Oakview Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Carmel, Illinois.
- Location
- 1320 West 9th Street, Mount Carmel, Illinois 62863
- CMS Provider Number
- 145376
- Inspections on file
- 21
- Latest survey
- April 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Oakview Nursing & Rehab during CMS and state inspections, most recent first.
A CNA was hired without verification of continuous employment or current certification, as required by the Health Care Worker Registry. The CNA had a break in her career and worked as a private sitter, not as a CNA, and was unaware of any lapse in certification. Facility staff were not aware of the lapse, and no documentation was found to confirm the CNA's eligibility or work history as required.
A resident with neurocognitive disorder and mobility dependence suffered a leg laceration requiring sutures after bumping into a grab bar missing a safety cap during a transfer. The facility's investigation identified the missing cap as a hazard, leading to the injury.
The facility failed to provide adequate activities for residents on weekends, as confirmed by resident interviews and staff statements. Despite planned activities on the calendar, residents reported a lack of engagement, with some only receiving coloring sheets occasionally. The interim Activities Director indicated CNAs should ensure weekend activities, but a CNA reported no activity staff presence and insufficient time to conduct activities, resulting in residents sitting in front of the TV.
The facility failed to ensure accurate MDS coding for three residents, leading to discrepancies in assessments. One resident's MDS inaccurately documented no serious mental illness despite PASRR Level II documentation indicating otherwise. Another resident's MDS incorrectly indicated no serious mental illness, and a third resident's MDS inaccurately recorded insulin injections without a physician order. The MDS Coordinator acknowledged these errors.
A facility failed to complete a Level II PASRR for a resident with a bipolar disorder diagnosis. The resident was admitted with unspecified dementia and later diagnosed with bipolar disorder. Despite active medication orders for the condition, the facility did not contact the PASRR agency for a Level II screening, as required by their policy.
A resident with multiple diagnoses, including joint disorders and lumbar disc displacement, did not receive necessary range of motion exercises for her lower extremities. Despite documented impairments and dependency on assistance, the resident's care plan lacked focus on preventing decline, and she was not receiving restorative nursing services. CNAs were unclear about their role in providing these exercises, and the Rehabilitation Director confirmed the absence of restorative services for the resident's lower body.
A facility failed to ensure a resident was free from unnecessary psychotropic medications. The resident, with diagnoses of major depressive disorder and anxiety disorder, was on Ativan, Buspirone, and Escitalopram. Despite a pharmacist's recommendation for dose reduction, the physician disagreed, citing stability. The resident expressed uncertainty about the necessity of Buspirone, and CNAs reported no regular behaviors warranting these medications. The facility's policy requires psychotropic medications only when necessary, but there was no evidence of gradual dose reduction or non-pharmacological interventions.
The facility failed to provide meals at a palatable temperature for residents who chose to eat in their rooms. Three cognitively intact residents reported receiving cold meals, with one noting delays in tray distribution. The issue was raised in Resident Council meetings, but the Dietary Manager was unaware of the ongoing problem, and promised solutions, such as ordering plate covers, were not implemented. The facility's policy requires hot foods to be served at 120°F or greater, but this standard was not consistently met.
The facility failed to ensure resident safety during transportation and transfers, resulting in a serious injury when a resident fell from a transport van. Additionally, the facility did not consistently use two staff members for mechanical lift transfers, as required by policy, due to staffing shortages. Furthermore, fall prevention measures were not implemented for a resident with a history of falls, as non-skid strips were not placed as planned.
The facility failed to provide sufficient staffing, resulting in delayed care and improper transfers for residents. One resident with severe cognitive deficits was not repositioned timely, leading to skin issues. Another resident experienced long wait times for assistance, resulting in incontinence episodes and improper transfers with only one staff member using a mechanical lift. Staff confirmed that having only one CNA per hall was insufficient to meet residents' needs.
The facility failed to provide adequate hot water in the shower rooms on the 200 and 500 halls, affecting residents who require assistance with showers. Water temperatures were found to be below required levels, and the Maintenance Director acknowledged ongoing issues with maintaining adequate temperatures. Two residents reported inconsistent water temperatures, leading to the need for showers on other halls, which they found degrading. Staff confirmed the inconsistency of hot water availability.
A facility investigation revealed misappropriation of funds affecting multiple residents, with discrepancies totaling $5,124.97. The former Administrator admitted to taking funds, and both the Administrator and Business Office Manager were implicated in payroll fraud. Despite the breach, some residents expressed no concerns about their funds being taken and replaced.
The facility failed to provide timely incontinence care and ensure the availability of shampoo/body wash for residents. Multiple residents reported delays in receiving assistance for toileting hygiene, leading to incontinence episodes. Staff interviews confirmed that staffing shortages contributed to these delays. Additionally, the facility lacked essential hygiene supplies, with observations revealing insufficient shampoo and body wash in storage areas and resident rooms.
A resident with severe cognitive deficits and a history of playful slapping was involved in an incident where he slapped the Activities Director, who then tapped him on the shoulder. The facility's investigation found the action inappropriate, despite no harm being intended. The resident's care plan acknowledges his behavior, but the facility's abuse prevention policy led to the determination of a deficiency in protecting the resident from physical abuse.
A resident reported missing money on two occasions, but the facility failed to report the allegation to the Administrator as required by policy. Despite the resident's cognitive intactness and reporting to staff, the Regional Director of Operations found no investigations related to the incident. The facility replaced part of the missing funds, but the lack of proper reporting constitutes a deficiency.
The facility failed to prevent pressure ulcers and maintain hand hygiene for three residents. One resident with severe cognitive deficits was left in a wheelchair for too long, leading to a non-blanching red area on the hip. Another resident with an unstageable pressure ulcer received treatment without proper hand hygiene by an LPN. A third resident was reportedly left in a wheelchair for up to 12 hours, causing exhaustion. The facility's policies on pressure ulcer prevention and hand hygiene were not followed.
Failure to Verify CNA Certification and Work History
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) was properly certified and eligible to work by verifying continuous employment on the Health Care Worker Registry. The staff roster showed that the CNA, identified as V11, was hired by the facility, and the registry check indicated work eligibility. However, the registry also stated that employers are responsible for verifying training, work history, and certifications. There was no documentation confirming V11's employment as a CNA after a certain date, and V11 herself reported a break in her CNA career to be a stay-at-home parent, during which she worked as a private sitter in a home setting, not as a CNA. V11 was unaware of any lapse in her certification. Interviews with facility staff, including the Administrator, Director of Nurses, and Medical Records/Office Assistant, revealed that none were aware of any certified staff working without proper certification. The Administrator and Medical Records/Office Assistant described their process for background and registry checks but could not confirm that V11's employment history as a CNA was verified prior to her hiring. An email from the Health Care Worker Registry indicated that V11's CNA certification had expired and that her work history was missing from the registry. The facility was unable to provide proof of V11's employment as a CNA during the period in question.
Resident Injured Due to Missing Safety Cap on Grab Bar
Penalty
Summary
The facility failed to provide an environment free of accident hazards, resulting in a resident acquiring a laceration on her left lower leg that required 12 sutures. The resident, who had been diagnosed with neurocognitive disorder with Lewy bodies, weakness, and unspecified diastolic heart failure, was dependent on assistance for mobility. During a transfer from her bed to a wheelchair, the resident's leg was injured by a sharp edge of a grab bar that was missing a safety cap. The resident's care plan had identified potential impairments to skin integrity and a risk for falls or injury due to various conditions, including weakness and unsteady gait. Despite these documented risks, the grab bar in the resident's room was not adequately maintained, leading to the injury. The incident occurred when two CNAs were transferring the resident, and the sharp edge of the grab bar caused two lacerations on her leg. The facility's investigation revealed that the grab bar was missing a black safety cap, which left a sharp area exposed. This environmental hazard was identified as a predisposing factor for the injury. The incident was reported, and the resident was sent to a local hospital for treatment, where the lacerations were sutured. The facility acknowledged the need for repair and maintenance of the grab bar to prevent such accidents in the future.
Inadequate Weekend Activities for Residents
Penalty
Summary
The facility failed to provide adequate activities for residents, particularly on weekends, as evidenced by interviews and record reviews. Four residents, all cognitively intact and alert, expressed dissatisfaction with the lack of activities during weekends. One resident specifically mentioned that sometimes they receive coloring sheets, but not consistently every weekend. During a resident council meeting, multiple residents confirmed the lack of weekend activities, despite the absence of documented complaints in the council minutes over the past year. The president of the resident council contradicted this, stating that complaints about the lack of activities are made every month. The interim Activities Director, who is also the Social Services staff, stated that CNAs are responsible for ensuring activities are offered on weekends. However, a CNA working on a recent weekend reported that there were no activity staff present and that she was not asked to conduct activities, nor did she have time to do so. The activities calendar for January 2025 listed several activities planned for the weekend, but these were not carried out, as residents were observed sitting in front of the TV instead. This indicates a disconnect between planned activities and their execution, leading to the deficiency in providing adequate resident engagement.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) coding for three residents, leading to discrepancies in their assessments. For one resident, the MDS inaccurately documented that the resident was not considered by the state Level II PASRR process to have a serious mental illness, despite the PASRR Level II documentation indicating otherwise. This resident had a history of serious mental illnesses, including bipolar disorder and schizophrenia, which were not accurately reflected in the MDS. Similarly, another resident's MDS incorrectly indicated no serious mental illness, despite PASRR Level II documentation confirming a diagnosis of bipolar disorder. The MDS Coordinator acknowledged these discrepancies during interviews. Additionally, a third resident's MDS inaccurately recorded that the resident received insulin injections, despite no physician order for insulin and the resident's statement of never having been diagnosed with diabetes or receiving insulin. The MDS Coordinator admitted to the error in the MDS entry. The facility's policy requires the Assessment Coordinator to ensure accurate resident assessments and submission to CMS' Quality Improvement and Evaluation System, which was not adhered to in these cases.
Failure to Complete Level II PASRR for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident diagnosed with a mental disorder. The resident, identified as R23, was admitted with diagnoses including unspecified dementia and bipolar disorder. The bipolar disorder diagnosis was added on 8/28/2024, and the resident's Annual Minimum Data Set (MDS) assessment on 11/18/2024 confirmed this diagnosis. Despite the presence of a psychiatric/mood disorder diagnosis and active medication orders for bipolar disorder, the facility did not provide evidence that the PASRR agency was contacted for a Level II screening. The Business Office Manager acknowledged the oversight, noting that the resident should have been referred for the screening. The facility's policy requires that new or changed behaviors indicating a serious mental disorder be referred for a PASRR Level II evaluation, which was not followed in this case.
Failure to Maintain Range of Motion for Resident
Penalty
Summary
The facility failed to maintain the range of motion for a resident, identified as R52, who was admitted with diagnoses including major depressive disorder, anxiety disorder, joint disorders, morbid obesity, and lumbar disc displacement. The resident's quarterly Minimum Data Set (MDS) indicated impairments in both lower extremities and a dependency on assistance for various self-care and mobility tasks. Despite these documented needs, the resident reported that no exercises or passive range of motion activities were conducted for her lower extremities, and she was not receiving any restorative nursing services for this purpose. The resident expressed that occupational therapy focused only on her upper extremities due to carpal tunnel syndrome, and she had not been engaged in any lower body exercises. Interviews with Certified Nurse Assistants (CNAs) revealed a lack of clarity regarding the responsibility for providing range of motion exercises, with CNAs assuming that restorative nursing handled these tasks. However, the Rehabilitation Director confirmed that the resident was not receiving restorative services for her lower extremities. Additionally, the resident's care plan lacked focus on limited range of motion or exercises to prevent decline, and there were no orders for restorative nursing. The facility's policy on resident mobility and range of motion emphasized the need for treatment and services to prevent avoidable decline, yet these were not implemented for the resident in question.
Failure to Ensure Resident is Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R52, was free from unnecessary psychotropic medications. R52 was admitted with diagnoses of major depressive disorder and anxiety disorder. The resident's medication regimen included Ativan, Buspirone, and Escitalopram, with the latter two medications having been started prior to admission. Despite a recommendation from a consultant pharmacist to assess the risk versus benefit and consider a dose reduction of these medications, the attending physician disagreed, citing the resident's stability. The resident expressed uncertainty about the necessity of Buspirone and noted that she had not been on anti-anxiety medication before admission. The facility's policy on psychotropic medication use and reduction emphasizes that such medications should only be used when necessary and effective for specific conditions. However, interviews with CNAs revealed that R52 did not regularly exhibit behaviors warranting the use of these medications. Additionally, the resident's care plan included non-pharmacological interventions, but there was no evidence of a gradual dose reduction or exploration of these alternatives. The lack of documented behaviors and the resident's own statements suggest that the facility did not adequately justify the continued use of psychotropic medications, leading to the deficiency.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to provide meals at a palatable temperature for residents who chose to eat in their rooms. Three residents, all of whom were cognitively intact, reported that their meals were often delivered cold. One resident mentioned that it sometimes took over 20 minutes for the nursing staff to distribute the trays after they were delivered to the hallway. Another resident expressed reluctance to ask staff to reheat her food, as she did not want to bother them. The issue of cold food was also raised in Resident Council meetings, with residents noting that meals were not warm when served in the hallways. The Dietary Manager was unaware of the ongoing issue, despite having previously informed the Resident Council that plate covers would be ordered to address the problem. However, these covers were never ordered, and the trays continued to be covered with foil, using open, non-insulated carts for delivery. The facility's policy on in-room dining specifies that hot foods should be served at 120 degrees Fahrenheit or greater to ensure palatability, but this standard was not consistently met. The Social Services representative confirmed that residents had decided to ask staff to reheat meals if they were too cold, indicating a lack of effective resolution to the problem.
Deficiencies in Resident Safety and Transfer Procedures
Penalty
Summary
The facility failed to ensure the safety of residents during transportation and transfers, resulting in serious injury. One resident, identified as R9, fell backwards out of a transport van onto the concrete, leading to fractures in her back. The incident occurred because the transportation aide did not engage the ramp to the van exit door before attempting to unload the resident. The aide assumed another staff member had raised the lift, which was not the case, leading to the resident being pushed out of the van and sustaining injuries. Additionally, the facility did not adhere to its policy of using two staff members for transfers involving a mechanical lift. Residents R3 and R4 reported instances where only one staff member was present during their transfers, which is against the facility's policy. This was corroborated by several CNAs who admitted to transferring residents alone due to staffing shortages. The Director of Nursing was unaware of this practice until it was brought to her attention, indicating a lack of oversight and communication within the facility. Furthermore, the facility failed to implement fall prevention interventions for resident R8, who had a history of falls and a fracture of the right femur. The care plan for R8 included the use of non-skid strips in front of the commode, but these were not in place at the time of observation. The Director of Nursing acknowledged that the strips were on a maintenance list but had not been installed, demonstrating a lapse in executing necessary safety measures to prevent falls.
Staffing Shortages Lead to Delayed Care and Improper Transfers
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its residents, affecting all 78 residents. One resident, with severe cognitive deficits and at risk for pressure ulcers, was observed sitting in a wheelchair for an extended period without being repositioned, leading to a non-blanching red area on the hip. The resident's care plan did not specify repositioning frequency, and staff were overwhelmed with duties, resulting in delayed care. Another resident, who is cognitively intact and dependent on staff for toileting, reported long wait times for call light responses, leading to incontinence episodes. The resident also experienced transfers with only one staff member using a mechanical lift, contrary to the care plan requiring two staff members. This was attributed to insufficient staffing levels. Additional residents reported similar issues, including delayed incontinence care and improper transfers due to staffing shortages. Staff interviews confirmed that having only one CNA per hall was insufficient to meet residents' needs timely, leading to unmet care requirements and increased wait times for assistance.
Inadequate Hot Water in Shower Rooms
Penalty
Summary
The facility failed to ensure that the shower rooms on the 200 and 500 halls had hot water, which has the potential to affect all residents residing on these halls. During the survey, the water temperatures in the shower rooms were found to be significantly below the required levels, with readings of 79.7 and 84.5 degrees Fahrenheit. The Maintenance Director acknowledged ongoing issues with maintaining adequate hot water temperatures, stating that the highest temperature achieved was 89 or 90 degrees Fahrenheit, and that the problem had persisted for about a month. Two residents, both cognitively intact and requiring assistance with showers, reported issues with the water temperature. One resident expressed that the water was sometimes warm enough but often reverted to being cold, necessitating showers on other halls, which was described as degrading. Staff members, including an LPN and a CNA, confirmed the inconsistency of hot water availability, particularly on the 500 hall. The facility's policy on water temperatures lacked specific temperature documentation, further complicating compliance with state regulations.
Misappropriation of Resident Funds
Penalty
Summary
The facility failed to protect residents from the misappropriation of funds, affecting 25 out of 26 residents reviewed for this issue. The incident came to light when a surveyor reported a complaint about the administration stealing money. An investigation revealed discrepancies in the resident trust fund accounts, with a total of $5,124.97 unaccounted for by receipts. The former Administrator and Business Office Manager were implicated, with the Administrator manually adding time to the Business Office Manager's payroll for days not worked. The Administrator admitted to taking funds due to personal need, which escalated over time. The facility's audit of the resident trust fund showed several residents had purchases listed without proper receipts. Despite the discrepancies, some residents expressed no concerns about their funds being taken and replaced. The facility's Abuse Prevention Policy emphasizes the residents' right to be free from misappropriation of property, yet the incident indicates a breach of this policy. The facility has since replaced the missing funds and notified all relevant parties, including the Medical Director, Local Police, and Ombudsman.
Deficiency in Timely Incontinence Care and Hygiene Supplies
Penalty
Summary
The facility failed to provide timely incontinence care and ensure the availability of shampoo/body wash for residents, as evidenced by multiple resident and staff interviews. Residents reported significant delays in receiving assistance for toileting hygiene, leading to incontinence episodes. For instance, one resident stated it could take up to thirty minutes for staff to respond to call lights, resulting in incontinence. Another resident reported waiting for two hours without assistance, during which time they experienced incontinence. Staff interviews corroborated these accounts, with several CNAs acknowledging that staffing shortages led to delays in providing necessary care. The facility's care plans for residents with self-care performance deficits did not adequately address their bowel and bladder care needs. For example, one resident's care plan included interventions for mechanical lift transfers but did not address toileting care. Another resident's care plan mentioned checking for incontinence every two hours and answering call lights promptly, yet the resident reported frequent delays in receiving assistance. Staff members confirmed that when only one CNA was assigned per hall, it was challenging to meet residents' needs in a timely manner, particularly for incontinence care. Additionally, the facility was found to be lacking in essential hygiene supplies, such as shampoo and body wash. Observations revealed that several storage areas and resident rooms were devoid of these supplies, with only a few bottles available in certain areas. Staff and family members had resorted to purchasing these items themselves. The Director of Nursing acknowledged the insufficiency of supplies, noting that two bottles would not suffice for the number of residents in the facility.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse, as evidenced by an incident involving a resident and a staff member. The incident occurred when a Certified Nursing Assistant (CNA) reported witnessing an unwanted contact between a resident and the Activities Director. The resident, who has severe cognitive deficits and a history of playful slapping, reportedly slapped the Activities Director on the bottom. In response, the Activities Director tapped the resident on the shoulder. The facility's investigation revealed that the Activities Director did not intend to harm the resident, but the action was still considered inappropriate. The incident was reported to the Director of Nursing, who initiated an investigation and removed the Activities Director from contact with residents. The resident involved in the incident has a complex medical history, including severe intellectual disability, autism, and impulse disorder, and is non-verbal with the mentality of a three-year-old. The resident's care plan acknowledges his tendency to playfully slap staff members and includes interventions to manage this behavior. Despite the resident's lack of injury and the playful nature of his actions, the facility's policy on abuse prevention emphasizes the right of residents to be free from abuse, leading to the determination that the incident constituted a deficiency in protecting the resident from physical abuse.
Failure to Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident funds to the Administrator, as required by their Abuse Prevention Policy and Procedures. A resident, identified as R4, reported missing money from his wallet on two separate occasions. Despite R4's report to a Licensed Practical Nurse (LPN), who claimed to have informed the Director of Nursing (DON), the Regional Director of Operations stated there were no investigations related to the missing money. The facility's policy mandates that employees report any suspicion of misappropriation to the administrator, which did not occur in this instance. R4, who is cognitively intact with a Brief Interview for Mental Status score of 15, reported the missing money to two staff members but could not recall their names. The facility's initial report, prompted by a state surveyor's inquiry, documented the incident and subsequent investigation, which included notifying local authorities and reviewing facility video footage. However, the investigation did not determine the whereabouts of the missing funds. The facility replaced $100 of the reported missing amount, but the failure to report the incident to the Administrator as per policy constitutes a deficiency.
Failure to Prevent Pressure Ulcers and Maintain Hand Hygiene
Penalty
Summary
The facility failed to implement necessary interventions to prevent pressure ulcers and did not adhere to hand hygiene standards during treatment administration for three residents. One resident, with severe cognitive deficits and at risk for pressure ulcers, was observed with a non-blanching red area on the right hip after being left in a wheelchair for an extended period without repositioning. The care plan did not specify repositioning frequency, and staff were unclear about their responsibilities, leading to inadequate care. Another resident, who was cognitively intact and had an unstageable pressure ulcer, received treatment from an LPN who did not perform hand hygiene between glove changes. The LPN admitted to skipping hand hygiene due to nervousness, which is against the facility's hand hygiene policy. This lapse in protocol could potentially contribute to infection risks. A third resident, with severe cognitive deficits and requiring substantial assistance, was reportedly left in a wheelchair for up to 12 hours, causing exhaustion. The care plan lacked specific interventions for repositioning, and there was a communication breakdown among staff regarding the resident's care needs. The facility's policies on pressure ulcer prevention and hand hygiene were not followed, contributing to these deficiencies.
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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