Neighbors Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Byron, Illinois.
- Location
- 811 West 2nd, Byron, Illinois 61010
- CMS Provider Number
- 145440
- Inspections on file
- 28
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Neighbors Health Center during CMS and state inspections, most recent first.
Multiple residents on one hall experienced prolonged cold room temperatures below the stated comfort range, with blankets placed over windows and AC units to block drafts and residents sleeping under several blankets or in coats and hoodies. Cognitively intact residents reported that it had been cold for weeks to months, described feeling sad, angry, disappointed, and depressed, and some refused showers or washed quickly because their rooms were too cold. Staff, including CNAs and an LPN, confirmed that the hall was "freezing" for an extended period, that residents complained continuously, and that they responded mainly by providing extra blankets and notifying maintenance. A representative payee monitor and the ombudsman observed or were aware of ongoing heating complaints, including residents in bed with multiple blankets and coats, and noted that heating concerns raised in resident council were not reflected in the minutes. The maintenance director and administrator reported boiler blockages and flow issues, acknowledged that a boiler remained down, and documented room temperatures in the mid-60s, which did not meet the expected comfortable temperature range.
Staff were observed distributing ice water to several residents using unsanitary practices, including placing a wet scoop on the water cart and holding cups above an open cooler, contrary to facility policy and increasing the risk of cross contamination.
A resident with severe cognitive impairment and a stage 4 pressure ulcer experienced a significant change in condition, including unusual inactivity and possible blood in urine. CNAs reported these changes to an LPN, who checked vital signs but did not perform or document a full assessment or notify the nurse practitioner as required by facility policy. The lack of timely assessment, documentation, and communication resulted in delayed care until the resident was sent to the hospital.
Multiple residents were subjected to physical abuse by other residents, resulting in serious injuries including a head laceration, subdural hematoma, and a spinal fracture. Staff and medical documentation confirmed that altercations occurred in common areas and resident rooms, with staff sometimes unable to intervene in time to prevent harm. The facility's abuse prevention policy was not effectively implemented, leading to residents being harmed by peers.
Mechanical lift equipment was not kept in safe working order, as multiple CNAs reported frequent battery failures and malfunctioning emergency release mechanisms during resident transfers. In several cases, a resident was left suspended in the air when the lift lost power, and staff had to manually lower the individual due to nonfunctional emergency releases. Staff and residents described ongoing problems with unreliable batteries and broken lift components, while maintenance and safety checks were not consistently performed.
During a shift change, an LPN, another LPN, and the Dietary Manager engaged in a loud argument at the nurses' station, using profane and insulting language about the facility's menu planning. A resident was present and witnessed the altercation, which violated the facility's policy on resident dignity and privacy.
Two residents were involved in a physical altercation, resulting in one being knocked down and kicked, with subsequent bruising documented. Despite the incident and later disclosure of physical contact, the facility did not report the abuse allegation to the state agency or police until months later, only after receiving an anonymous hotline call. The facility's policy requiring immediate reporting of abuse was not followed.
A resident sustained a head injury when their wheelchair flipped backwards during transport by non-clinical staff. The incident was not reported to clinical staff, and upon return, the acting DON/ADON assessed the resident but failed to document the assessment, perform or document neuro checks, or notify the physician. The RN assigned to the resident did not complete or document neuro checks, and the event was not recorded in the medical record, contrary to facility policy.
Staff transferred multiple residents using a mechanical lift with a non-functioning emergency release and unreliable batteries. In one case, a CNA had to manually lower a resident when the lift failed, and the broken equipment was not removed from use. Staff continued to use the malfunctioning lift for other residents, and transfers were performed without proper assessment or care plan updates for residents with cognitive and physical impairments.
The facility did not maintain accurate and up-to-date medical records for three residents following significant incidents, including a transport van fall, an elopement, and a mechanical lift malfunction. In each case, staff were aware of the events but failed to document them in the residents' records as required by facility policy.
The facility failed to accurately monitor and record the weights of several residents, resulting in significant discrepancies without reweighs or physician notifications. Despite the facility's policy requiring investigation of significant weight changes, this was not followed, leading to a deficiency in maintaining residents' nutritional status.
The facility failed to securely store medications when the ADON found the nurse's keys under a binder on the medication cart. The DON confirmed that keys should always be with the nurse to ensure medication security, as per the facility's policy revised in August 2023.
A facility failed to follow proper infection control practices during incontinence care and linen handling. A CNA transported soiled linens without bagging them, contrary to policy, and another CNA did not change gloves between dirty and clean tasks while caring for a resident with multiple health issues. The DON confirmed the importance of these practices to prevent cross-contamination.
Two residents in an LTC facility did not receive adequate ADL assistance, leading to deficiencies in personal hygiene and incontinence care. One resident, with Alzheimer's and other conditions, did not receive oral care or shaving assistance as required. Another resident, with severe malnutrition and dementia, did not receive proper incontinence care from a new CNA. The DON confirmed that these care practices are standard and all aides are trained accordingly.
A resident with a catheter was observed with the urinary drainage bag improperly placed on his thighs, contrary to the care plan and facility policy requiring it to be below bladder level to prevent backflow and UTIs. The DON confirmed the importance of proper bag positioning, especially since the resident had recently been treated for a UTI.
Prolonged Inadequate Room Temperatures and Resident Discomfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident room temperatures within a comfortable range, resulting in prolonged cold conditions on the 100 hall for most residents reviewed. Multiple resident rooms had blankets placed on windowsills and over air conditioning units to block drafts. Residents consistently reported that their rooms had been cold for weeks to months, particularly during the winter, and that the problem persisted whenever the outside temperature was low. Facility temperature logs for the 100 hall documented room temperatures ranging from approximately 62.6 to 68.1 degrees Fahrenheit on specific dates, with a baseboard temperature as low as 54.6 degrees Fahrenheit, which is below the stated comfortable range of 71 to 81 degrees Fahrenheit. Cognitively intact residents described needing multiple blankets to stay warm, with some sleeping under three to five blankets or wearing coats and hoodies in bed. Several residents stated that it had been cold “all winter” or for “months,” and some reported specific low temperatures such as 61 degrees. Residents reported feeling sad, angry, disappointed, depressed, and as though they were not being heard because of the ongoing lack of heat. Some residents refused showers or had to wash quickly due to the cold in their rooms, and at least one resident’s shower refusal was documented on a shower sheet. Residents also reported that while they were offered the option to move to other, warmer units, they declined because they did not want to move their belongings or change rooms. Staff interviews corroborated the residents’ reports, with CNAs and nursing staff describing the 100 hall as “freezing” and cold for about a month to several months, noting that residents complained all day about being cold and often stayed in bed. Staff reported that they responded by providing extra blankets, wearing hoodies themselves while working, and notifying maintenance, but they were not informed why the hall remained so cold. A representative payee monitor and the ombudsman both observed or were aware of ongoing heating issues, with the monitor noting a clear temperature difference between administrative and resident areas and seeing residents in bed with multiple blankets and wearing coats. The ombudsman stated that residents had been complaining about no heat for most of the winter and that these concerns were raised in a resident council meeting, although the meeting minutes did not reflect the heating complaints. The maintenance director acknowledged receiving complaints about cold temperatures on specific dates and identified problems with the facility’s boiler system, including a blockage in the fourth boiler and flow issues throughout the building, with the 100 wing being the most concerning. He stated that the fourth boiler remained down and that room temperatures were being kept at 68–69 degrees, which is below the 71–81 degree comfort range cited in the deficiency. Blankets were intentionally placed on windowsills and air conditioners to reduce drafts. The administrator reported that there were blockages in the boiler system and that a new heating and cooling system had been ordered but not yet installed. The facility’s own severe cold weather procedures required assuring that heating systems were working correctly in residents’ rooms, and the Illinois Department on Aging residents’ rights booklet stated that the facility must be safe, clean, comfortable, and homelike, underscoring that the prolonged cold conditions and substandard room temperatures constituted a failure to provide a comfortable environment.
Unsanitary Water Distribution Practices Identified
Penalty
Summary
Facility staff failed to provide water to residents in a sanitary manner, as observed during the distribution of ice water to five residents. An activity aide used a scoop to fill residents' cups from a cooler containing water and ice, placing the wet scoop back onto the water cart after each use, rather than storing it in a sanitary location. Additionally, the aide held residents' water cups, which had been removed from their rooms, directly above the open cooler while filling them. The food service director confirmed that these practices were not in accordance with facility policy, which prohibits placing the scoop on the cart and holding cups above the cooler due to the risk of cross contamination. These actions were observed during the survey and were inconsistent with the facility's policy on ice dispensing, which requires food and beverages to be stored, prepared, distributed, and served in a sanitary manner to prevent foodborne illness.
Failure to Assess and Document Change in Resident Condition
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and a history of a stage 4 sacral pressure ulcer was properly assessed and monitored following a change in condition. Staff observed that the resident, who was typically confused but active and frequently attempted to get up unassisted, was unusually inactive, did not use her call light, and did not attempt to get out of bed. Certified Nursing Assistants (CNAs) reported these changes to the nurse on duty, who responded only by checking vital signs multiple times throughout the shift but did not perform or document a comprehensive assessment or follow-up. Additionally, possible blood in the resident's urine was reported during the morning shift, but there was no documented assessment or notification to the nurse practitioner until the resident was sent to the hospital later that night. The facility's policy required prompt assessment, documentation, and notification of changes in a resident's condition, but these steps were not followed. The nurse on duty did not recall being informed of the possible blood in urine and did not document any assessment or communication regarding the resident's change in status. The Director of Nursing and Nurse Practitioner both confirmed that, according to facility policy and standard practice, a full assessment and notification should have occurred, and all actions should have been documented in the resident's medical record. The lack of timely assessment, documentation, and communication led to a delay in appropriate care for the resident.
Failure to Prevent Resident-on-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect multiple residents from physical abuse, resulting in significant injuries. In one incident, a resident in the memory care dining room sustained a posterior head laceration and an acute subdural hematoma after an altercation with another resident. Staff accounts indicate that two residents were struggling over a chair, leading to both falling, with one resident landing on top of the other and causing a head injury that required hospital treatment. Witnesses described one resident shoving a chair into another, causing a fall and head trauma, with visible damage to the wall and significant bleeding. Documentation from the hospital confirmed the head injury and subdural hematoma, and staff noted that the aggressor had previously shown aggression toward staff but not other residents. Another incident involved two roommates who had a history of disagreements. During an altercation, one resident fell from his wheelchair and was then kicked multiple times by his roommate. Staff intervened to separate them, and subsequent medical assessment revealed bruising consistent with defensive injuries and a fracture in the lower spine. The resident reported being kicked while on the floor, and staff and nurse practitioner documentation supported the account of physical abuse. The aggressor admitted to kicking the other resident after a verbal threat, and the victim was later discharged from the facility. The facility's records and staff interviews indicate that these incidents were not isolated and involved failures to prevent resident-on-resident abuse. The facility's abuse prevention policy affirms the right of residents to be free from abuse, but the documented events show that residents were subjected to physical harm by other residents, with staff sometimes unable to intervene in time to prevent injury. The incidents were reported to the state agency and local authorities, but the documentation reveals gaps in preventing and documenting abuse between residents.
Mechanical Lift Equipment Not Maintained in Safe Working Order
Penalty
Summary
The facility failed to ensure that mechanical lift equipment was maintained in safe and operable condition for five residents who required mechanical lifts for transfers. Multiple CNAs reported that batteries for the mechanical lifts frequently failed to hold a charge, resulting in situations where residents were left suspended in the air or unable to be safely lowered during transfers. In one instance, a CNA described attempting to lower a resident onto the toilet when the lift battery died, and after trying several replacement batteries that also failed, the emergency release mechanism did not function. The CNA ultimately had to manually lower the resident using a gait belt and her own knees for support. The same lift was later observed to have a broken emergency release ring that was not attached to the shaft, rendering it ineffective. Other staff members confirmed ongoing issues with lift batteries, malfunctioning emergency releases, and damaged wheels on some lifts. Residents who regularly used the sit-to-stand machines also reported repeated incidents where lifts lost power while they were suspended. The facility's maintenance policy assigns responsibility for equipment upkeep to the maintenance department, but interviews revealed uncertainty about whether safety checks had been performed and that staff continued to use lifts with known safety issues.
Resident Exposed to Undignified Staff Altercation at Nurses' Station
Penalty
Summary
Staff members, including two LPNs and the Dietary Manager, engaged in a loud verbal altercation at the nurses' station during shift change. The argument involved the use of profane and insulting language, with one LPN calling the dietitian derogatory names and using explicit language. The altercation was witnessed by other staff, including a CNA who attempted to intervene and de-escalate the situation. During this incident, at least one resident was present and seated by the nurses' station, within earshot of the argument. The facility's policy on resident privacy and dignity specifically instructs staff to avoid discussing private or personal issues in public and to refrain from using patronizing or insulting language. Despite this, the staff's conduct during the altercation failed to uphold these standards, resulting in a situation where a resident was exposed to undignified and inappropriate staff behavior.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving two residents was reported to the state surveying agency in a timely manner. In December 2023, two residents were involved in a physical altercation in their shared room, which resulted in one resident being knocked down and kicked by the other. Progress notes indicated that one resident initially denied physical contact but later reported being kicked while on the floor, with visible bruising to his right upper arm, elbow, and head. Despite these allegations and physical findings, the incident was not reported to the state agency or local police at the time it occurred. The facility's administrator stated that the incident was not reported initially because it was determined that no contact had occurred. However, months later, after receiving an anonymous compliance hotline call, the administrator reported the incident to the state agency and local police, eight months after the original event. The facility's own abuse prevention policy requires immediate reporting of abuse allegations, but this protocol was not followed in this case. Documentation shows that the facility only submitted a report after the anonymous call, and no further information was provided to the state agency beyond the original late report.
Failure to Assess, Document, and Notify After Resident Head Injury During Transport
Penalty
Summary
A resident was transported to an orthopedic appointment by the facility's former Maintenance Director, who was not clinical staff. During transport, the resident's wheelchair flipped backwards, causing the resident to hit his head and sustain a scrape. The Maintenance Director did not notify the facility of the incident, relying on the resident's statement that he was fine and the fact that he was at a doctor's office. The resident's daughter discovered the injury at the appointment and contacted the facility, expressing concern about not being informed of the incident. Upon return to the facility, the acting DON/ADON, who had a background in neurology trauma, assessed the resident and determined he was fine but did not document the assessment, perform or document neuro checks, or notify the physician as required by facility policy. The RN assigned to the resident was instructed to perform hourly neuro checks but did not complete or document them, citing being busy with nursing students. The resident's electronic medical record contained no documentation of the incident, neuro checks, or physician notification, despite facility policies requiring such actions following a fall or head injury.
Failure to Ensure Safe Resident Transfers Due to Faulty Equipment
Penalty
Summary
The facility failed to ensure that residents were transferred safely using properly functioning equipment, as evidenced by multiple incidents involving three residents. Staff used a sit-to-stand machine and a mechanical lift with a non-functioning emergency release and unreliable batteries. In one instance, a CNA attempted to lower a resident onto the toilet using the sit-to-stand machine, but the battery died and the emergency release did not work. The CNA had to manually lower the resident to a wheelchair, and the broken equipment was not removed from use or labeled as defective. Staff reported that management had been informed about the unreliable equipment, but no immediate action was taken to prevent further use. Additionally, staff continued to use the same malfunctioning mechanical lift to transfer other residents, despite being aware that the emergency release was not operational. The care plan for one resident specified the use of a mechanical lift due to cognitive impairment and physical limitations, but staff attempted a sit-to-stand transfer without a proper assessment or care plan update. Maintenance staff later confirmed the emergency release was not attached as required, and the facility's maintenance policy indicated responsibility for keeping equipment safe and operable at all times.
Failure to Document Resident Incidents in Medical Records
Penalty
Summary
The facility failed to ensure that resident records were up to date and accurate for three residents. In the first instance, a resident was involved in an incident where he flipped backwards in his wheelchair while being transported in a van and hit his head. This event was confirmed by the resident, his daughter, and the former Maintenance Director, but there was no documentation of the incident in the resident's electronic medical record. The facility's fall prevention and management policy requires documentation of such events, including outcomes, observations, and notifications. In the second case, a resident exited the building through a dining room door and was found outside on the sidewalk. Staff responded to the alarm and brought the resident back inside without injury. The LPN involved stated she was told by the Administrator to hold off on charting, and no documentation of the event was found in the resident's record. The facility's policy requires reporting and documentation of missing residents. In the third case, a resident experienced a malfunction with a sit-to-stand machine during toileting, requiring manual assistance to be safely lowered. The CNA, LPN, and Social Service Director were aware of the incident, but no documentation was made in the resident's record, contrary to the facility's charting and documentation policy.
Failure to Ensure Accurate Weight Monitoring
Penalty
Summary
The facility failed to ensure accurate weights were obtained and recorded for five residents, leading to a deficiency in monitoring their nutritional status. The report highlights significant discrepancies in daily weight recordings for these residents, with no reweighs conducted or physicians notified of the changes. For instance, one resident experienced a 21.8-pound weight loss in one day, and another had a 26.6-pound weight gain in a single day, yet there was no documentation of reweighs or physician notification. The Director of Nursing acknowledged that a weight change of five or more pounds in a day should prompt a reweigh, but this standard was not met. The facility's policy on weight management requires investigation of significant or trending weight changes, but this was not adhered to. The Assistant Director of Nursing noted that notification to a physician would depend on specific parameters, but expected reweighs for large discrepancies. Despite these expectations, the report shows a lack of action in response to significant weight changes, indicating a failure to follow the facility's policy and standard care practices.
Medication Storage Security Lapse
Penalty
Summary
The facility failed to securely store medications, as observed during a survey. During a medication storage review, the Assistant Director of Nursing (ADON) had to locate the nurse to obtain the keys to the medication cart. Upon returning, the ADON found the narcotic count binder on the cart with the nurse's keys underneath its cover. The ADON used these keys to open the medication cart. The ADON acknowledged that the keys should be with the nurse at all times and not left on the cart. The Director of Nursing (DON) confirmed that the keys should always be with the nurse to ensure medication security and prevent residents from accessing the cart. The facility's policy, revised in August 2023, mandates that drugs and biologicals be stored safely, securely, and orderly.
Infection Control Deficiencies in Linen Handling and Incontinence Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during incontinence care and linen handling. A Certified Nursing Assistant (CNA) was observed transporting soiled linens without bagging them, holding them against her body, which is against the facility's policy. The CNA admitted to being aware of the correct procedure but did not follow it due to nervousness. The Director of Nursing confirmed that the facility's policy requires soiled linens to be transported in a bag or using a soiled linen cart to prevent cross-contamination. Additionally, during incontinence care for a resident with multiple health issues, including cerebral infarction and urinary tract infection, two CNAs failed to change gloves and perform hand hygiene between dirty and clean tasks. One CNA continued to wear contaminated gloves while handling clean items and performing various tasks, contrary to the facility's gloves policy. The Director of Nursing emphasized the importance of changing gloves between dirty and clean areas to prevent the transfer of germs, feces, and urine to clean areas.
Deficiencies in ADL and Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, leading to deficiencies in personal hygiene and incontinence care. One resident, diagnosed with Alzheimer's disease, major depressive disorder, dementia with psychotic disturbance, and type 2 diabetes, required maximum assistance for oral and personal hygiene. During a morning care session, a CNA provided incontinence care, dressing assistance, and hair brushing but failed to offer or provide oral care or shaving assistance, despite the resident's care plan indicating a risk for ADL decline. The resident expressed dissatisfaction with the lack of shaving assistance, indicating a preference for having facial hair removed. Another resident, with severe protein-calorie malnutrition and dementia with behaviors, was found to have moderate cognitive impairment and incontinence issues. A new CNA provided toileting assistance but failed to perform incontinence care after removing a soiled brief, instead applying a new brief without cleaning the resident. The Director of Nursing confirmed that incontinence care is standard practice for infection prevention, dignity, and cleanliness, and all aides are trained to perform these tasks. The facility's policies on ADLs and incontinence care emphasize the importance of maintaining hygiene and preventing infection.
Improper Positioning of Urinary Drainage Bag
Penalty
Summary
The facility failed to ensure proper positioning of an indwelling urinary drainage bag for a resident with a catheter, leading to a potential risk of urinary tract infections (UTIs). The resident, who had diagnoses including cerebral infarction, heart disease, obstructive and reflux uropathy, benign prostatic hyperplasia, and a UTI, was observed with the catheter bag placed on top of his thighs while lying in bed. This placement was contrary to the care plan and facility policy, which required the bag to be positioned below the bladder level to prevent backflow of urine. During an observation, the Director of Nurses (DON) and a Certified Nursing Assistant (CNA) transferred the resident using a mechanical lift, and the DON acknowledged the need to hold the bag below the bladder during the transfer. The DON later confirmed that the resident had required antibiotics for a UTI a few weeks prior and emphasized the importance of keeping the catheter bag below the bladder to prevent backflow and potential UTIs. The facility's policy also specified that the drainage bag should be attached to the bed frame below the bladder level, not touching the floor, to ensure proper urine flow and avoid backflow.
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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