Moweaqua Rehab & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Moweaqua, Illinois.
- Location
- 525 South Macon Street, Moweaqua, Illinois 62550
- CMS Provider Number
- 146162
- Inspections on file
- 51
- Latest survey
- February 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Moweaqua Rehab & Hcc during CMS and state inspections, most recent first.
Two residents in a LTC facility experienced significant medication errors due to staff failing to administer medications as per physician orders. One resident did not receive prescribed intravenous antibiotics on multiple occasions, while another was given an incorrect dose of anti-epileptic medication. The facility lacked a formal policy on medication errors, contributing to these oversights.
A resident with behavioral issues exhibited physical and verbal aggression towards others, including punching, kicking, and using expletives. Despite documented concerns about the resident's behavior, the facility failed to implement effective interventions, resulting in harm to other residents. Staff reported the resident's frequent wandering and aggression, highlighting the facility's inadequate response to protect residents from abuse.
A facility failed to update care plans for residents after incidents of abuse by an aggressive resident. The aggressive resident, with memory and decision-making impairments, engaged in physical and verbal altercations with others. Despite documented incidents, care plans for affected residents lacked updates or interventions to address the abuse, highlighting a significant oversight in ensuring resident safety.
A resident experienced significant weight loss and malnutrition due to the facility's failure to implement dietary recommendations and communicate effectively with the Registered Dietician and physician. The resident, with a history of multiple medical conditions, was hospitalized for malnutrition and dehydration, resulting in a gastric tube placement. Upon readmission, the facility did not follow tube feeding orders correctly and failed to provide oral nutrition, leading to further deterioration of the resident's condition.
A resident with a history of intellectual disability and chronic leukemia experienced significant weight loss and malnourishment due to the facility's failure to monitor and document tube feeding administration. Despite dietician recommendations, there was no documentation of their implementation or physician notification. The resident's tube feeding was not administered as per hospital discharge orders, leading to further weight loss and vomiting. Staff failed to document essential care aspects, and communication lapses hindered the resident's nutritional management.
The facility failed to provide adequate personal care to three dependent residents, including bathing, oral care, and nail care. One resident with multiple diagnoses reported unclean and overgrown toenails despite requests for assistance. Another resident, severely cognitively impaired, was found in unsanitary conditions with greasy hair, an odor of feces, and unclean teeth and nails, with no recorded care for 28 days. A third resident, cognitively intact, reported infrequent showers and oral care, confirmed by documentation.
Two residents reported feeling disrespected by a CNA, identified as V15, who was described as impatient and intolerant of their needs. Both residents, who are cognitively intact, expressed discomfort with V15's behavior, leading to an investigation by the facility. The Corporate Director of Nursing emphasized the expectation of providing dignity to all residents.
A resident with advanced ALS and cognitive awareness expressed a desire to return to the hospital due to dissatisfaction with care at the facility. Despite being able to communicate using a letter board, the resident's requests were ignored, leading to anxiety and refusal of care. Staff acknowledged the resident's cognitive ability and the facility's inability to meet his needs due to understaffing, but the Nurse Practitioner advised against hospital transfer.
The facility failed to provide adequate RN coverage on multiple days, with zero RN hours scheduled for five days, potentially affecting all 54 residents. This was identified through a review of the Nursing Schedule and Resident Midnight Census, with the Director of Nursing employed in a supervisory role.
The facility failed to employ a qualified Director of Food and Nutrition Services and a certified Food Protection Manager, leading to unsanitary conditions and improper food handling. The dishwasher was not sanitizing dishes effectively, and the ice machine was not operational, with soiled ice bags placed in contact with existing ice. Food items were improperly stored without labels, and the kitchen was found to be unsanitary, with debris and waste on the floors.
The facility failed to sanitize dishes effectively, with staff unaware of proper testing procedures and a dishwasher showing zero sanitizer concentration. Cross-contamination risks were present with soiled ice bags and improperly stored food. The kitchen was unsanitary, with soiled equipment and floors, potentially affecting all 54 residents.
The facility failed to implement a comprehensive quality program, affecting all 54 residents. Despite having a QAPI policy outlining a systematic approach to quality and safety, the Administrator was unaware of an active quality program in place. This indicates a lack of implementation of the QAPI program, which is supposed to include regular meetings, daily quality assurance activities, and performance improvement plans.
The facility failed to implement quality-based performance improvement projects and data collection, affecting all 54 residents. Despite having a QAPI policy, an LPN was unaware of any projects, and the Administrator could not provide documentation of such activities over the past year.
The facility did not hold quarterly quality improvement committee meetings with all required members, potentially affecting all 54 residents. The QAPI policy requires systematic and data-driven approaches to quality, but only one of four required sign-in sheets was provided, missing an Infection Preventionist. The Administrator acknowledged the need for all required members, including the Medical Director, Administrator, DON, Infection Preventionist, and Pharmacist, to attend these meetings.
The facility failed to resolve grievances for several residents regarding staffing, food service, and timely care. Despite a policy requiring grievances to be addressed within five days, issues such as delayed call light responses, cold food, and late meal services remained unresolved. Residents reported dissatisfaction with meal and medication timeliness, highlighting the facility's non-compliance with its grievance policy.
The facility failed to provide adequate care for residents, including timely toileting and incontinence care, assistance with meals, and proper fingernail hygiene. A resident with hemiplegia reported long waits for incontinence care, while another with multiple sclerosis experienced delays in meal assistance. Additionally, a resident was found with feces under her nails, highlighting lapses in hygiene care. The facility's grievance log showed multiple complaints about delayed call light responses.
A facility failed to follow physician orders for a resident's nonpressure wound care. The resident, who is cognitively intact, had orders for wound vacuum dressing changes three times a week, which were not completed on several occasions. The resident reported a fall that led to the need for a wound vacuum. The DON was unaware of the missed treatments, and the facility lacked a specific policy for wound vacuums.
The facility failed to meet the nutritional needs and preferences of several residents by not adhering to prescribed dietary orders. A resident received a meal inconsistent with their mechanical soft diet, another did not receive their requested breakfast, and two others did not receive all items on their prescribed meal plans. These discrepancies were confirmed through observations and staff interviews.
The facility failed to provide timely and palatable meals, affecting several residents. Meals were often served late and cold, with scheduled times not adhered to, leading to numerous resident complaints. Observations noted issues such as blackened dinner rolls and cold puree, with staff conflicts contributing to delays.
A resident experienced a fall at the facility, resulting in the dehiscence of a surgical incision and significant bleeding. Despite the injury, the facility failed to conduct a thorough investigation or root cause analysis. The administrator did not consider the wound dehiscence a new injury, and the corporate nurse confirmed the absence of a specific policy for incident reporting and investigation, highlighting a deficiency in resident safety protocols.
A facility failed to provide appropriate respiratory care for a resident by not administering oxygen as ordered, not correctly applying the nasal cannula, and not maintaining clean, dated, and labeled oxygen tubing. The resident's nasal cannula was improperly positioned, and the oxygen was set at 2.5 liters instead of the ordered 2 liters. Additionally, the oxygen tubing was not replaced weekly, and the humidification bottle was empty. The Director of Nursing acknowledged the oversight, highlighting a lapse in monitoring by the nursing staff.
The facility failed to properly assess and manage psychotropic medication use for residents, leading to deficiencies in behavior tracking and non-pharmacological interventions. One resident was on multiple psychotropic medications without proper assessment or behavior identification. Another resident received duplicate therapies without documented behavior tracking or rationale for medication use. A third resident exhibited abnormal movements due to medication, with no behavior tracking or consideration of alternative treatments. The DON confirmed the lack of documentation for these issues.
A facility failed to provide dental services for a resident who was edentulous and required dentures. The resident's nutritional assessment noted the need for supplements due to being edentulous, yet the Social Services Director did not recall discussing dentures with the resident, and the facility lacked a dentist to provide them. The resident's family confirmed the need for dentures, and the DON noted the resident received nutritional supplements due to poor eating habits.
The facility failed to provide the correct food consistency for three residents, leading to dietary inconsistencies and potential health risks. A resident with AMS was given inappropriate ground consistency food and expressed fear of choking. Another resident with a mechanical soft diet order was served thin liquids and inappropriate food textures, while a third resident requiring pureed texture was given regular chocolate milk without thickener. These issues highlight a systemic failure in dietary management.
The facility failed to maintain the dignity and hygiene of residents by neglecting incontinence care and personal hygiene. A resident with skin impairments was found in soiled bedding, while another missed multiple scheduled showers, resulting in poor grooming. A third resident, dependent on staff for hygiene, was observed with food debris and unclean fingernails. Staff acknowledged the oversight, and the facility lacked a policy for post-meal hygiene assistance.
The facility failed to maintain a clean environment for several residents, with rooms found cluttered with debris, food particles, and overflowing garbage. Residents expressed dissatisfaction with the cleanliness, and staff interviews revealed a lack of a Housekeeping Supervisor and insufficient cleaning practices. The Regional Clinical Nurse confirmed the absence of a specific cleaning policy, with an expectation for daily cleaning.
The facility failed to provide scheduled showers for five residents, who require substantial assistance with bathing. These residents, some of whom are cognitively impaired, received fewer showers than planned, with inadequate documentation of refusals or staff interventions. One resident reported not being asked before being marked as refusing showers, and another was observed with poor hygiene. The ADON acknowledged the need for improved hygiene practices.
A facility failed to implement fall interventions for a high-risk resident with multiple medical conditions, leading to several unwitnessed falls. Despite care plan instructions to redirect the resident and rearrange room furniture, these measures were not effectively executed. Observations and staff interviews indicated a lack of consistent supervision, contributing to the resident's repeated falls.
The facility failed to administer antibiotics as ordered for two residents. One resident did not receive Doxycycline on two occasions, with no documentation of physician notification or reasons for refusal. Another resident missed several doses of Augmentin, with no explanations recorded. The facility's policy requires physician notification and documentation when orders cannot be followed, which was not done.
A resident, dependent on staff for activities and social interaction due to impaired mobility, had personal belongings stored in the hallway due to inadequate room space. The resident expressed concerns about potential theft and discomfort from the door hitting the bed. A corporate RN confirmed the lack of space due to two bariatric beds in the room, and the facility acknowledged the issue.
The facility failed to provide regular bathing for three residents, leading to a deficiency in hygiene care. A resident, dependent on staff for bathing, did not receive a documented bath or shower for a month. Another resident, requiring assistance, was scheduled for bi-weekly showers but only received one in a month. A third resident, also dependent on staff, received only one shower in a month. The facility lacked a policy on bathing, and staff could not provide adequate documentation of showers given.
A resident with Type II Diabetes Mellitus was not provided with appropriate diabetic care upon readmission to the facility. Despite a history of fluctuating blood glucose levels and a recent hospital admission for hypoglycemia, there was no documentation of blood glucose monitoring until several days later. The Corporate RN confirmed that the admitting nurse should have sought a physician's order for monitoring upon admission.
A resident did not receive Tramadol for several days due to the facility's failure to obtain a prescription before the supply was depleted. The resident experienced significant pain, with levels reaching 8/10, and reported difficulty sleeping. The facility lacked a policy for pain control and was in the process of updating its procedures with new medical providers.
The facility failed to provide timely lab services for two residents. One resident's urinalysis was delayed despite orders, and another resident did not receive a hemoglobin A1C test as ordered. The delays and omissions were confirmed by facility staff.
The facility failed to provide scheduled showers to four residents, leading to hygiene issues and discomfort. A resident with cognitive impairment received only two showers in August and none in September, while another resident developed a yeast infection due to infrequent showers. Despite being scheduled for twice-weekly showers, residents reported inconsistent care, with grievances filed and acknowledged by the DON, who cited staffing assignments as a contributing factor.
The facility failed to ensure timely responses to call lights for three cognitively intact residents with specific care needs, leading to prolonged wait times and unmet care requirements. The Director of Nurses acknowledged the issue, citing higher resident acuity as a contributing factor.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as per physician orders for two residents, leading to significant medication errors. Resident R7, who has multiple medical diagnoses including Multiple Sclerosis and a Sacral Pressure Ulcer, was prescribed Ertapenem Sodium intravenously for a wound infection. However, the medication was not administered on several occasions, and there was no documentation of notification to the physician or the resident's Power of Attorney. The nurse responsible did not locate the medication and failed to notify the physician, despite the facility having a backup medication storage system. Resident R8, diagnosed with Epilepsy and Dementia, was prescribed Briviact 50 mg twice daily. On one occasion, R8 was mistakenly given a double dose of 100 mg due to a mix-up with another resident's medication card. Although R8 did not experience significant medical complications from this error, the potential for harm was acknowledged by the Nurse Practitioner. The facility lacked a policy or guidelines on medication errors, and the expectation was for nursing staff to follow physician orders and notify providers if errors occurred. The deficiencies highlight a lack of adherence to medication administration protocols and communication failures within the facility. The absence of a formal policy on handling medication errors contributed to the oversight, resulting in residents not receiving critical medications as prescribed. The facility's administrator confirmed the lack of a policy and emphasized the expectation for staff to follow physician orders and communicate any discrepancies to the provider.
Failure to Protect Residents from Abuse by Aggressive Resident
Penalty
Summary
The facility failed to protect residents from abuse, resulting in multiple incidents involving a resident with behavioral issues. This resident, identified as R1, exhibited physical and verbal aggression towards other residents, including punching, kicking, and using expletives. The facility's abuse prevention policy clearly states that residents have the right to be free from abuse, yet R1's actions affected several residents, including R2, R3, and R4, causing physical harm and emotional distress. R1's behavioral issues were documented in various records, including a Resident Assessment and Progress Notes, which highlighted R1's confusion, aggression, and wandering behavior. Despite these documented concerns, the facility failed to implement effective interventions to manage R1's behavior. R1's aggression led to a physical altercation with R2, resulting in R2 sustaining injuries that required medical evaluation and treatment. Additionally, R1 verbally abused R3 and physically assaulted R4, further demonstrating the facility's inability to protect residents from harm. The facility's incident reports and staff interviews revealed a pattern of R1's aggressive behavior and the facility's inadequate response. Staff members reported R1's frequent wandering into other residents' rooms and attempts to take their belongings. Despite the facility's awareness of R1's behavior, there was a lack of consistent supervision and intervention, allowing R1 to continue posing a threat to other residents. The facility's failure to address R1's behavior and protect residents from abuse constitutes a significant deficiency in care.
Failure to Revise Care Plans After Resident Abuse Incidents
Penalty
Summary
The facility failed to revise care plans for residents following incidents of physical and verbal abuse by one resident towards others. This deficiency affected four residents who were involved in separate incidents with the aggressive resident. The facility's abuse log documented multiple instances of physical aggression by the resident, including attempts to remove another resident's hat, throwing water, and kicking. Despite these documented incidents, the care plans for the affected residents did not reflect any updates or interventions to address the abuse or prevent future occurrences. The aggressive resident, who has documented memory problems and impaired decision-making abilities, exhibited behaviors that placed themselves and others at risk. The resident's care plan noted behavioral problems but lacked specific interventions for staff to implement. The resident's actions included wandering into other residents' rooms, physical altercations, and verbal aggression, which were not adequately addressed in the care plans of the affected residents. The facility's failure to update care plans following these incidents left the affected residents without documented strategies to manage or mitigate the risk of further abuse. The lack of care plan revisions for the residents who experienced abuse highlights a significant oversight in ensuring their safety and well-being. This deficiency was observed despite multiple reports and documentation of the aggressive resident's behavior, indicating a need for more proactive care planning and intervention strategies.
Failure to Implement Dietary Recommendations Leads to Resident Malnutrition
Penalty
Summary
The facility failed to adhere to dietary recommendations and proper communication protocols, resulting in significant weight loss and malnutrition for a resident. The resident, who had a history of intellectual disability and various medical conditions, was admitted to the facility and experienced a 13.5% weight loss over three and a half months. The facility did not document the resident's weight in September and failed to implement the Registered Dietician's recommendations for supplements and an appetite stimulant. The resident was hospitalized due to malnutrition and dehydration, leading to the placement of a gastric tube for supplemental nutrition. Upon readmission to the facility, the resident's tube feeding orders were not followed correctly, and oral nutrition was not provided for several days. The facility did not notify the Registered Dietician of the resident's new tube feeding order, nor did they inform the physician of the dietician's previous recommendations for weight gain. The resident's condition deteriorated significantly, with severe underweight, poor hygiene, and dental issues observed. The facility's lack of communication and failure to implement dietary interventions contributed to the resident's continued weight loss and malnutrition. The Registered Dietician and Medical Doctor were not adequately informed, preventing them from taking necessary actions to address the resident's nutritional needs.
Failure to Monitor and Document Tube Feeding Administration
Penalty
Summary
The facility failed to adequately monitor and document the administration of tube feeding for a resident, leading to significant health issues. The resident, who had a history of intellectual disability, chronic leukemia, and other medical conditions, was admitted with a regular diet order but experienced significant weight loss shortly after admission. Despite recommendations from a dietician, there was no documentation of their implementation or physician notification. The resident was later hospitalized for malnourishment and dehydration, resulting in the placement of a feeding tube. Upon returning to the facility, the resident's tube feeding was not administered as per the hospital's discharge orders, contributing to further weight loss and episodes of vomiting. The facility's staff failed to document essential aspects of the resident's care, such as tube placement verification, feeding amounts, and complications like vomiting. The registered nurse admitted to stopping the tube feeding without notifying a physician or dietician, and the dietician was unaware of the resident's vomiting episodes or the physician's rejection of her recommendations. The nurse practitioner and corporate director of nursing confirmed that proper documentation and communication were lacking, which hindered the resident's nutritional management and care. These failures resulted in the resident's continued malnourishment and weight loss, highlighting significant deficiencies in the facility's care processes.
Failure to Provide Adequate Personal Care to Dependent Residents
Penalty
Summary
The facility failed to provide adequate personal care, including bathing, oral care, and nail care, to three residents who were dependent on staff assistance for activities of daily living. Resident 1, who was cognitively intact and had multiple diagnoses including sepsis and rheumatoid arthritis, reported that her toenails were too long and unclean, despite requesting assistance from the nursing staff. Observations confirmed that her nails were overgrown and had debris between the toes, indicating a lack of proper nail care as outlined in her care plan. Resident 3, who was severely cognitively impaired and had a history of intellectual disability and other medical conditions, was found in unsanitary conditions with greasy hair, an odor of feces, and unclean teeth and nails. The resident's care plan required assistance with oral care and bathing, but documentation showed a lack of recorded care for the past 28 days. Similarly, Resident 4, who was cognitively intact and diagnosed with conditions such as amyotrophic lateral sclerosis, was observed with greasy hair and unclean teeth. The resident reported not receiving regular showers or oral care, and documentation confirmed infrequent bathing and a lack of oral care over the past month.
Failure to Ensure Resident Dignity by CNA
Penalty
Summary
The facility failed to ensure the dignity of two residents, R4 and R5, as evidenced by their interactions with a Certified Nursing Assistant (CNA), identified as V15. R4, who has diagnoses including amyotrophic lateral sclerosis and depression, reported feeling disrespected by V15, stating that the CNA was impatient and intolerant of her needs. R4, who is cognitively intact, expressed her concerns to another CNA, V11, who noted that R4 was visibly upset by the interaction. The facility's administrator, V1, confirmed that an investigation into R4's allegations was ongoing, and V15 had been suspended pending the outcome. Similarly, R5, who has diagnoses including hypothyroidism, anxiety, and a history of cerebrovascular accident, also reported feeling disrespected by V15. R5, who is also cognitively intact, stated that V15 was impatient and rushed her during care, leading to feelings of discomfort and hesitation to report the issue. Despite not having problems with other staff members, R5 felt that V15's behavior was intolerant and disrespectful. The Corporate Director of Nursing, V2, acknowledged that the facility's expectation is to provide dignity to all residents during care.
Failure to Honor Resident's Self-Determination
Penalty
Summary
The facility failed to honor a resident's repeated requests for a change in living arrangements, which led to significant distress for the resident. The resident, who has advanced Amyotrophic Lateral Sclerosis and is non-verbal, expressed a desire to return to the hospital due to dissatisfaction with the care provided. Despite being cognitively intact and able to communicate using a letter board, the resident's requests were not acted upon, resulting in anxiety, fear, and refusal to eat, drink, or receive care. Observations noted that the resident was left unattended with meals and drinks, and staff did not offer assistance, further exacerbating the resident's distress. Staff interviews revealed that the facility was understaffed, with insufficient personnel to meet the resident's needs or effectively communicate with him. Both a Licensed Practical Nurse and a Registered Nurse acknowledged the resident's cognitive ability to make decisions and his expressed desire to return to the hospital. However, the Nurse Practitioner advised against transferring the resident, and the facility lacked a specific policy on resident self-determination. Attempts to contact the Nurse Practitioner for further clarification were unsuccessful, highlighting a breakdown in communication and decision-making processes within the facility.
Insufficient RN Coverage in Facility
Penalty
Summary
The facility failed to provide sufficient Registered Nursing (RN) hours on two of sixteen days reviewed for RN staffing, potentially affecting all 54 residents in the facility. The Nursing Schedule from January 8, 2025, through January 18, 2025, showed that on five specific days, including January 8, 9, 12, 13, and 14, the facility scheduled zero hours of RN coverage for a 24-hour period. This deficiency was identified through interviews and record reviews, including the facility's Nursing Schedule and the Resident Midnight Census dated January 21, 2025, which documented 54 residents residing in the facility. Additionally, a time card for the Director of Nursing, employed in a supervisory role, was provided by the Regional Consultant Administrator.
Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services and a person-in-charge with the required Food Protection Manager Certification, potentially affecting all 54 residents. The Dietary Manager, who was actively supervising operations, admitted to not being a certified dietary manager or having equivalent training, and was unaware of any dietician employed at the facility. This lack of qualified personnel led to several deficiencies in the food and nutrition services. During the survey, it was observed that the facility failed to effectively sanitize dishes, prevent cross-contamination of ice, and maintain proper food storage practices. The dishwasher was not properly sanitizing dishes, as the sanitizer concentration was measured at zero parts per million. Additionally, the ice machine was not operational, and commercially prepared ice bags, which were visibly soiled, were placed in direct contact with existing ice. Food items in the reach-in coolers were not labeled with dates, and raw bacon was stored improperly, posing a risk of contamination. The facility's kitchen and pantry areas were found to be unsanitary, with floors covered in decomposing food debris and other waste. The can opener was soiled with food accumulations and metal shavings, and bulk sugar was stored improperly with a disposable cup in direct contact. These conditions indicate a failure to maintain sanitary food service areas, as required by regulations. The facility's assessment documented the need for a dietician and certified dietary manager, but these positions were not filled, contributing to the observed deficiencies.
Sanitation and Cross-Contamination Issues in Facility Kitchen
Penalty
Summary
The facility failed to effectively sanitize dishes, as observed on multiple occasions. A cook and a dietary aide were unaware of how to use sanitizer test strips to test the dishwasher for adequate sanitizer concentration. The dishwasher sanitizer solution was found to have zero parts per million of chlorine, indicating ineffective dish sanitation. Despite a dietary aide noticing the issue and reporting it to the dietary manager, no action was taken. Additionally, the dishwasher log sheet had not been updated since early October, showing a lack of routine testing. The facility also failed to prevent cross-contamination of ice and stored food. The ice machine was not operational, and commercially prepared ice bags, which were visibly soiled, were placed directly into the ice bin. The cook intended to mix this ice with newly produced ice, further risking contamination. In the kitchen, several food items in the reach-in coolers were not labeled with dates, and raw bacon was stored directly on top of ready-to-eat foods, increasing the risk of cross-contamination. Furthermore, the facility did not maintain sanitary conditions in the kitchen. Bulk sugar was stored with a disposable cup in direct contact with it, and the can opener was soiled with food accumulations and metal shavings. The kitchen floors were excessively soiled with food debris and other waste, and these conditions persisted over two days of observation. These unsanitary conditions have the potential to affect all 54 residents residing in the facility.
Failure to Implement Comprehensive Quality Program
Penalty
Summary
The facility failed to implement a comprehensive quality program, which has the potential to affect all 54 residents residing in the facility. The facility's Quality Assurance Performance Improvement (QAPI) policy, dated January 2024, outlines a systematic, comprehensive, and data-driven approach to maintaining and providing safety and quality. This includes monitoring quality/performance, finding opportunities for improvement, improving performance, achieving resident/family desired outcomes, meeting regulatory requirements, understanding the CNA survey process and regulations, and providing a QAPI path to correcting issues. The program is supposed to consist of monthly/quarterly meetings, daily quality assurance activities, quality tasks, and performance improvement plans. However, during an interview on 11/19/24, the Administrator stated she was unaware of an active quality program functioning in the facility at that time, indicating a lack of implementation of the QAPI program.
Lack of Performance Improvement Projects and Data Collection
Penalty
Summary
The facility failed to develop and implement quality-based performance improvement projects, including the collection and measurement of data, which has the potential to affect all 54 residents. The facility's Quality Assurance Performance Improvement (QAPI) policy, dated January 2024, outlines a systematic, comprehensive, and data-driven approach to maintaining safety and quality. However, during an interview, an LPN who had been employed at the facility for several years stated she was unaware of any performance improvement projects or quality measures being implemented. Additionally, the Administrator was unable to provide documentation of any performance improvement projects over the past year.
Failure to Hold Quarterly Quality Meetings with Required Members
Penalty
Summary
The facility failed to hold quarterly quality improvement committee meetings and did not include all required members in these meetings, which has the potential to affect all 54 residents in the facility. The facility's Quality Assurance Performance Improvement (QAPI) policy, dated January 2024, outlines the need for systematic, comprehensive, and data-driven approaches to maintaining safety and quality, involving all caregivers in problem-solving. However, the facility only provided one of the four required sign-in sheets for the last four quarterly quality meetings, which did not include an Infection Preventionist in attendance. The Administrator acknowledged the expectation for quarterly quality meetings to be held with all required members, including the Medical Director, Administrator, Director of Nursing, Infection Preventionist, and Pharmacist.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to resolve grievances for four residents regarding issues with staffing, food service, and timely care. The facility's grievance policy, dated May 2018, states that grievances should be addressed and resolved within five days, with the final outcome communicated to the person who originated the grievance. However, the facility did not adhere to this policy, as evidenced by unresolved grievances documented in resident council minutes and individual grievances. Residents reported ongoing issues with call lights taking too long to be answered, cold food, and late meal services, which were attributed to low staffing and missing ingredients. Specific grievances included a three-hour delay in answering a call light for a leaking catheter, late breakfast and lunch services, and untimely care resulting in a resident soiling herself. Interviews with residents revealed dissatisfaction with the timeliness of meal and medication services, with some residents receiving breakfast after 9:00 AM and medications being administered after meals. These grievances were not resolved within the specified timeframe, indicating a failure to comply with the facility's grievance policy.
Deficiencies in Resident Care and Response Times
Penalty
Summary
The facility failed to provide adequate care for residents in several areas of daily living, including fingernail care, bathing, and timely toileting/incontinence care. Specifically, three residents were affected by these deficiencies. One resident, who requires substantial assistance due to conditions such as hemiplegia and Parkinson's disease, reported that call lights were not answered promptly, leading to discomfort and prolonged periods in soiled incontinence briefs. Another resident with multiple sclerosis and feeding difficulties reported that staff would leave meal trays without providing the necessary assistance for eating, resulting in delays of up to an hour before help arrived. Additionally, a resident was observed eating with feces under her fingernails, which was confirmed by a Certified Nursing Assistant. The Director of Nursing stated that nail care should be provided on shower days, especially when feces is present. The facility's grievance log documented multiple complaints about delayed call light responses, including instances where residents were left in urine or had to wait hours for assistance with leaking catheters. These findings indicate a pattern of inadequate care and response times, impacting the residents' quality of life and hygiene.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to adhere to physician orders for the treatment of a nonpressure wound for a resident identified as R54. The resident, who is cognitively intact, had a physician's order documented in the Treatment Administration Record (TAR) for November to change the wound vacuum dressing every Monday, Wednesday, and Friday. However, the treatment was not completed on several specified dates in November. The resident reported that the surgical incision reopened after a fall at the facility, necessitating the use of a wound vacuum. The Director of Nursing acknowledged being unaware of the missed treatments, and the Corporate Nurse confirmed the absence of a specific policy for wound vacuums at the facility.
Failure to Adhere to Dietary Orders and Preferences
Penalty
Summary
The facility failed to ensure that the residents' menus and individual food plans met their nutritional needs and preferences. For Resident R19, the meal served did not align with the physician's order for a regular diet with mechanical soft texture and nectar thick fluids. The meal included items that were not suitable for the prescribed diet, such as hard carrots and thin liquids, which were not in accordance with the dietary slip for that meal. Additionally, the family member of R19 demonstrated that the carrots were hard and cold, indicating a failure to provide the appropriate texture and temperature. Resident R43 reported that her meals had not been correct since the previous week, with specific complaints about not receiving the requested meal of biscuits and gravy, and instead being served scrambled eggs and oatmeal. The meal ticket confirmed the discrepancy, as it documented biscuits and gravy as the chosen meal, but the plate contained only scrambled eggs. Similarly, Resident R14, who was on a pureed diet, did not receive the pureed frosted cake as documented in the facility menu. Lastly, Resident R16 did not receive the complete breakfast as ordered, missing pureed pineapple and toast, which was confirmed by a Certified Nursing Assistant. These incidents highlight the facility's failure to adhere to prescribed dietary orders and resident preferences, impacting the nutritional care provided to the residents.
Deficiency in Meal Service Timeliness and Quality
Penalty
Summary
The facility failed to serve timely and palatable meals to residents, affecting seven residents out of a sample of 34. Observations and interviews revealed that meals were consistently served late and often cold, with residents reporting dissatisfaction with the food's temperature and taste. Meal times were scheduled for 7:30 AM, 12:00 PM, and 5:30 PM, but residents reported receiving meals significantly later, sometimes as late as 2:00 PM for lunch. The facility's grievance log documented 47 formal complaints related to food issues, including cold and tasteless meals, and meals not being served on time. Specific incidents included a resident receiving a dinner roll that was blackened and hard, and another resident's lunch measuring only 90 degrees Fahrenheit. Additionally, staff conflicts in the kitchen were reported, contributing to the delays. Residents expressed frustration and discomfort due to the late and cold meals, with one resident's family member noting that the puree served was ice cold. These deficiencies were observed over multiple days, indicating a pattern of inadequate meal service that affected the residents' dining experience and satisfaction.
Failure to Investigate Resident Fall and Injury
Penalty
Summary
The facility failed to investigate, determine the root cause, and implement resident-centered fall interventions for a resident who experienced a fall. The resident, who was cognitively intact, reported falling at the facility, which resulted in the dehiscence of a surgical incision on their left lower extremity, causing significant bleeding. The incident was documented in the resident's progress notes, which described the fall occurring when the resident attempted to move from their wheelchair to their bed, with their daughter present in the room. Despite the evident injury and the resident's subsequent visit to the emergency room, the facility did not conduct a thorough investigation or root cause analysis of the fall. The facility's administrator provided only a brief risk management note reiterating the progress note without further investigation. When questioned, the administrator stated that no in-depth investigation was conducted because they did not consider the wound dehiscence a new injury. Additionally, the corporate nurse confirmed that the facility lacked a specific policy for incident reporting and investigation, indicating a systemic issue in handling such incidents. This lack of investigation and policy adherence represents a deficiency in ensuring the safety and well-being of residents.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as R160, by not administering oxygen as ordered, not correctly applying the nasal cannula, and not maintaining clean, dated, and labeled oxygen tubing. The facility's Oxygen Administration Policy requires an order for oxygen administration, proper placement of the nasal cannula, and weekly replacement of equipment and supplies, including the nasal cannula and humidifier bottle. However, observations revealed that R160's nasal cannula was improperly positioned, blowing into the resident's cheek, and the oxygen was set at 2.5 liters instead of the ordered 2 liters. Additionally, the oxygen tubing was not replaced weekly as required, with the tubing dated 11/7/24, and the humidification bottle was found empty on multiple occasions. The Director of Nursing, identified as V2, acknowledged that R160 should have been receiving the ordered amount of oxygen and that the nursing staff, including Certified Nursing Assistants, are responsible for monitoring oxygenation to ensure compliance with the physician's orders. Despite these responsibilities, the facility failed to ensure that the oxygen was administered correctly, the tubing was in place and dated, and the oxygen was humidified as per the facility's policy and the physician's orders. This deficiency was identified during observations and interviews conducted on 11/17/24 and 11/18/24.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to adhere to its policy on psychotropic medication use, resulting in deficiencies in the assessment and management of residents on such medications. For Resident 262, the facility did not complete a psychotropic medication assessment or identify targeted behaviors to justify the use of multiple psychotropic medications, including Aripiprazole, Duloxetine, Doxepin, and Amitriptyline. The care plan for Resident 262 did not address the use of these medications, and the Corporate Nurse confirmed the lack of assessment and behavior identification. Resident 30 was prescribed multiple psychotropic medications, including Alprazolam, Sertraline, Buspirone, and Abilify, without documented behavior tracking or individualized non-pharmacological interventions. Despite pharmacy recommendations to address duplicate therapies and reduce Sertraline dosage, the physician disagreed without providing a rationale. The Director of Nursing confirmed the absence of behavioral tracking documentation for Resident 30. Resident 41 was on several psychotropic medications, including Cymbalta, Mirtazapine, Rexulti, Trazadone, and Austedo, with no documented behavior tracking or non-pharmacological interventions. The resident exhibited abnormal involuntary movements, which were not adequately addressed despite pharmacy recommendations to consider an alternate antipsychotic. The Director of Nursing acknowledged the lack of behavioral tracking documentation, and observations noted the resident's uncontrollable movements, which the resident was aware of but unable to stop.
Failure to Provide Dental Services for Edentulous Resident
Penalty
Summary
The facility failed to provide necessary dental services for a resident who was edentulous and expressed a desire for dentures. The resident's nutritional assessment indicated the need for nutritional supplements in addition to a regular pureed diet with snacks due to being edentulous. Despite this, the Social Services Director did not recall discussing the need for dentures with the resident, and the facility did not have a dentist available to provide dentures. The resident's family member also confirmed that they had not been approached regarding the resident's dental needs, despite the resident's ongoing need for dentures. The Director of Nursing acknowledged that the resident was provided nutritional supplements due to poor eating habits and the need for additional calories.
Failure to Provide Correct Food Consistency for Residents
Penalty
Summary
The facility failed to provide the correct food consistency for three residents, leading to significant dietary inconsistencies and potential health risks. Resident 263, diagnosed with Advanced Amyotrophic Lateral Sclerosis (AMS), was observed with a full breakfast of ground consistency food, which was inappropriate given his condition. The resident communicated through a board that he was not offered assistance with feeding or drinks and expressed fear of choking. The Registered Dietitian was unaware of the resident's dietary needs and had not evaluated him, as she conducted consultations remotely. A subsequent evaluation by Speech Therapy determined the resident was unsafe with pureed food and thickened liquids, leading to a recommendation for nothing by mouth (NPO) and an emergency room evaluation for aspiration. Resident 19, with a physician order for a mechanical soft diet with nectar thick fluids, was repeatedly served thin liquids and inappropriate food textures, such as hard carrots and whole brownie squares, contrary to her dietary requirements. Her family member, who assisted with meals, confirmed these inconsistencies and noted that the resident was not receiving the correct food consistency. Similarly, Resident 16, who required a pureed texture diet with nectar thick fluids, was observed drinking regular chocolate milk without thickener. These observations indicate a systemic failure in the facility's dietary management, resulting in residents receiving incorrect food consistencies that could compromise their health and safety.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
The facility failed to maintain the dignity of four residents by not providing adequate care and attention to their personal hygiene and incontinence needs. Resident R11, who has skin impairments related to incontinence, was found lying in bed with soiled sheets and a bed pad, emitting an odor of urine and bowel movement. The Certified Nursing Assistant (CNA) on duty admitted to not having changed R11 since the start of their shift, despite being aware of the resident's incontinence and the need for regular checks and changes. Resident R4, who requires assistance with bathing and toileting, was not provided showers on multiple scheduled days, as documented in the facility's records. Observations revealed that R4 had ungroomed facial hair with food debris and fingernails packed with an unknown brown substance, indicating a lack of personal hygiene care. The facility's records did not document any refusals or follow-ups regarding R4's missed showers, further highlighting the neglect in maintaining the resident's dignity. Resident R7, who is severely cognitively impaired and dependent on staff for personal hygiene, was observed with food debris on her face and clothing, overgrown chin hairs, and fingernails packed with a dark brown substance. The CNA responsible for R7's care acknowledged the oversight in cleaning the resident after meals, and the Assistant Director of Nurses (ADON) confirmed that staff should ensure residents are cleaned up after eating. The facility lacked a policy to ensure staff assist residents with hygiene after meals, contributing to the deficiency in maintaining residents' dignity.
Facility Fails to Maintain Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a clean environment for four residents, as observed during a survey. The residents' rooms were found to be cluttered with debris, food particles, and overflowing garbage, indicating a lack of regular cleaning. One resident, who is cognitively intact and requires maximum assistance with daily activities, expressed dissatisfaction with the cleanliness of their room, stating it was cleaned only twice a week. Another resident, moderately cognitively impaired, had a room with debris on the floor and unmade bed, while a third resident, severely cognitively impaired, had an overflowing garbage can and a room that smelled of urine. The fourth resident, also severely cognitively impaired, reported that their room was always dirty, with food debris and soiled tissues on the floor. Interviews with facility staff revealed that there was no Housekeeping Supervisor, and housekeeping was only available during the day shift. Housekeepers admitted that sometimes resident rooms were not thoroughly cleaned due to other duties such as room moves or deep cleans. The Maintenance Director confirmed the absence of a Housekeeping Supervisor and stated that they were not responsible for housekeeping. The Regional Clinical Nurse acknowledged the lack of a specific cleaning policy and confirmed that the expectation was for rooms to be cleaned daily, with nursing staff responsible for cleaning up nursing-related incidents.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide planned showers for five residents, leading to a deficiency in care. Residents R2, R3, R4, R5, and R6, who were reviewed for showers, did not receive the required number of showers as per their care plans. These residents, who are not cognitively intact and require substantial assistance with bathing, were documented to have received fewer showers than scheduled, with no adequate documentation of refusals or staff interventions. Resident R2, with impaired mobility and right-sided hemiparesis, received only a fraction of the scheduled showers in August and September, with no showers documented in October. Similarly, Resident R5, who has weakness and contractures, received only three showers in August and September, with no documentation of offers or interventions. Resident R6, with limited mobility due to a cerebral vascular accident, also received fewer showers than scheduled, with no documentation of further offers or interventions. Resident R3, who is cognitively intact but requires maximum assistance, reported not receiving showers despite being marked as refusing them. R3 expressed dissatisfaction with the lack of showers, stating that staff did not ask before marking refusals. Resident R4, moderately cognitively impaired, was observed with poor hygiene, including ungroomed facial hair and dirty fingernails, indicating a lack of personal care. The Assistant Director of Nurses acknowledged the need for better hygiene practices and stated that there is no facility policy mandating two showers per week, although the standard of care is two baths per week.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident identified as R4, who was at high risk for falls due to multiple medical conditions including a right femur fracture, hemiplegia, diabetes, and repeated falls. R4's care plan included interventions such as redirecting him to common areas when wandering in his wheelchair and rearranging furniture in his room to prevent falls. However, these interventions were not effectively implemented, as evidenced by multiple unwitnessed falls and observations of R4 walking independently in his room without staff supervision. Despite being identified as a high fall risk, R4 experienced several unwitnessed falls, including incidents where he was found on the floor after attempting to stand or walk independently. Staff interviews revealed that the planned intervention to rearrange R4's room was not executed, and staff were unable to consistently monitor R4 to prevent falls. Observations confirmed that R4 was often left unsupervised, leading to situations where he was at risk of falling, such as standing or walking without assistance.
Failure to Administer Antibiotics as Ordered
Penalty
Summary
The facility failed to administer antibiotics as ordered by the physician for two residents, R2 and R10, which was identified during a review of their electronic Medical Administration Records (e-MAR) for August 2024. For R2, there was an order for Doxycycline Monohydrate to be administered twice daily for pneumonia. However, the medication was not given on two occasions: the morning dose on August 21 due to the resident's refusal, and the evening dose on August 23 for unspecified reasons. There was no documentation of the physician being notified about these missed doses or any explanation for the refusal in R2's medical record. Similarly, R10's e-MAR showed an order for Augmentin to be administered twice daily, but several doses were not given between August 21 and August 25, marked with codes indicating the need to see progress notes for reasons. However, there was no further documentation in R10's medical record explaining why these doses were not administered. The facility's policy requires that if a physician's order cannot be followed, the physician should be notified, and a notation should be made in the patient's clinical record, which was not adhered to in these cases.
Inadequate Storage and Space for Resident's Belongings and Bed
Penalty
Summary
The facility failed to provide adequate storage for a resident's personal belongings and sufficient space to accommodate a resident bed. The resident, who is dependent on staff for activities, cognitive stimulation, and social interaction due to impaired mobility, expressed a preference to not be around others in social settings. On the date of observation, two boxes of the resident's personal belongings were found in the hallway outside the resident's room, with a personal pillow exposed on top of the boxes. The resident expressed concern about the potential theft of her belongings and discomfort due to the lack of space in her room. Additionally, the resident reported that staff had to move her bed to close the door, which often resulted in the door hitting the bed and causing discomfort. A corporate registered nurse confirmed the presence of two bariatric beds in the room, contributing to the lack of space for personal belongings. The facility's representative acknowledged the room's inability to accommodate the resident's personal belongings, resulting in items being stored in the hallway and on a wheelchair across from the room.
Failure to Provide Regular Bathing for Residents
Penalty
Summary
The facility failed to provide regular bathing or showering for three residents, leading to a deficiency in hygiene care. Resident R5, who is cognitively intact and totally dependent on staff for bathing, was admitted on 8/29/24 and did not receive a documented bath or shower from 9/1/24 to 10/1/24. R5 expressed that they had not received a full bath since admission and desired to have their feet washed. The facility's Corporate RN could only provide documentation of one shower on 9/17/24, and the facility lacked a policy regarding bathing or showering for residents. Resident R2, who requires assistance with bathing, was scheduled to receive showers twice a week but only received one shower in September 2024. R2 confirmed that since their admission on 7/25/24, they had only received one shower. Similarly, Resident R7, who is dependent on staff for bathing twice weekly, only received one shower in September 2024. The Corporate RN acknowledged that all residents should receive a minimum of two showers per week but could not provide documentation to support that this standard was met.
Failure to Provide Diabetic Care for a Resident
Penalty
Summary
The facility failed to provide appropriate diabetic care for a resident diagnosed with Type II Diabetes Mellitus, among other conditions. The resident was admitted to the facility with a history of fluctuating blood glucose levels, as evidenced by a previous hospital admission for hypoglycemia. Despite this, there was no documentation of blood glucose monitoring for the resident on the days immediately following their readmission to the facility. It was not until several days later that a physician's order for blood glucose checks before meals was documented. The deficiency was confirmed by a Corporate Registered Nurse, who acknowledged that the admitting nurse should have notified the Physician or Nurse Practitioner to obtain an order for blood glucose monitoring upon the resident's admission. This oversight in diabetic care management highlights a lapse in following up with the physician to ensure proper monitoring and care for the resident's condition, which could have been critical given the resident's medical history.
Failure to Obtain Prescription for Pain Medication
Penalty
Summary
The facility failed to obtain a prescription for a controlled pain medication, Tramadol, for a resident (R5) before the existing supply was depleted. R5 had a physician's order for Tramadol 50 mg for moderate pain, initiated on 8/29/24. However, the Medication Administration Record (MAR) showed that R5 did not receive Tramadol from 9/6/24 to 9/11/24, during which time R5's pain levels ranged from 0 to 8 on a scale of 1-10. On 10/2/24, R5 reported experiencing significant pain and difficulty sleeping due to the lack of medication. A progress note from 9/9/24 indicated that a nurse practitioner was informed of the need for a prescription, but it was not sent in time to prevent the lapse in medication availability. The facility's Registered Nurse (RN) Corporate Nurse confirmed the unavailability of Tramadol for R5 during the specified period and acknowledged that the medication should have been available, especially given the resident's high pain level. The facility administrator admitted that there was no existing policy for pain control and that the facility was in the process of updating policies and procedures with new medical providers, leaving them without policies until the process was completed.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide timely laboratory services for two residents, leading to deficiencies in care. For one resident, a nurse practitioner ordered a urinalysis on 9/9/24, which was documented by a licensed practical nurse the following day. However, the order was not entered into the clinical physician orders, and the urine sample was not collected until 10/1/24. The corporate nurse confirmed the delay and the lack of documentation regarding physician notification about the delay. Another resident, admitted for short-stay rehabilitation following a COVID-19 illness, had a physician order for a hemoglobin A1C test on 8/29/24. Despite this, the resident's electronic medical record showed no laboratory results, and the resident confirmed that no blood was taken during their stay. The facility administrator verified that there were no lab results on file for this resident, indicating a failure to perform the ordered laboratory tests.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide showers to dependent residents, affecting four out of five residents reviewed for showers and hygiene care. Resident 1, who is severely cognitively impaired and requires moderate assistance with showers, was scheduled to receive showers twice a week but only received two showers in August and none in September. Resident 2, cognitively intact and requiring moderate assistance, also experienced a lack of showers, receiving only two in August, which led to a yeast infection under abdominal folds. Resident 4, who is cognitively intact but dependent on staff for bathing, reported not receiving showers since admission, resulting in dry, peeling skin and a persistent yeast infection. Resident 5, cognitively intact with bilateral lower limb impairments, received only two showers in August despite requiring partial/moderate assistance. The facility's grievance log and resident council meeting minutes document multiple complaints about showers not being given, with grievances filed by residents and the resident council. The Director of Nursing (DON) acknowledged the issue, stating that the facility had a shower aide during the day, but showers were inconsistent, and charting was not completed. The DON assigned Certified Nursing Assistants (CNAs) to specific room assignments, making them responsible for providing and charting showers. Despite these assignments, the facility failed to ensure that residents received the minimum of two showers or bed baths per week.
Failure to Answer Call Lights Timely
Penalty
Summary
The facility failed to ensure call lights were answered in a timely manner for three residents, all of whom were cognitively intact and had specific care needs. Resident R3, diagnosed with muscle weakness and bladder incontinence, reported that call lights often took a long time to be answered, with CNAs sometimes turning off the call light without providing assistance. This issue was documented in resident council meetings over three consecutive months. Resident R5, diagnosed with difficulty in walking and overactive bladder, experienced a 32-minute wait for assistance after activating the call light, only to find staff talking at the nurse's station. Resident R6, diagnosed with a history of falling and needing assistance with personal care, also reported long wait times for call light responses, particularly during the evening shift. The Director of Nurses acknowledged the issue, attributing it to the higher acuity of residents needing more assistance. The deficiency was identified through interviews and record reviews, which confirmed that the facility did not meet the residents' needs for timely assistance. The care plans for all three residents indicated a need for prompt response to call lights due to their conditions, such as risk of falls and incontinence. Despite these documented needs, the facility's staff failed to provide timely assistance, leading to prolonged wait times and unmet care requirements. The Director of Nurses confirmed the importance of quick response times, especially for residents requiring help with toileting and activities of daily living, but acknowledged the current delays in service.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
