In one incident, a Licensed Practical Nurse observed a resident groping another resident, exposing her breasts and abdomen. The initial report of this sexual abuse was sent to the State Agency five days after the incident, and the final report was sent eleven days after the allegation was made. There was no documentation that local law enforcement was notified of the alleged sexual abuse, despite policy requirements. The Administrator confirmed the delay in reporting and the lack of notification to law enforcement. In a separate incident, a resident was hit on the shoulder by another resident during incontinence care, resulting in a complaint of shoulder pain rated as 3/10, though no visible injury was noted. The incident was not reported to the State Agency within the required two-hour window; instead, it was reported the following day. The Administrator acknowledged the delay and stated unawareness of the two-hour reporting requirement. These failures affected four residents reviewed for abuse in the sample of 38.
Failure to Assess and Document Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident was properly assessed following an alleged fall. The resident, who had severe dementia, anxiety, and depression, was found sitting on the floor in her room and reported she had fallen but could not recall the details. Certified Nursing Assistants notified an LPN of the incident, but the LPN did not immediately assess the resident and instructed staff to return her to bed. The resident was later sent to the emergency department, where she was diagnosed with closed fractures of the 8th and 9th ribs on the right side. There was no documentation in the nursing progress notes regarding the fall, assessment, notifications, or the time the resident was sent to the emergency department. Further interviews revealed that the LPN who received the resident back from the emergency department was not informed of the fall and found no documentation in the notes. The Assistant Director of Nursing confirmed that the facility's policy requires immediate assessment and documentation after a fall, including a detailed progress note and notifications. The facility's post-fall procedure was not followed, as there was no evidence of a fall risk evaluation, assessment, or proper documentation in the resident's record.
Failure to Provide Personal Needs Allowance and Financial Assistance for Medicaid Residents
Penalty
Summary
The facility failed to provide effective administrative oversight to ensure that residents on Medicaid received their Personal Needs Allowance (PNA), assistance with supplemental income financial applications, and proper management of personal funds. The administrator and business office manager did not ensure that residents were receiving their entitled PNA, nor did they assist residents in applying for Supplemental Security Income (SSI) or disability benefits when appropriate. The facility also failed to prevent the use of residents' personal funds for Medicaid-covered services, as evidenced by the deduction of room and board payments from a resident's trust account. One resident, who had been in the facility for nearly a year, reported not receiving her social security or the $60 monthly PNA, leaving her without money for personal expenses such as haircuts or shoes. The resident's trust account showed a significant deduction for room and board, and no deposits had been made since her admission. The business office manager confirmed that the resident was owed the PNA for the past year and that her trust funds had been depleted due to improper deductions. Additionally, the facility did not ensure that residents without income were assisted in applying for SSI or disability benefits, resulting in several residents not receiving any monthly PNA. Interviews with staff revealed a lack of knowledge and action regarding the application process for SSI or disability benefits. The social services staff and business office manager both stated they had not assisted any residents with these applications. The administrator was unaware of the issues with residents' income and PNA, and there was no documentation to show that residents had been informed or assisted regarding their financial entitlements. This lack of oversight and failure to follow established procedures affected all Medicaid residents in the facility.
Failure to Provide Personal Needs Allowance and Financial Assistance
Penalty
Summary
The facility failed to provide medically-related social services and financial assistance to ensure that residents received their entitled state-funded payments and personal needs allowances (PNA). One resident, who had been in the facility for nearly a year, was not receiving her monthly PNA despite being on Medicaid. Her trust account showed a balance of only $0.01 for several months, with no deposits or transactions, and she reported having no money for personal expenses such as haircuts or shoes. The Business Office Manager confirmed that the resident's Social Security payments were not being received by the facility due to the payee not being updated, resulting in the resident not receiving her monthly allowance. Additionally, three other residents, all under the age of 65 and with Medicaid as their payer source, were not receiving a monthly PNA because they had no income. Staff interviews revealed that neither the Business Office Manager nor Social Services had assisted these residents in applying for Supplemental Security Income (SSI) or disability benefits, which would have enabled them to receive a PNA. The staff were unclear about the process and responsibilities for initiating SSI or disability applications, and there was no documentation to show that these residents had been assessed or assisted in obtaining financial benefits. Job descriptions for the Social Services Assistant, Admissions Coordinator, and Business Office Coordinator outlined responsibilities for ensuring residents' financial arrangements and facilitating access to benefits. However, the facility did not follow through with these duties for the affected residents. The lack of action resulted in multiple residents not receiving funds for personal needs, and there was no evidence that the facility had made appropriate referrals or provided necessary assistance to secure these benefits.
Improper Use of Resident Personal Funds for Medicaid-Covered Services
Penalty
Summary
The facility failed to ensure that a resident's personal funds were not used to pay for items or services covered by Medicaid. According to the facility's Financial Responsibility Agreement and Medicaid guidelines, residents eligible for Medicaid should not be charged for medical or personal supplies routinely supplied to all residents, and their Personal Needs Allowance (PNA) should not be used for items or services paid for by Medicaid. Despite this, a resident who had been on Medicaid since admission had $1,086.20 deducted from her personal trust account for room and board, which should have been covered by Medicaid and her social security income. The resident's trust account was subsequently depleted, with no deposits made since her admission, and she did not receive her monthly PNA due to issues with social security checks not being delivered to the facility or the facility not being set as her payee. The business office manager confirmed that the resident's Medicaid and social security should have covered her room and board, and that the resident had not received her $60 monthly PNA for the past year. The deduction from the resident's trust account for room and board was made at the direction of her financial power of attorney, but this action was inconsistent with Medicaid regulations. The resident reported having no money for personal expenses, relying only on occasional bingo winnings or gifts from friends, and her trust account balance was reduced to one cent.
Failure to Ensure Privacy of Resident Mail Delivery
Penalty
Summary
The facility failed to ensure that a resident's mail was delivered unopened and without being read, as required by resident rights policies. Specifically, the Business Office Manager (V4) admitted to opening two envelopes addressed solely to the resident, which contained life insurance checks related to the resident's late spouse. The envelopes were not addressed to the facility, and the resident reported receiving both envelopes already opened. The Business Office Manager stated that the mail was opened by accident, but both envelopes were opened before being delivered to the resident. The resident's family member confirmed that all banking is managed by the family and not the facility, and that the envelopes were clearly marked as life insurance correspondence addressed only to the resident. Interviews with staff confirmed that resident mail should be delivered sealed and only opened at the resident's request. The Activity Director (V7) stated that mail is typically received from the Business Office Manager and delivered to residents unopened, except in cases where the recipient is unclear. In this instance, however, the mail was clearly addressed to the resident, and the facility's own policy affirms the right to privacy in sending and receiving mail. The incident was corroborated by both the resident and a family member, as well as the staff member responsible for sorting and delivering mail.
Failure to Follow Sanitary Food Handling Procedures
Penalty
Summary
The facility failed to adhere to its policy on sanitary handling of food items during mealtimes, which has the potential to affect all 75 residents. The facility's Hand Washing and Glove Usage Policy requires employees to use proper hand washing procedures and gloves in accordance with State and Federal Sanitation Guidelines. On a specific date, a Certified Nursing Assistant (CNA) was observed preparing food trays for residents without using gloves or washing hands. The CNA handled bread with bare hands, buttered it, and placed it back on the meal tray. This action was contrary to the facility's policy, as confirmed by the CNA and other staff members, including an Activities staff member and a Licensed Practical Nurse (LPN), who stated that staff should wear gloves when touching residents' food.
Failure to Timely Respond to Call Lights
Penalty
Summary
The facility failed to answer call lights in a timely manner for 11 residents, as revealed through record review and interviews. During a resident council meeting, multiple residents reported significant delays in call light responses, with some residents waiting over two hours for assistance. One resident mentioned having to fix their own oxygen supply due to the lack of timely response, while another reported that staff would turn off the call light without returning to provide help. These delays were reported to occur across all shifts, with some residents experiencing these issues multiple times a week. The facility's Regional Director of Operations admitted that there was no specific policy on answering call lights, although the expectation was that residents' needs should be met whenever a call light is activated. The facility administrator stated that call lights should be answered within 30 minutes, but this standard was not being met, as evidenced by the residents' testimonies. The lack of a formal policy and the failure to adhere to the 30-minute response expectation contributed to the deficiency in providing timely assistance to residents.
Failure to Provide Bedtime Snacks to Residents
Penalty
Summary
The facility failed to provide bedtime snacks to 11 residents, all of whom were reviewed for bedtime snacks in a sample of 33. The facility's Dining Service Mealtimes policy requires that an HS (Hour of Sleep) snack be offered to all residents at 8:00 PM. However, during a resident council meeting, all 11 residents reported not receiving bedtime snacks. Additionally, a Certified Nursing Assistant (CNA) confirmed that only some residents are offered bedtime snacks, indicating a deviation from the facility's policy. Among the affected residents, several have Type II Diabetes Mellitus, which may necessitate regular nutritional intake. The Regional Director of Operations acknowledged that all residents should be offered bedtime snacks, yet the practice was not consistently followed. The CNA, who has been working at the facility since February, stated that not all residents are offered a bedtime snack, further corroborating the residents' claims. This inconsistency in providing snacks highlights a failure to adhere to the established policy, impacting the nutritional care of the residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and indwelling medical devices, as observed in four out of twelve residents reviewed for EBP. The policy outlined in the Infection Prevention and Control Manual requires the use of gowns and gloves during high-contact resident care activities for those at increased risk for multidrug-resistant organism (MDRO) acquisition. However, observations revealed that residents with conditions such as an arteriovenous fistula, wounds, and indwelling urinary catheters did not have the necessary personal protective equipment (PPE) available in their rooms, nor were there any signs indicating the need for EBP. Additionally, staff members, including licensed practical nurses, registered nurses, and certified nursing assistants, confirmed they had not received training or in-service on Enhanced Barrier Precautions. The Infection Preventionist acknowledged the oversight and communicated the need for EBP to the facility administrator. The lack of training and awareness among staff, coupled with the absence of PPE and signage, contributed to the facility's failure to adhere to the infection control policy, thereby increasing the risk of MDRO transmission among residents.
Failure to Provide Written Notice of Hospital Transfer
Penalty
Summary
The facility failed to provide a resident and/or their representative with a written notice of hospital transfer, which is a requirement for ensuring proper communication and rights awareness. The deficiency was identified for one resident in a sample of 33. The resident had a hospital unpaid leave documented on their Census Profile, covering specific dates. However, there was no evidence in the resident's chart of a written notice of transfer or discharge being provided. This was confirmed during an interview with the Social Service Assistant, who acknowledged the absence of documentation or evidence of such notification.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide a copy of the Bed Hold Policy to a resident or their representative when the resident was transferred to a hospital. The facility's policy, revised in February 2024, requires that a Bed Hold Agreement be obtained for each occurrence of hospital or therapeutic leave, and that the resident or their representative be notified of this policy. However, in the case of the resident reviewed, there was no documentation indicating that the Bed Hold Policy was provided. The resident, who had a diagnosis of Dementia with Agitation, was admitted to a local hospital after an incident where they attempted to harm themselves with broken glass. Despite the facility's procedure, the Social Service Assistant confirmed that there was no record of the Bed Hold Policy being given to the resident or their representative.
Failure to Obtain Level II PASRR for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to obtain a Level II PASRR (Pre-Admission Screening and Resident Review) screening for a resident who was newly diagnosed with a mental illness. The resident, identified as R67, was admitted to the facility with a PASRR Level I determination indicating no need for a Level II screening, as there was no severe mental illness, intellectual disability, or related condition noted at that time. However, on July 6, 2023, a nurse practitioner documented a new evaluation diagnosing the resident with Disorganized Schizophrenia, noting that the resident was delusional and prone to outbursts or attempts to elope when upset. Despite this new diagnosis, the resident's medical record did not show evidence of a Level II PASRR screening being conducted. The Regional Director of Operations confirmed that the facility did not request a Level II PASRR after the diagnosis of Disorganized Schizophrenia was made.
Failure to Document PTSD Triggers and Interventions
Penalty
Summary
The facility failed to assess and identify potential triggers and provide specific personalized interventions for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The facility's Trauma Informed Care Policy, dated October 2022, outlines the importance of considering residents' past traumatic experiences to develop person-centered care plans that avoid re-traumatization. However, the resident's Trauma Informed Care form, effective August 2024, did not document any PTSD triggers or interventions. Additionally, the resident's care plan, which was initiated in August 2023 and revised in June 2024, also lacked documentation of identified triggers or interventions for PTSD. The deficiency was identified during a review of the resident's records and an interview with the Regional Director of Operations. The resident's Physician Order Sheet and Preadmission Screening and Resident Review (PASRR) both documented a diagnosis of PTSD. Despite this, the facility did not have any documented triggers or interventions for the resident's PTSD. The Regional Director of Operations acknowledged the oversight, stating that updates to the facility's computer forms during a receivership transition might have contributed to the lack of documentation. The care plan was updated on the day of the interview to identify the triggers.
Failure to Document Justification and Obtain Consent for Antipsychotic Use
Penalty
Summary
The facility failed to document behaviors justifying the use of antipsychotic medications, obtain consent prior to their use, and perform an annual gradual dose reduction for two residents. Resident R10, who is severely cognitively impaired, was prescribed ABH gel for unspecified dementia and anxiety disorder without documented behaviors that would justify its use. The medical record lacked a consent form and a care plan for the use of this medication. Observations and staff interviews indicated that R10 did not exhibit behaviors that posed a risk or disrupted care, and could be easily redirected. Resident R67, diagnosed with disorganized schizophrenia, was prescribed Haldol Decanoate IM monthly without documented behaviors to justify its use. The medical record did not include a consent form, a care plan, or evidence of a gradual dose reduction attempt since the medication's initiation. Staff interviews confirmed that R67 did not exhibit behaviors warranting the medication and primarily wanted to rest, receiving hospice services. The facility's failure to comply with its policies on psychotropic medication use and gradual dose reduction was evident in these cases.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse for several residents, resulting in multiple incidents of resident-to-resident physical and sexual abuse. Resident R3, who was severely cognitively impaired and had a history of aggressive behavior, was involved in several altercations. R3 physically assaulted R11 by hitting and shaking her arm, shoved R10 to the ground causing a head injury, punched R9 in the face, and threw water on R12. Additionally, R4 sexually assaulted R3 by placing his hand down R3's pants when R3 wandered into R4's room. These incidents highlight the facility's failure to implement effective interventions and supervision to prevent such occurrences. R3's care plan did not adequately address her aggressive behaviors or provide interventions to prevent further incidents. Despite R3's known history of physical aggression and cognitive impairment, the facility did not update her care plan to include strategies for managing her behavior or preventing her from entering other residents' rooms. Similarly, R4's care plan lacked interventions to address inappropriate sexual behavior, which contributed to the incident involving R3. The facility's staff also failed to provide adequate supervision and intervention during these incidents. Staff members were unable to redirect R3 effectively, and there were instances where staff left residents unsupervised, allowing altercations to occur. The facility's policies on abuse prevention and intervention were not properly implemented, leading to a situation of Immediate Jeopardy for the residents involved.
Failure to Provide Functional Mechanical Lift for Bariatric Resident
Penalty
Summary
The facility failed to ensure that a mechanical lift was available and in working order for a bariatric resident who was dependent on transfers. The resident, a female with a history of chronic atrial fibrillation, depression, morbid obesity, hypertension, type 2 diabetes, and chronic sinusitis, was admitted to the facility and required assistance for activities of daily living and transfers. Her care plan specified the use of a mechanical lift with two staff members for transfers. However, the facility's mechanical lifts were either not functioning properly or were inadequate for the resident's weight, leading to difficulties in transferring her safely. The facility's staff reported multiple issues with the mechanical lifts. The new lift, which had a maximum weight capacity of 750 pounds, failed to lift the resident high enough for a transfer, even when the bed was lowered to its lowest position. The older blue lift, with a capacity of 500 pounds, was unreliable and often stopped working mid-transfer, requiring an ambulance to assist in returning the resident to bed. Despite attempts to address the issue by ordering a new sling and lift, the problems persisted, and the resident expressed dissatisfaction and concern for her safety during transfers. Interviews with staff and the resident revealed that the facility's administration, including the Director of Nursing and the Administrator, were aware of the ongoing issues but had not effectively resolved them. The resident felt neglected and unsafe, as the lifts had previously tipped and failed to function properly. Staff confirmed that the mechanical lifts had not been reliable since April, and despite reporting these issues to the administration, the problems remained unresolved, impacting the resident's ability to get out of bed as desired.
Failure to Investigate Resident-to-Resident Altercations
Penalty
Summary
The facility failed to conduct a thorough investigation of two resident-to-resident altercations involving physical abuse. The incidents involved three residents, R3, R11, and R12, and were not properly investigated as required by the facility's Abuse, Prevention, and Prohibition Policy. The policy mandates immediate reporting and thorough investigation of any alleged abuse, which was not adhered to in these cases. In the first incident, R3, who has a history of severe cognitive impairment and aggressive behavior, physically assaulted R11 by punching and shaking her arm. This altercation was witnessed by a CNA, who reported that R3 was swinging her arms aggressively and had a history of such behavior. Despite the severity of the incident, the facility did not conduct an investigation or report the incident to the state agency as required. In the second incident, R3 threw a glass of water on R12, another resident with moderate cognitive impairment. This incident was reported to the facility administrator, who dismissed it as a behavior issue rather than abuse, and no investigation was conducted. The administrator later admitted to not being aware of the incidents or failing to investigate them, which resulted in a lack of documentation and reporting to the state agency.
Medication Unavailability for Resident with Depression and Diabetes
Penalty
Summary
The facility failed to ensure the availability of essential medications for a resident, identified as R1, who was diagnosed with depression and type 2 diabetes mellitus. The resident did not receive their prescribed antidepressant, Venlafaxine HCl ER, for three consecutive days, and their diabetes medication, Victoza, for approximately a week. This lapse in medication administration was due to the medications being on order or back order, and there was no evidence of alternative measures being taken to address the unavailability. Interviews with the nursing staff revealed a lack of communication with the resident's physician regarding the unavailability of the medications. The LPNs responsible for R1's care did not notify the doctor or seek alternative prescriptions during the period when the medications were unavailable. Additionally, there were no documented interventions or progress notes in R1's medical record indicating that the facility took steps to mitigate the impact of the missed doses. The Director of Nursing confirmed that the facility's protocol for handling medication shortages was not followed. The protocol requires nurses to check the emergency medication box, contact the pharmacy, and notify the resident's doctor to obtain further orders. However, these steps were not documented or executed, resulting in R1 experiencing adverse effects such as severe headaches, depression, and fatigue due to the missed medications.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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