Nature Trail Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Vernon, Illinois.
- Location
- 1001 South 34th Street, Mount Vernon, Illinois 62864
- CMS Provider Number
- 146021
- Inspections on file
- 21
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Nature Trail Health And Rehab during CMS and state inspections, most recent first.
Two residents with documented weight loss and malnutrition risk did not consistently receive ordered nutritional interventions. One resident with severe PCM and on dialysis was ordered a liberal renal diet with double protein at all meals but was repeatedly served trays without the double protein, missing items such as salad and bread, and reported receiving only breakfast and dinner on dialysis days, with meals often cold and unappetizing. Another resident with dementia and significant prior weight loss was ordered a daily health shake with lunch, along with other supplements, yet over multiple observed lunches the health shake was absent despite being highlighted on the diet card and acknowledged by staff as ordered. These inactions resulted in inadequate implementation of prescribed diets and supplements intended to maintain residents’ nutritional status.
Surveyors found that multiple community bathrooms and shower rooms on several halls lacked accessible call light activation systems, despite facility policy requiring call lights to be within resident reach in rooms and bathrooms. In some areas, the call light string by the toilet was positioned behind the toilet and too short to be easily reached, and in other bathrooms and shower rooms there were no call lights accessible from either the toilet or the shower stall. The Maintenance Director acknowledged that toilets and shower stalls should have reachable call light strings, and facility records showed that 60 residents were residing in the facility at the time.
The facility failed to provide warm water in two rooms, affecting four cognitively intact residents with multiple chronic conditions, including COPD, diabetes, heart failure, chronic respiratory failure with hypoxia, severe protein-calorie malnutrition, and major depressive disorder. These residents reported that the water in their bathroom sinks never became warm, even after running it for an extended period. Surveyors confirmed this by measuring sink water temperatures of approximately 67°F and 71°F using a calibrated thermometer. The Maintenance Director was aware that these rooms on one hall did not have hot water, had advised a resident to let the water run longer, and later stated he did not know why the rooms lacked hot water or how to fix it, despite a facility policy requiring a safe, comfortable, homelike environment.
Surveyors determined that the facility failed to ensure food was served at an appetizing temperature, particularly at breakfast. A calibrated thermometer showed sample pancakes and sausage at about 80°F and tasting cold. Several alert and oriented residents, including those who typically eat in their rooms, reported that breakfast items such as sausage, eggs, and pancakes were often cold or barely warm, and one resident stated he was told to eat in the dining room if he wanted hotter food. The Dietary Manager acknowledged that food should be served hot and not at 80°F and was unsure whether a policy existed for cold food.
A resident with heart failure, dysphagia, diabetes, and bipolar disorder, who was cognitively intact per BIMS, did not have a documented care plan meeting following the comprehensive assessment. The resident reported never being invited to such a meeting, and facility staff were unable to locate a signature sheet or progress notes showing that a care plan meeting occurred. This was inconsistent with the facility’s care plan policy, which requires that residents and their representatives be invited and encouraged to participate in the development and revision of the individualized plan of care.
Two residents who were dependent on staff for ADLs did not receive adequate hygiene and bathing assistance. One resident with dementia and blindness had long, visibly dirty fingernails over multiple days despite being care planned for assistance with personal hygiene, and staff provided inconsistent explanations of when nail care was performed, with the DON confirming there was no set schedule. Another resident with impaired mobility, cognitively intact and dependent on staff for bathing, reported not receiving scheduled baths, and documentation showed a nine-day period without bathing assistance, with an "NA" entry on a scheduled bath day that the DON later acknowledged meant the resident went without the expected care, contrary to the facility’s policy requiring at least twice-weekly bathing offers.
Staff failed to follow hand hygiene standards during catheter and incontinence care for three cognitively intact residents with conditions including Guillain-Barré syndrome, neuromuscular bladder dysfunction, chronic kidney disease, heart failure, benign prostatic hypertrophy, and hydronephrosis. CNAs providing Foley catheter and incontinence care changed gloves multiple times after cleaning and drying peri areas, catheter insertion sites, tubing, and buttocks, but did not perform hand hygiene between glove changes. In interviews, some CNAs admitted they forgot to use the hand sanitizer they carried, while others reported that sanitizer was not available in the room. This practice did not comply with the facility’s hand hygiene policy, which identifies hand hygiene as the primary means to prevent infection and requires it as the final step after PPE removal.
A resident with multiple serious medical conditions and moderately impaired cognition consented in writing to receive an influenza vaccine, but the facility did not administer it during the current stay. The immunization record showed the last flu shot was from a prior year, and the DON confirmed the vaccine had not been given and could not explain why. This occurred despite a facility policy requiring that current and newly admitted residents be offered influenza vaccination during the flu season.
Two residents were found to have medications left at their bedside for self-administration, contrary to facility policy. One resident, who was cognitively intact, had medications left without her knowledge, while another with moderate cognitive impairment had pills left on her bedside table to take at her convenience. Nursing staff admitted to this practice, and facility leadership confirmed it was against policy, which requires licensed nurses to administer and ensure medications are taken as ordered.
A resident at high risk for falls due to dementia and other conditions experienced two falls in a facility, resulting in a hip fracture. Despite orders for bed and chair alarms, these did not function during the incidents. Staff interviews revealed that the alarms were not checked properly, and a fall mat was missing. The facility's failure to ensure the effectiveness of fall prevention measures led to the resident's injuries.
The facility failed to provide adequate ROM care for five residents, leading to deficiencies in their care. A resident with hemiplegia did not receive therapy or ROM exercises, despite being cognitively intact and expressing a desire for therapy. Another resident with Parkinson's disease and moderate cognitive impairment also lacked documented orders for ROM, and staff admitted to not having a structured restorative program. Similar deficiencies were observed in three other residents, highlighting a systemic issue in the facility's approach to maintaining and improving residents' ROM.
The facility did not provide the required 80 square feet of floor space per resident for 38 residents, as rooms 100-109, 111, 201-209, and 211 were certified as two-bed rooms but measured only 144 square feet, equating to 72 square feet per resident. Despite this, several residents expressed no concerns about the room size, and the Resident Council Meeting Minutes documented no issues regarding room size.
The facility failed to develop a comprehensive care plan for a resident with a history of substance abuse. The care plan lacked goals and interventions for stimulant use and did not include strategies for monitoring the resident during community passes. This oversight led to the resident feeling unfairly treated and potentially contributed to his decision to discharge against medical advice.
Failure to Provide Ordered Double Protein Portions and Nutritional Supplements for Residents With Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nutrition and ordered supplements to residents with identified nutritional risks and weight loss. One resident with severe protein calorie malnutrition, end stage renal disease, and multiple other diagnoses was ordered a liberal renal diet with double protein portions at all meals. The resident’s care plan and nutritional assessments identified him as at risk for malnutrition and documented that he would likely benefit from adding double protein to all meals. Despite this, observations on multiple days showed that his lunch trays did not include the ordered double protein portions, and some menu items such as salad and bread were missing without explanation, even though his diet card specified them. The same resident was also receiving dialysis three times per week and reported that on dialysis days he only received breakfast and dinner. He stated that the facility did not send a lunch with him to dialysis and that when he returned in the mid- to late afternoon, he was usually offered something to eat so close to dinner that he would then not eat the evening meal, resulting in only two meals on those days. He also reported that the food he received in his room was often cold and unappetizing, including plain pasta with no sauce and cold, burnt sausage and cold eggs and pancakes, which led him to eat very little. Weight records documented that his weight decreased from 172.6 pounds to 147.0 pounds between late November dates, a loss of 25.6 pounds or 14.83% in less than 30 days, and he confirmed a current weight in the mid‑140s when reweighed. A second resident with Alzheimer’s disease, major depressive disorder, GERD with esophagitis, and documented significant weight loss was ordered a regular diet with mechanical soft texture and nectar thick liquids, along with a daily health shake, Med Pass 2.0 three times a day for weight loss, and super cereal at breakfast. Her care plan identified risk for nutritional deficit and included providing nutritional supplements as ordered. The MDS documented that she was dependent for eating and had experienced weight loss of 5% or more in one month or 10% or more in six months, and the dietician’s note identified an 11% weight loss in six months and risk for malnutrition. However, over at least four consecutive lunch observations, the resident’s meal trays did not include the ordered health shake, even though it was highlighted on the diet card and staff, including CNAs and the Dietary Manager, acknowledged that the shake should have been provided and could not explain its absence. The facility’s own policy on weight assessment and intervention required that significant weight changes be confirmed and that the dietitian be notified in writing if verified, and stated that the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss. In practice, the registered dietician reported being notified of the first resident’s significant weight drop but stated she was waiting for confirmation of the weight and had not heard back. For both residents, there were clear physician and dietician orders for enhanced nutrition and supplements, but observations and interviews showed that ordered double protein portions, health shakes, and complete meals were not consistently provided as specified, contributing to the identified deficiency in providing sufficient food and fluids to maintain residents’ health.
Inaccessible Call Light Systems in Community Bathrooms and Shower Rooms
Penalty
Summary
Surveyors identified that the facility failed to provide an accessible call light activation system in multiple community bathrooms and shower rooms, despite a policy requiring call light devices to be kept within resident reach in rooms and bathrooms. On the 200 hall, one shower room across from a resident room had a call light string by the toilet positioned behind the toilet, extending only to about 3 inches above the bottom of the toilet tank, and there was no call light available from the shower stall area. In another 200 hall shower room located across and between two resident rooms, there was no call light accessible near either the toilet or the shower stall. On the 300 hall, one shower room lacked a call light accessible from the shower stall area, and a second 300 hall shower room had no call light accessible from either the toilet or the shower area. On the 100 hall, the shower room did not have a call light accessible from the shower stall. The Maintenance Director later stated that toilets and shower stalls should have call light strings available and within reach for residents to use if they were to fall. The facility’s LTC application documented that 60 residents resided in the facility at the time of the survey.
Failure to Provide Warm Water in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide warm water in resident rooms, compromising residents’ right to a safe, clean, comfortable, and homelike environment. Four cognitively intact residents reported that the water in their bathroom sinks did not get warm. Two residents sharing one room, both with multiple chronic conditions including COPD, diabetes, severe protein-calorie malnutrition, major depressive disorder, and schizophrenia, stated that the water in their room never became warm. A calibrated metal stemmed thermometer, verified at 32.5°F using the ice point method, was used to measure the water temperature at their bathroom sink after the water had been running for over 10 minutes; the temperature was 67.5°F. One of these residents reported having informed the Maintenance Director, who told her they needed to let the water run longer, but the water still did not become warm. Two additional cognitively intact residents in another room, both with extensive medical histories including chronic respiratory failure with hypoxia, COPD, heart failure, diabetes with hyperglycemia, anemia, arthropathy, hypothyroidism, sleep apnea, chronic pain syndrome, and muscle wasting, also reported that the water in their bathroom sink did not get warm. When the surveyor measured the water temperature at their sink after running it for several minutes, it registered 71.0°F. The Maintenance Director acknowledged awareness of the lack of hot water in these two rooms on the 100 hall and stated he did not know why those rooms did not have hot water and did not know how to fix the problem. This situation occurred despite a facility policy stating that residents are to be provided with a safe, clean, comfortable, and homelike environment.
Failure to Serve Palatable, Hot Breakfast Meals
Penalty
Summary
Surveyors found that the facility failed to provide food at an appetizing temperature for four residents who received cold food. On the morning of 12/04/25, a surveyor-verified, calibrated digital metal stem thermometer showed that a sample breakfast tray had a pancake at 80.6°F and sausage at 80.0°F, and both items tasted cold and unappetizing. One resident, who was alert and oriented, reported that the food was sometimes burnt and cold. Another alert and oriented resident stated that the breakfast sausage and eggs were always cold and reported being told that if he wanted hotter food, he should eat in the dining room; he later stated that his sausage was burnt and cold and his pancake was not very warm that morning. A third alert and oriented resident, who usually eats in her room, stated that her food, especially breakfast, was not always hot. A fourth alert and oriented resident, who also usually eats in her room, stated that sometimes the food was barely warm and that the sausage and pancake that day were not good. The Dietary Manager acknowledged that food served in the dining room or in resident rooms should be hot, not 80°F, and was unsure whether there was a policy for cold food. These observations and interviews demonstrated that multiple residents consistently received breakfast items, particularly sausage and pancakes, at temperatures that were not hot or appetizing, both in the dining room and in resident rooms, and that the measured temperatures of sampled food items were significantly below typical hot-holding or serving temperatures.
Failure to Conduct and Document Resident Care Plan Meeting
Penalty
Summary
The facility failed to ensure that a care plan meeting was conducted and documented for one cognitively intact resident following completion of the comprehensive assessment, as required by facility policy. The resident was admitted with diagnoses including heart failure, dysphagia, diabetes, and bipolar disorder, and had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Review of the resident’s current medical record showed no signature sheet or progress notes indicating that a care plan meeting had been held, and the facility was unable to provide reproducible evidence that such a meeting occurred. In interview, the resident reported not being invited to a care plan meeting, and the social services staff member confirmed she could not locate any documentation of a care plan meeting in the resident’s record, despite the facility’s care plan policy stating that residents and their representatives are to be invited and encouraged to participate in development and revision of the care plan and that efforts will be made to schedule these meetings at a suitable time.
Failure to Provide Adequate Hygiene and Bathing Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), specifically hygiene and bathing, for two residents who were dependent on staff. One resident with Alzheimer’s disease, dementia, blindness in one eye, and an MDS indicating dependence on staff for all ADLs, including personal hygiene, was care planned for assistance with dressing, grooming, and personal hygiene. Despite this, surveyors repeatedly observed the resident’s fingernails to be long, yellowed, and visibly dirty with brown buildup and other unknown substances under the nails over several days. Certified nurse aides (CNAs) gave inconsistent descriptions of when nail care was provided (e.g., every Thursday, at every shower, daily, during manicure day), and the DON confirmed there was no specific time nail care was to be performed, only that it should be done as needed. Even after the nails were clipped, surveyors observed that the buildup under the nails remained. The Administrator stated that nails should be kept clean and trimmed to the resident’s desired length and agreed that the observed condition of the nails was unacceptable. The facility’s ADL policy required appropriate hygiene care, including grooming, for residents unable to carry out ADLs independently. The second resident, who was cognitively intact with diagnoses including major depressive disorder, morbid obesity, and Guillain-Barré syndrome, was documented as dependent on staff for bathing and had a care plan focus on ADL self-care performance deficit related to impaired mobility, with an intervention to assist with ADLs such as dressing, grooming, and personal hygiene as needed. The care plan did not specifically address bathing. The resident reported not receiving bathing assistance as scheduled, stating he was supposed to receive help on Wednesdays and Saturdays but did not always get it. Review of documentation for a one-month period showed that the resident received assistance with bathing on only six specified days, with a notation of “NA” (not applicable) on one scheduled bath day, resulting in a nine-day gap without documented bathing assistance. The DON initially did not know what “NA” meant, later confirmed it meant “not applicable,” and acknowledged that the resident went nine days without assistance with bathing and that he should not have gone that long without being offered a bath or shower. The facility’s bathing policy required that residents be offered a means of bathing at least twice a week at a time and by a method of their choosing, recognizing their right to refuse care.
Failure to Perform Hand Hygiene Between Glove Changes During Catheter and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff performed hand hygiene according to current standards of practice during catheter and incontinence care for three cognitively intact residents. One resident with Guillain-Barré syndrome, neuromuscular bladder dysfunction, and urinary retention had an indwelling Foley catheter with care ordered every shift. During observed catheter care, the CNA changed gloves multiple times after cleaning the insertion site, washing the tubing, and drying the area, but did not perform hand hygiene between glove changes. In a subsequent interview, the CNA acknowledged she should have performed hand hygiene between glove changes and stated it slipped her mind. Another resident with chronic kidney disease, heart failure, obesity, osteoarthritis, osteoporosis, history of falls, and myoclonus required two-person assist for toileting. Two CNAs were observed providing incontinence care, including washing and drying the peri area and buttocks, and changing gloves after each step, but they did not perform hand hygiene between glove changes. Both CNAs later stated they had hand sanitizer in their pockets but either forgot to use it or were unsure why they did not. A third resident with benign prostatic hypertrophy and hydronephrosis with renal and ureteral calculus had an indwelling Foley catheter with orders for catheter care every shift. Two CNAs provided catheter care, changing gloves after cleaning the insertion site, tubing, and buttocks, and after drying, but did not perform hand hygiene between glove changes; they stated they did not have hand sanitizer in the room. The facility’s handwashing/hand hygiene policy states that hand hygiene is the primary means to prevent the spread of infections, that products and supplies shall be readily accessible and convenient for staff use, and that hand hygiene is the final step after removing and disposing of PPE.
Failure to Administer Influenza Vaccine After Resident Consent
Penalty
Summary
The facility failed to provide an influenza vaccination to one resident who had consented to receive it. The resident was admitted on 11/04/25 with multiple significant diagnoses, including spondylosis, critical illness myopathy, severe protein calorie malnutrition, monoclonal gammopathy, dependence on renal dialysis, osteophyte, acute on chronic systolic heart failure, major depressive disorder, Alzheimer's disease, muscle wasting and atrophy, pleural effusion, candidal stomatitis, atrioventricular block, paroxysmal atrial fibrillation, and chronic systolic heart failure. The resident’s Minimum Data Set documented a Brief Interview for Mental Status score of 12, indicating moderately impaired cognition. On 11/05/25, the resident’s Vaccine Informed Consent Form documented that the resident accepted the influenza vaccine, with “yes” marked for receiving the influenza vaccination. Despite this documented consent, the Immunization Report showed the most recent influenza vaccination for the resident was dated 12/19/2022, prior to the current admission, and there was no record of an influenza vaccine being administered during the current stay. During an interview on 12/04/25 at 11:31 AM, the Director of Nursing confirmed that the resident had not received an influenza vaccination while at the facility and stated she did not know why it had not been given. This failure occurred despite the facility’s written policy, dated 09/2015, which states that current and newly admitted residents will be offered the influenza vaccine from October through the end of March each year, in accordance with recommendations from CDC and other professional organizations.
Medications Improperly Left at Bedside for Self-Administration
Penalty
Summary
The facility failed to ensure the proper and safe administration of medications in accordance with its own policy for two residents. In the first instance, a resident with diagnoses including bradycardia, heart failure, hypertension, and diabetes was found to have medications left at her bedside without her knowledge. The resident, who was cognitively intact, reported that nurses frequently left her medications at her bedside because she was difficult to wake in the mornings. On one occasion, an adult protective specialist visiting the resident observed a medicine cup with medications left on the resident's assistive device chair cushion. The nurse responsible for administering the medications documented them as given but did not recall leaving them at the bedside, despite the resident's statement and the observation by the visitor. In the second case, another resident with Alzheimer's disease and moderate cognitive impairment reported that nurses left her morning medications on her bedside table, and she would take them at her convenience. During an interview, the resident confirmed that her medications were currently sitting on her bedside table, and this was observed by surveyors. The LPN who delivered the medications admitted to leaving them on the bedside table and was unaware of any policy prohibiting this practice. The resident's care plan did not include self-administration of medications as a goal or focus area. Facility policy requires that medications be administered safely by licensed nurses at the specified time, following recommended methods, and that staff ensure medications are swallowed before leaving the resident. Both the DON and the Administrator confirmed that medications should not be left at the bedside and that staff are expected to follow policy and procedures. The failure to administer medications as required and leaving them at the bedside for residents to take on their own constituted a deficiency in pharmaceutical services.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement effective interventions to prevent falls for a resident, identified as R122, who was at high risk for falls due to conditions such as unspecified dementia, weakness, and atrial fibrillation. Despite having orders for bed and chair alarms, these alarms did not function during two separate fall incidents. The first fall occurred while the resident was eating dinner in his room, resulting in a minor head injury and subsequent transfer to the emergency room. The second fall happened when the resident slid out of bed, leading to a left intertrochanteric fracture, which required surgical intervention. Interviews with staff and the resident's roommate revealed that the alarms did not sound during either fall, and a fall mat was not observed in the room during the first incident. The resident's care plan included interventions such as assisting to the toilet before bed and using bed and chair alarms, but these measures were not effectively implemented or monitored. The CNA responsible for checking the alarms at the start of each shift could not explain why the alarms failed to activate. The Director of Nursing and other staff members confirmed that the alarms were supposed to be checked for placement and function every shift, yet the alarms did not alert staff during the falls. The resident's roommate, who witnessed the falls, corroborated that the alarms did not sound. The facility's failure to ensure the proper functioning of fall prevention measures directly contributed to the resident's falls and subsequent injuries.
Deficiencies in Range of Motion Care for Residents
Penalty
Summary
The facility failed to provide adequate services to maintain or improve the range of motion (ROM) for five residents, leading to deficiencies in their care. Resident R23, who has hemiplegia and hemiparesis following a cerebral infarction, did not receive any documented orders for ROM or restorative nursing programs. Despite being cognitively intact and expressing a desire for therapy, R23 reported not receiving any therapy or ROM exercises. Observations confirmed that ROM exercises were not performed on the affected side of R23's body, indicating a lack of comprehensive care. Resident R28, diagnosed with Parkinson's disease and moderate cognitive impairment, also did not have any documented orders for ROM or restorative nursing programs. The resident's care plan required extensive assistance for daily activities, yet observations showed that ROM exercises were not consistently performed. The facility's staff admitted to not having a structured restorative program, and the MDS nurse confirmed that ROM was not coded due to the absence of such a program. Similarly, residents R3, R37, and R52 experienced deficiencies in their care related to ROM. R3, with severe cognitive impairment and multiple contractures, did not receive consistent ROM exercises, and the restorative CNA admitted to not following any specific guidelines. R37, who has hemiplegia and a history of stroke, reported not receiving any daily exercises or therapy, despite having a contracture in the left hand. R52, with impaired lower extremities, also did not receive any restorative nursing programs post-therapy, as confirmed by the resident and the facility's staff. These findings highlight a systemic issue in the facility's approach to maintaining and improving residents' ROM, as evidenced by the lack of structured programs and consistent care.
Facility Fails to Meet Room Size Requirements
Penalty
Summary
The facility failed to provide the required 80 square feet of floor space per resident for 38 out of 38 residents reviewed for room size in a sample of 55. The rooms in question, specifically rooms 100-109, 111, 201-209, and 211, are certified as two-bed rooms but measure only 12 feet by 12 feet, equating to 144 square feet, which is approximately 72 square feet per resident bed. This deficiency was confirmed through observations, interviews, and record reviews conducted by the surveyors. Despite the deficiency, several residents, including those in rooms 50, 51, 56, 11, and 35, expressed no concerns regarding the room size and were alert and oriented to person, place, and time. Additionally, the Resident Council Meeting Minutes from July 2024 through January 2025 documented no concerns regarding the size of resident rooms. The facility's daily roster confirmed that the affected residents resided in the rooms that did not meet the required space standards.
Failure to Develop Comprehensive Care Plan for Resident with Substance Abuse History
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident with a history of substance abuse. The resident's care plan did not include goals and interventions to address stimulant use, stimulant-induced disorder, or stimulant abuse in remission. Despite the resident's documented history of methamphetamine abuse and a hospital summary indicating this diagnosis, the care plan lacked focus areas related to substance abuse. The resident expressed efforts to avoid methamphetamine use, but the care plan did not reflect any strategies or monitoring for this issue. The deficiency was further highlighted when the resident went out on a community pass and returned late. The Director of Nursing and other staff members acknowledged that there were no care plan interventions for drug screening or community passes. The Medical Doctor ordered a drug test upon the resident's return due to his history of drug use, but the resident was not informed in advance about this requirement. The lack of a comprehensive care plan and clear communication led to the resident feeling unfairly treated and potentially contributed to his decision to discharge against medical advice.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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