Odd Fellow-rebekah Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Mattoon, Illinois.
- Location
- 201 Lafayette Avenue East, Mattoon, Illinois 61938
- CMS Provider Number
- 145772
- Inspections on file
- 44
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Odd Fellow-rebekah Home during CMS and state inspections, most recent first.
The facility failed to prevent resident-to-resident physical abuse when one resident with a history of verbal aggression and another resident with documented physical and behavioral issues were involved in an altercation near the nurse station. A CNA reported seeing one resident push the other, causing a fall to the floor, after which the injured resident was sent to the hospital and returned with a soft cast and later a wrist brace for a shattered and displaced distal radius fracture. The LPN on duty was notified of the incident, found the resident on the floor, and reported that the injured resident may have provoked the other resident, while both residents’ care plans already documented significant behavioral concerns.
A resident with dementia, high fall risk, and care-planned interventions requiring the bed to be kept in the lowest position was assisted by a CNA who raised the bed and then turned away while the resident was on the bed. With the bed elevated about two feet from the floor and without continuous supervision, the resident slid off, landed on the floor, and struck the head, resulting in soft tissue swelling and a 2-cm laceration above the eyebrow that required ER treatment and wound closure. Staff interviews confirmed the bed was not in the low position and that the resident was known to attempt to scoot off the bed.
The facility failed to report an allegation of resident-to-resident abuse to the state as required by its abuse prohibition policy. The policy directs that alleged abuse, including incidents resulting in serious bodily injury, be immediately reported to the Administrator and then to the state within a specified timeframe. In this case, a resident was allegedly pushed by another resident during a physical altercation, causing a fall, an ER evaluation, and a wrist fracture requiring a soft cast. An LPN reported the incident to the Administrator, but the Administrator acknowledged that the incident was not reported to the State Agency despite the requirement to report all abuse allegations.
The facility failed to investigate an allegation of resident-to-resident physical abuse after a resident was reportedly pushed by another resident, resulting in a fall, emergency room visit, and a right-hand fracture requiring a soft cast. Facility policy requires the Administrator or designee to investigate all alleged abuse after reporting to IDPH, and documentation shows that an LPN notified the Administrator of the incident on the day it occurred. Despite this notification and the documented injury, the Administrator later acknowledged that no investigation was conducted into the alleged abuse involving the two residents.
The facility failed to provide adequate urinary incontinence care and maintain cleanliness for multiple residents on one hall, as evidenced by a persistent, moderately offensive urine odor in the hallway and in several resident rooms, some of which contained hand-held urinals. A cognitively intact resident reported that staff changed her incontinence brief without cleansing her, leaving her smelling of urine despite a care plan requiring assistance with toileting hygiene and use of barrier cream. An RN stated that agency staff sometimes changed residents’ incontinence briefs but left bed pads soaked with urine, allowing odor to permeate from rooms into the hallway.
Two cognitively impaired roommates were found lying in bed without access to their nurse call lights, which were observed coiled on the floor behind a room divider curtain and out of reach. One resident was nonverbal at the time of observation, while the other stated she would use the call light to get staff attention but did not know where it was and thought it might be across the room. Documentation showed both residents were severely cognitively impaired, and a Restorative RN believed one resident would not be able to use a call light, contrary to the resident’s own statement that she would use it if it were within reach.
A resident with severe cognitive impairment and extensive ADL needs was observed multiple times seated in a wheelchair with a cloth lap belt tied behind the chair that the resident could not self-release. Documentation, including the care plan, prior orders, and device evaluation, referenced only a self-release belt, while the EMR lacked a physician order and assessment for the non-self-releasing belt in use. The resident’s regular RN and the DON reported that the belt type had been changed from a self-releasing to a non-self-releasing style due to frequent falls, and confirmed the resident was unable to release the new belt and that no corresponding physician order or restraint assessment had been completed, contrary to facility policy.
A resident with atrial fibrillation, CHF, peripheral vascular disease, and a chronic right foot ulcer had an arterial wound on the right second toe requiring ordered wound care with cleansing and application of hydrogel and dressings. During an observed dressing change, an LPN removed scissors from a scrub pocket, did not disinfect them, used them to cut dressings, and then placed the cut dressing directly on the open toe wound, which had yellow drainage and a red, swollen periwound. The resident reported poor circulation and an existing infection in the toe, and the LPN later acknowledged cross contamination, contrary to facility policy requiring disinfection of scissors before and after dressing changes.
A resident with severe cognitive impairment, multiple medical conditions, and a high risk for pressure ulcers had a Stage 4 sacral pressure ulcer requiring ordered wound care with wound wash, collagen powder, and gauze soaked in quarter-strength bleach solution. During a bedside dressing change, an LPN and a CNA allowed the privacy curtain to contact the open bleach solution bottle, bedside table, and dressing supplies, and the LPN used scissors taken from a scrub pocket without disinfecting them before cutting the dressings. The LPN then applied the contaminated dressing directly to the resident’s sacral wound, contrary to facility policy requiring disinfection of scissors before and after dressing changes.
A resident with chronic right foot ulcer and peripheral vascular disease, care-planned for Enhanced Barrier Precautions (EBP) due to wounds, had an EBP sign on the door and a PPE cart outside the room. An LPN performed wound care on the resident’s open, draining right second toe wound with red, swollen periwound but did not wear an isolation gown, despite facility policy requiring gown and gloves for high-contact care such as wound care. The resident reported that staff usually did not wear gowns during wound care and stated that both gown and gloves should be used. In interview, the LPN acknowledged knowing the resident was on EBP and on antibiotics for toe wounds and admitted she should have worn a gown, contrary to the facility’s EBP protocol.
Two residents were involved in a physical altercation where one resident, with bilateral lower limb prosthetics, was kicked by another and retaliated by kicking back using her prostheses. The incident was reported by a CNA to an LPN, and the resident who was kicked sustained bruising. The DON confirmed the incident was reported, and the facility failed to prevent this abuse as required by policy.
A resident with a history of past abuse and multiple medical conditions did not have a trauma-centered care plan or documented interventions for verbally aggressive behaviors, despite staff awareness of these issues. The DON confirmed the absence of a person-centered care plan addressing the resident's trauma and behavioral needs.
A resident with a non-pressure abdominal wound did not receive daily wound care as ordered by the physician. On review, the wound was found uncovered and the treatment administration record showed the wound care was not completed or documented on a specific date. The DON confirmed the treatment was missed and the responsible LPN did not perform the required care.
A resident with a left heel pressure ulcer did not receive physician-ordered daily dressing changes or heel floating as required. Observations revealed an outdated dressing and no pillow to float the heels, while documentation showed missed treatments on several dates. The DON confirmed that these orders were current and not followed.
The facility failed to administer medications as ordered and in a timely manner for four residents. Residents reported receiving medications at inconsistent times, with MARs showing multiple instances of late administration. There was no documentation of physician notification for these discrepancies. Staff interviews revealed that medications were often administered late due to workload, and there was a discrepancy in understanding the acceptable time window for medication administration.
The facility failed to maintain a clean and homelike environment in the shower room, affecting 49 residents. Observations revealed a black substance on the tile walls and missing floor tiles, confirmed by staff and residents. A resident reported a mildew smell, and a CNA noted that the shower chair gets stuck in the missing tiles. The Maintenance and Housekeeping Supervisors acknowledged the issues, with plans to remodel the bathroom in the winter.
A resident experienced significant weight loss due to the facility's failure to implement nutritional supplements recommended by the dietician and notify the physician of continued weight loss. Despite being at risk for altered nutrition, the resident's care plan was not followed, leading to a deficiency in maintaining the resident's nutritional status.
A resident with a complex medical history missed multiple doses of critical medications due to pharmacy and insurance issues, leading to significant medication errors. The facility failed to document or communicate these errors, resulting in the resident experiencing gastrointestinal upset and hospitalization. The DON was unaware of the missed doses until an investigation was conducted.
The facility failed to implement appropriate fall prevention and response measures for two residents, one of whom was on anticoagulant therapy and sustained a fatal head injury. The facility did not develop or implement necessary interventions, conduct thorough investigations, or complete fall risk assessments. Additionally, the 15-minute monitoring system was not effectively documented or executed, compromising resident safety.
The facility failed to provide follow-up care for residents with behavioral issues despite non-pharmacological interventions and did not refer a resident who made a suicidal statement to behavioral health services. Four residents with dementia did not receive documented follow-up care after interventions failed, and a resident expressing self-harm was not referred to behavioral health services, despite being placed on suicide watch.
A CNA was given unauthorized access to the medication room keys by an LPN, contrary to facility policy, which states that only licensed personnel should have access. The LPN handed the keys to the CNA to retrieve ice packs, but quickly followed to supervise. The Director of Nursing confirmed this was against policy, which restricts key access to licensed staff.
The facility failed to follow infection control protocols, affecting four residents on contact and enhanced barrier precautions. Staff did not wear appropriate PPE during care activities, improperly disposed of contaminated PPE, and neglected hand hygiene between glove changes, leading to potential cross-contamination.
A facility failed to complete a recapitulation of stay for a resident at the time of discharge. The facility's policy requires a discharge summary to be completed and signed by the physician within 30 days of discharge. However, the resident's electronic medical record lacked this documentation. The DON confirmed that the necessary discharge summary was not completed for the resident, who was moderately cognitively impaired.
A resident with specific medical conditions requiring compression stockings was found wearing non-skid socks instead, leading to increased swelling. The resident expressed frustration over the recurring issue, and an LPN confirmed the oversight, acknowledging that CNAs were responsible for applying the stockings in the morning.
The facility failed to properly assess and monitor pressure ulcers for three residents, leading to deficiencies in care. A resident at risk for pressure ulcers lacked a pressure relief cushion in her chair, despite her care plan indicating its necessity. Another resident with severe cognitive impairment had no documented treatment plan for existing pressure ulcers, and was not provided with heel protectors. A third resident had pressure ulcers on both buttocks, but the care plan lacked documentation and interventions, and treatment was not consistently completed.
The facility failed to follow care plan interventions and label enteral feeding bottles for two residents with G-tubes. Both residents were observed with their heads of bed flat during feeding, contrary to care plan instructions. Feeding bottles were not labeled with necessary information, leading to discrepancies in feeding schedules. An LPN and the DON acknowledged these deficiencies.
A resident with multiple medical conditions did not receive prescribed medications, resulting in a 7.69% medication error rate. The medications, Dapagliflozin Propanediol (Farxiga) and Lansoprazole Suspension, were unavailable due to pharmacy and insurance issues. The LPN confirmed the absence of these medications, and the DON acknowledged the expectation for medications to be available at all times.
A resident with multiple medical conditions, including vascular dementia and anticoagulant use, experienced a fall with a head injury. The facility failed to notify the physician until the following day, despite the resident's high fall risk and subsequent diagnosis of a closed head injury after a second fall. The facility lacked a specific policy for timely physician notification after such incidents.
Two residents were left exposed during incontinence care due to staff failing to ensure privacy. One resident was exposed to a roommate, while another was exposed when staff entered the room without proper privacy measures. These incidents violated the facility's policy on resident dignity and privacy.
Two residents in a facility, both dependent on staff for personal care, were observed with inadequate grooming and hygiene. One resident, with multiple medical conditions, had overgrown facial hair with food debris and expressed a desire to be clean-shaven, which was not addressed. Another resident with Alzheimer's was seen with food debris and phlegm on his clothing, indicating a lack of assistance during meals. The facility lacks a formal ADL policy, and the Director of Nursing acknowledged the need for better attention to residents' personal hygiene.
A resident with multiple medical conditions, including urinary incontinence, did not receive timely incontinence care, resulting in a Stage II pressure ulcer. Observations showed the resident was left without care for nearly an hour, and staff admitted to not providing care since the start of their shift. The facility's policy lacked specific timeframes for incontinence care, contributing to the deficiency.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Wrist Fracture
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, resulting in one resident sustaining a fractured right wrist. One resident had a care plan dated 8/14/25 indicating verbal behaviors such as yelling and threatening others, and another resident had a care plan dated 4/15/24 documenting impaired moods/behaviors with physical behaviors including hitting others, swinging a purse at others, throwing things, attempting to break windows, and flashing others. On the night of 12/27/25, while an LPN was passing medications, a CNA informed her that one resident was on the floor after being pushed by another resident. The LPN found the resident on the floor near the nurse station close to the fireplace, attempted to assess her, and the resident refused assessment and demanded to be sent to the hospital. The LPN reported that the resident who fell may have provoked the other resident, which may have led to the pushing. The CNA later stated she was present when the incident occurred but did not see how it started; when she turned around, she saw one resident push the other, causing a fall to the ground. She reported that staff separated the residents and notified the nurse, and she wrote a statement about the incident. The resident who fell was sent to the emergency room for evaluation and returned the next day with a soft cast to the right hand. An X-ray dated 12/28/25 documented a shattered and displaced distal radius fracture. During a later observation, the injured resident was seen sitting in a common area with a platform walker and a wrist brace, and stated that her hand was broken because she interfered in a fight and was pushed, though she could not identify who pushed her. These events occurred despite prior documentation of both residents’ behavioral issues in their care plans.
Failure to Maintain Low Bed and Supervision Leads to Fall With Injury
Penalty
Summary
Failure to maintain a resident’s bed in the lowest position and to provide adequate supervision resulted in a fall with injury. The facility’s fall policy requires assessment of fall risk and individualized, person-centered care planning, with all staff having access to the care plan and Kardex to ensure consistent implementation of fall prevention strategies. The resident involved had unspecified dementia with agitation and required substantial/maximal assistance for bed mobility. A fall risk assessment identified the resident as high risk for falls, and the care plan documented that the bed was to be maintained in the lowest position due to unsteady gait, poor balance, and generalized weakness. Despite this, on the day of the incident the CNA raised the bed from its lowest position while preparing the resident for the day. According to staff interviews and the incident report, the CNA assisted the resident to a sitting position on the edge of the bed, then laid the resident back down and turned away to retrieve clothing or a mechanical lift device while the bed remained elevated approximately two feet from the floor. During this time, the resident slid off the bed, landing on her buttocks and then falling forward, striking her head on the floor. The LPN who responded confirmed that the bed was not in the low position when she entered the room and noted that the resident was known to attempt to scoot off the bed and could be combative during transfers. The DON acknowledged that if the care plan required a low bed, the CNA should have maintained the bed in the lowest position and should not have turned away from the resident while the bed was not in a low position. The resident was treated in the emergency room for soft tissue swelling around the left eye and a 2-centimeter laceration above the left eyebrow, which was closed with adhesive glue.
Failure to Report Resident-to-Resident Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report to the state an allegation of resident-to-resident abuse involving two residents. The facility’s abuse prohibition policy, revised 1/29/2026, requires that any incident involving alleged abuse be immediately reported to the Administrator, and that the Administrator provide the Illinois Department of Public Health with initial notice of the alleged abuse via the OHCR Portal, email, or fax, with alleged violations of abuse or those resulting in serious bodily injury to be reported immediately but no later than two hours after the allegation is made. R4’s health status note dated 12/27/25 documents that R4 allegedly had a physical altercation with another resident that resulted in R4 falling to the ground and being sent to the emergency room for evaluation. An event note dated 12/28/25 in R4’s EMR documents that R4 was pushed by another resident, and progress notes from the same date show that R4 returned to the facility with a soft cast to the right hand due to a wrist fracture following the incident. A health status note dated 12/28/25 documents that V4, an LPN, notified V1, the Administrator, about the incident. During an interview on 2/19/26, V4 stated she called the Administrator and reported the incident, and on 2/20/25 at 3:00 p.m., the Administrator stated he did not notify the State Agency about the incident involving R4 and R6, acknowledging that he should report all allegations of abuse incidents.
Failure to Investigate Alleged Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to investigate allegations of resident-to-resident physical abuse involving two residents after an incident in which one resident was allegedly pushed by another, causing a fall and injury. The facility’s abuse prohibition policy, revised 1/29/2026, requires the Administrator or designee to investigate all alleged incidents of abuse after an initial report of suspected abuse or neglect is sent to IDPH. A health status note dated 12/2/25 documents that one resident had a physical altercation with another resident that resulted in a fall and required transfer to the emergency room. A progress note dated 12/28/25 shows that the resident returned with a soft cast to the right hand due to a fracture following the incident, and an event note from the same date documents that the resident was pushed by another resident. A health status note dated 12/28/25 further documents that an LPN notified the Administrator about the incident between the two residents, and the LPN stated she called the Administrator on the day it occurred. On 2/20/26 at 3:00 p.m., the Administrator stated he did not investigate the incident, despite acknowledging that he should investigate all alleged abuse reported to him. These findings show that, although the incident, injury, and alleged abuse were documented and reported to the Administrator as required by facility policy, no investigation was conducted into the alleged resident-to-resident physical abuse involving the two residents.
Failure to Provide Adequate Incontinence Care and Maintain Resident Cleanliness
Penalty
Summary
The facility failed to provide appropriate urinary incontinence care and maintain resident cleanliness for multiple residents on the [NAME] Hall. During observations conducted over several days, surveyors noted a consistent, distinct, and moderately offensive urine odor in the [NAME] Hallway, with the odor more pronounced in the rooms of several identified residents. Some of these rooms contained hand-held plastic urinals. The urine odor persisted on subsequent observation days and was again noted in the hallway and around specific resident rooms. One cognitively intact resident reported that staff did not wipe her clean when changing her incontinence undergarments, stating that staff removed the wet brief and applied a dry one without cleansing her, which resulted in her smelling like urine and put her at risk for skin breakdown. Her care plan documented that she was at risk for skin impairment, required staff assistance for toileting hygiene, and needed barrier skin protection cream after incontinence episodes. A registered nurse reported that agency staff had been changing residents’ incontinence undergarments but leaving absorbent pads on the bed soaking wet, which contributed to urine odor permeating from resident rooms into the hallways.
Call Lights Not Kept Within Reach of Cognitively Impaired Roommates
Penalty
Summary
Surveyors identified a deficiency in honoring residents’ rights to be treated with respect and dignity and to retain and use personal possessions when two cognitively impaired roommates were found without access to their nurse call lights. On 11/19/25 at 1:20 PM, both residents were observed lying in their beds with each nurse call light activation device coiled on the floor between the bed and wall behind the room divider curtain, out of reach. One resident only opened her eyes and stared when greeted and made no verbal response, while the other stated she would use the call light if she needed staff attention but did not know where it was and believed it might be across the room by the dresser. Record review showed both residents had Brief Interview for Mental Status and Narrative Summary Scores indicating they were severely cognitively impaired. A Restorative RN later stated that one resident likely had the physical ability but not the cognitive ability to use a call light, and believed the other resident would not be able to use a call light, expressing surprise when informed of the resident’s statement about using it if available.
Failure to Obtain Physician Order and Assessment for Non-Self-Releasing Restraint
Penalty
Summary
The deficiency involves the facility’s failure to obtain a physician order and complete an assessment for the use of a non-self-releasing physical restraint on a resident with severe cognitive impairment. The resident’s MDS documented severe cognitive impairment and dependence or significant assistance needs for toileting, bed mobility, transfers, bathing, dressing, and personal hygiene. The care plan and related documentation, including a physician order sheet and physical device evaluation, specified the use of a self-release belt when the resident was up in a wheelchair, to be released during rounds, ADLs, meals, supervised activities, and as needed. A restraint consent documented verbal consent for a soft belt restraint, but the EMR did not contain a physician order or assessment specifically for a non-self-releasing seat belt. Surveyor observations on multiple days showed the resident seated in a wheelchair on a pommel cushion with a cloth lap belt whose long straps were tied to the bottom of the back of the wheelchair, and the belt was not self-releasing. When asked to remove the belt, the resident was unable to do so and expressed dislike for it. The resident’s regular RN reported that the resident previously used a front-latch belt that could be self-released, but the facility changed to a soft belt the resident could not remove due to frequent falls. The DON confirmed that the resident had multiple falls, that the resident and family agreed to use a non-self-releasing belt, that the change to this belt occurred months earlier, and that the resident could not release it. The DON also confirmed there was no physician order or assessment in place for this non-self-releasing physical restraint, despite facility policy requiring assessment of alternatives, physician and POA notification, consent, and ongoing review before and during restraint use.
Failure to Disinfect Scissors Resulting in Cross Contamination During Wound Care
Penalty
Summary
The deficiency involves a failure to prevent cross contamination during wound care for one resident with a right second toe arterial wound. The resident’s EMR lists diagnoses including atrial fibrillation, chronic heart failure, non-pressure chronic ulcer of the right foot, and peripheral vascular disease, and the MDS documents the resident as cognitively intact and needing assistance with mobility and ADLs. A physician order directed staff to cleanse the right second toe with wound wash without scrubbing or using excessive force, then apply hydrogel to the wound bed, followed by an absorbent dressing, absorbent pad, stretch gauze, and tape. During observed wound care, an LPN set up wound supplies on the resident’s table, then removed scissors from her scrub top pocket and used them to cut the dressings to size without disinfecting the scissors before use. The LPN then placed the cut dressing directly over the resident’s right second toe wound, which had an open area with a moderate amount of yellow drainage, three yellow areas in the middle of the wound, and a red, swollen periwound. The resident reported poor circulation in the right lower leg and stated there was an infection in the right second toe wound. The LPN later confirmed she had cross contaminated the wound by using contaminated scissors, and the facility’s infection preventionist stated that scissors stored in scrub pockets should be disinfected before wound care, consistent with the facility’s aseptic dressing change policy requiring disinfection of scissors prior to and after use.
Cross Contamination During Stage 4 Pressure Ulcer Dressing Change
Penalty
Summary
Failure to prevent cross contamination during pressure ulcer care occurred during treatment of a resident with a Stage 4 sacral pressure ulcer. The resident was documented on the MDS as severely cognitively impaired and dependent on staff for oral hygiene, bathing, dressing, toileting, personal hygiene, bed mobility, and transfers. The EMR listed medical diagnoses including muscle wasting and atrophy, wedge compression fracture of the second lumbar vertebra, macular degeneration, sacral pressure ulcer, and abnormalities of gait and mobility. The resident’s pressure ulcer risk assessment identified the resident as high risk for pressure ulcers, and the wound evaluation summary documented a Stage 4 sacral pressure ulcer on the sacrum that was an open ulceration cluster with moderate serous drainage and noted as “Not at Goal.” Physician orders directed cleansing the sacral area with wound wash, applying collagen powder, packing the wound with gauze soaked in quarter-strength bleach solution, and covering with an absorbent pad secured with retention tape. During observed wound care, an LPN/wound nurse and a CNA completed dressing care at the bedside. While the LPN prepared the wound dressings on the bedside table, the table was pushed into the resident’s privacy curtain, causing the curtain to directly touch the open top of the bleach solution bottle, the entire length and part of the sides of the bedside table, and the dressing supplies. The LPN did not disinfect her scissors after removing them from her scrub top pocket and before cutting the dressings, despite facility policy requiring scissors used for dressing changes to be disinfected prior to and after use. The LPN then placed the contaminated dressing directly on the resident’s Stage 4 sacral pressure ulcer, which was described as having a dark red center, white edges, dark red periwound, and moderate serous drainage. The LPN later confirmed she had cross contaminated the wound supplies by allowing the privacy curtain to touch them and by not disinfecting the scissors after they had been returned to her pocket.
Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves staff failure to follow the facility’s Enhanced Barrier Precautions (EBP) protocol and CDC-based guidelines for use of personal protective equipment (PPE) during wound care. A cognitively intact resident with medical diagnoses including atrial fibrillation, chronic heart failure, a non-pressure chronic ulcer of the right foot, and peripheral vascular disease had a physician’s order for specific wound care to the right second toe. The resident’s care plan documented a requirement for EBP due to wounds, and a sign indicating EBP was posted on the resident’s door, with a PPE cart located outside the room. During observation, an LPN performed wound care on the resident’s right second toe, which had an open area with a moderate amount of yellow drainage and three yellow areas in the middle of the wound with a red and swollen periwound, but did not wear an isolation gown while providing this care. The resident reported having poor circulation in the right lower leg and stated that nurses did not usually wear a gown when providing wound care, further stating that staff should absolutely wear both gown and gloves when caring for the arterial wound on the right second toe. In a subsequent interview, the LPN acknowledged awareness that the resident was on EBP and on antibiotics for toe wounds requiring isolation precautions, and admitted she should have worn an isolation gown to help prevent the spread of bacteria. The facility’s Enhanced Barrier Precautions Protocol, revised April 8, 2024, specifies that PPE consisting of gloves and gown should be used during high-contact resident care activities such as wound care, which was not followed in this instance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, as required by its Abuse Prevention and Reporting policy. One resident with a history of muscle weakness, diabetes, neuropathy, and bilateral lower limb amputations with prosthetics reported being kicked by another resident in the hallway. In response, the first resident retaliated by kicking the other resident back using her prosthetic limbs. The incident was documented in the care plans and nurse progress notes, with both residents confirming the altercation. The resident who retaliated stated a personal history of past abuse and expressed a determination to defend herself against any perceived aggression. A Licensed Practical Nurse (LPN) confirmed that a Certified Nurse Aide reported the incident, and the resident who was kicked in the legs was found to have bruising on her bilateral lower extremities. The Director of Nursing (DON) verified that the facility submitted a final incident report detailing the sequence of events, including the use of prosthetics in the altercation. The facility's failure to prevent this physical altercation between residents constitutes a deficiency in protecting residents from abuse as outlined in their policy.
Failure to Develop Trauma-Centered Care Plan for Resident with Abuse History
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing trauma and abuse for a resident with a history of being verbally and physically abused by a former spouse. Despite the facility's policy requiring care plans to address medical, physical, mental, and psychosocial needs, and to be reviewed and revised by the interdisciplinary team after each assessment, the resident's care plan did not include trauma-centered interventions or address behaviors such as verbal aggression and yelling at others. The resident, who has multiple diagnoses including muscle weakness, diabetes with neuropathy, atrial fibrillation, chronic kidney disease, and bilateral below-knee amputations, reported being abused in the past and described recent incidents of physical altercations with another resident. Interviews with facility staff confirmed that the resident had discussed past abuse and exhibited verbally aggressive behaviors, but no trauma-centered care plan or behavioral interventions were documented in the medical record. The Director of Nursing acknowledged the absence of a person-centered care plan and specific interventions for the resident's behaviors, confirming that the deficiency was present at the time of the survey.
Failure to Provide Physician-Ordered Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to provide physician-ordered treatment and services for a non-pressure abdominal wound for one resident. The resident developed an open area on the left lower abdomen, which was documented and assessed by nursing staff. The physician ordered daily wound care treatment, including cleansing with wound wash or normal saline, application of Xeroform dressing, and coverage with border foam, to be performed every day shift until healed. However, on a subsequent observation, the resident's wound was found to be open, partially scabbed, and without any dressing present, contrary to the physician's orders. Record review revealed that the treatment administration record for the resident showed no documentation or nurse initials indicating that the wound care was completed on a specific date. The Director of Nursing confirmed that the treatment was a current order and should have been completed and documented. The nurse responsible for wound treatments did not perform the required care on the specified date, resulting in a failure to follow the physician's orders for wound management.
Failure to Provide Ordered Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide physician-ordered treatments and services necessary for the healing of a pressure ulcer for one resident. The resident had a physician order for daily cleansing and dressing changes to a left heel pressure ulcer, as well as an order to float the heels on a pillow at all times. On observation, the dressing on the resident's left heel was found to be dated two days prior, and there was no pillow present to float the heels. Review of the Treatment Administration Record showed that the dressing change was not completed or documented on multiple dates, and the order to float the heels was not followed. The Director of Nursing confirmed that these orders were current and should have been carried out and documented.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications as ordered by the prescriber and in a timely manner for four residents. Resident 1 reported receiving medications at inconsistent times, including being woken up in the middle of the night for medications not scheduled for that time. The Medication Administration Record (MAR) for Resident 1 showed multiple instances of late administration, with no documentation that the physician was notified of these discrepancies. Resident 2 also experienced irregular medication administration times, as confirmed by their MAR, which documented several instances of late medication administration. Despite the resident's care plan indicating a risk for hypothyroidism and cardiac arrhythmias, there was no record of physician notification regarding the late doses. Similarly, Resident 3's MAR showed late administration of medications, with no documentation of physician notification, despite the resident's care plan highlighting risks for gastrointestinal distress and other conditions. Resident 4's MAR documented late administration of medications, including a significant delay in administering Aspercreme. The care plan for Resident 4 noted risks related to altered skin integrity and other health issues, yet there was no documentation of physician notification for the late doses. Interviews with facility staff revealed that medications were often administered late due to workload, and there was a discrepancy between staff understanding of the acceptable time window for medication administration and the facility's policy.
Deficiency in Shower Room Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the [NAME] shower room, affecting 49 residents. Observations revealed a black substance on the tile walls and missing floor tiles, which were confirmed by both staff and residents. A resident reported a mildew smell and the presence of a black substance between the tiles. A Certified Nursing Assistant corroborated the resident's observations, noting that the shower chair gets stuck in the missing floor tiles, making the environment unpleasant. The Maintenance Supervisor acknowledged awareness of the issues, stating that the black substance could not be cleaned off the walls and that several floor tiles were missing. The Housekeeping Supervisor confirmed that the black substance was resistant to cleaning efforts, despite daily cleaning and spraying between showers. The facility has plans to remodel the bathroom in the winter, but no immediate corrective actions were mentioned in the report.
Failure to Implement Nutritional Supplements and Notify Physician
Penalty
Summary
The facility failed to maintain a resident's nutritional status and prevent significant weight loss by not implementing nutritional supplements recommended by the dietician and failing to notify the physician and dietician when significant weight loss continued. This deficiency affected a resident diagnosed with Protein Calorie Malnutrition and Muscle Wasting and Atrophy. The resident was prescribed a regular diet with thin liquids and was identified as being at risk for altered nutrition. Despite these risks, the facility did not follow through with the dietician's recommendation for nutritional supplements, leading to continued weight loss. The resident's weight management was not adequately monitored, as evidenced by a significant weight loss from 130.6 pounds upon admission to 120.1 pounds within a short period. The dietician had assessed the resident and recommended a liquid nutritional supplement to prevent further weight loss, but this recommendation was not implemented, nor was the physician notified of the ongoing weight loss. The Director of Nurses confirmed that the facility should have acted on the dietician's recommendations and closely monitored the resident's weight, but these actions were not taken, resulting in a significant deficiency in the resident's care.
Medication Errors Lead to Resident Hospitalization
Penalty
Summary
The facility failed to administer physician-prescribed medications to a resident, identified as R321, resulting in significant medication errors. R321, who has a complex medical history including Diabetes Mellitus Type II and Gastroesophageal Reflux Disease (GERD), missed multiple doses of critical medications, namely Dapagliflozin (Farxiga) for blood glucose control and Lansoprazole for GERD. The Medication Administration Record (MAR) indicated that Farxiga was not administered on several occasions, and Lansoprazole was not given on multiple days due to issues with insurance authorization and pharmacy reordering. The deficiency was further compounded by the lack of proper documentation and communication. Nurses signed off on the administration of medications that were not actually given, and there was no documentation explaining the missed doses or notification to the physician. The Director of Nurses (DON) was unaware of the missed doses until informed by the investigation, highlighting a breakdown in the facility's medication administration and reporting processes. As a result of these medication errors, R321 experienced gastrointestinal upset and malaise, leading to hospitalization. The facility's failure to administer the prescribed medications contributed to the resident's hospitalization, as confirmed by the physician and pharmacist involved. The report underscores the critical nature of medication management and the need for accurate documentation and communication within the facility.
Failure to Implement Fall Prevention and Response Measures
Penalty
Summary
The facility failed to develop and implement appropriate post-fall interventions and treatment for a resident on anticoagulant therapy, identified as R171, who sustained a head injury. Despite being severely cognitively impaired and at high risk for falls, R171 did not receive the necessary restorative ambulation program or adequate supervision. The resident experienced multiple falls, including one that resulted in a subdural hematoma, leading to their death. The facility's lack of documentation and failure to notify the physician after the initial fall on 9/15/24 contributed to the inadequate response to the resident's condition. Additionally, the facility did not conduct thorough investigations or complete fall risk assessments for another resident, R67, who experienced multiple unwitnessed falls. The Director of Nursing (DON) admitted to not interviewing staff or residents who might have had knowledge of the falls and relied solely on nurses' notes for information. The absence of a systematic approach to fall investigations and risk assessments further highlights the facility's deficiencies in managing fall risks. The facility's policies and procedures, such as the 15-minute monitoring system, were not effectively implemented or documented. Staff were unable to provide evidence that R171 was being checked every 15 minutes as required. The lack of a policy on restorative programming and the failure to ensure consistent monitoring and documentation contributed to the facility's inability to prevent and adequately respond to fall incidents, ultimately affecting the safety and well-being of the residents involved.
Failure to Provide Behavioral Health Follow-Up and Referral
Penalty
Summary
The facility failed to provide necessary follow-up care for residents exhibiting behavioral issues despite the use of non-pharmacological interventions. Specifically, four residents with various forms of dementia and associated behavioral disturbances did not receive documented follow-up care after non-pharmacological interventions were attempted and proved ineffective. The Director of Nursing acknowledged that there was no further follow-up documented for these residents, and the facility lacked a specific policy for managing behaviors beyond the Severe Behavior Policy. Additionally, the facility did not refer a resident who made a suicidal statement to behavioral health services. This resident, who was moderately cognitively impaired and required assistance with daily activities, expressed a desire to harm herself. Although the facility took immediate measures such as placing the resident on suicide watch and removing harmful items from her room, there was no discussion or documentation of a referral to behavioral health services. The Director of Nursing admitted that a referral should have been considered, especially given the resident's difficulty adjusting to the facility.
Unauthorized Access to Medication Room Keys
Penalty
Summary
The facility failed to ensure that only licensed personnel had access to the medication room keys on the west hall, which had the potential to affect all 46 residents residing in that area. During an observation, a Certified Nursing Assistant (CNA) requested the medication room keys from a Licensed Practical Nurse (LPN) to retrieve ice packs for a resident. The LPN handed over the keys without hesitation, allowing the CNA to access the medication room unsupervised initially. Although the LPN quickly followed the CNA to the medication room, this action was against the facility's policy, which mandates that medication room keys remain in the possession of licensed nursing personnel at all times. The Director of Nursing confirmed that the medication room keys should never be handed to a CNA, except in an emergency where the nurse must supervise the CNA the entire time. The facility's policy on the storage of medications clearly states that access to the medication supply is restricted to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. This incident highlights a breach in protocol, as the LPN admitted to not usually letting the keys out of sight, yet did so in this instance.
Infection Control Breaches in PPE Usage and Disposal
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, affecting four residents under contact and enhanced barrier precautions. For one resident with Vancomycin Resistant Enterococci (VRE) in the urine, a registered nurse did not wear a gown while administering intravenous antibiotics, despite the resident being on contact precautions. The nurse's clothing came into contact with the resident's bed linens, which the resident had been adjusting, indicating a breach in protocol. Another incident involved a licensed practical nurse who improperly disposed of contaminated personal protective equipment (PPE) after administering medications to a resident on enhanced barrier precautions due to a gastrostomy tube. The nurse placed the contaminated gown and gloves on a medication cart in the hallway, rather than disposing of them in the designated bins within the resident's room. This action potentially exposed other residents to infectious organisms as the nurse continued to use the contaminated cart for medication administration. Additionally, two certified nursing assistants and two student CNAs failed to wear appropriate PPE, except for gloves, while providing incontinence and catheter care to a resident on enhanced barrier precautions. Furthermore, a licensed practical nurse did not perform hand hygiene between glove changes during wound and incontinence care for another resident, leading to potential cross-contamination. These actions were contrary to the facility's policies on infection control and enhanced barrier precautions, which require the use of gowns and gloves during high-contact care activities.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a recapitulation of stay for a resident at the time of their planned discharge. According to the facility's policy titled 'Discharge Record Processing,' revised on 10/25/2022, a discharge summary is required to be completed and signed by the physician, with all discharged records finalized within 30 days of discharge. However, for the resident in question, identified as R118, there was no documentation of a recapitulation of stay in their electronic medical record. The resident, who was moderately cognitively impaired, was admitted and later discharged from the facility, but the necessary discharge documentation was not completed. This was confirmed by the Director of Nurses, who acknowledged that the specific form, including the discharge summary, was not completed for this resident.
Failure to Apply Physician-Ordered Compression Stockings
Penalty
Summary
The facility failed to apply physician-ordered compression stockings for a resident diagnosed with Bilateral Primary Osteoarthritis of the Knee, Type II Diabetes Mellitus Without Complications, and Acute Embolism and Thrombosis of Unspecified Deep Veins of the Left Lower Extremity. The physician's order required the application of bilateral compression hose in the morning and removal at bedtime. On the day of observation, the resident was found seated in a wheelchair wearing non-skid socks instead of the prescribed compression hose, with visibly swollen feet. The resident expressed agitation, stating that a CNA had put on non-skid socks instead of the compression hose and that this was a recurring issue, leading to increased leg swelling. A Licensed Practical Nurse confirmed the resident was not wearing the compression hose as ordered and acknowledged that CNAs were responsible for applying them in the morning, which had not been done.
Deficiencies in Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to adequately assess and monitor pressure ulcers for three residents, leading to deficiencies in their care. Resident R26, who was at risk for developing pressure ulcers, did not have a pressure relief cushion in her recliner chair, despite her care plan indicating the need for such a device. Observations revealed that R26 spent most of her day seated in the recliner without the necessary cushion, which could contribute to pressure ulcer development. Additionally, R26 had a history of a coccyx pressure ulcer, and the absence of a cushion was acknowledged by the LPN as a potential issue. Resident R10, who was severely cognitively impaired and had multiple medical diagnoses, including a Stage II sacral pressure ulcer, did not have a documented treatment plan for this ulcer. The care plan also lacked focus areas, goals, or interventions for the sacral and left ankle pressure ulcers. Observations over several days showed that R10 was not provided with heel protectors or had her feet floated, which are essential measures to prevent further skin breakdown. Resident R18, with moderate cognitive impairment and several medical conditions, had pressure ulcers on both buttocks. However, the care plan did not document any focus area, goal, or interventions for these wounds. The treatment for the left buttock ulcer was not completed on two occasions, and there was no assessment or documentation for the right buttock ulcer. The LPN responsible for wound care was unaware of the new ulcer due to a lack of documentation and communication, highlighting a significant gap in the facility's wound management protocol.
Failure to Implement Care Plan and Label Enteral Feeding Bottles
Penalty
Summary
The facility failed to implement care plan interventions and properly label enteral feeding bottles for two residents with Gastrostomy tubes (G-tube). The facility's policy requires feeding solutions to be labeled with the date and time once opened, and the head of the bed to be elevated during and after feeding to prevent aspiration. However, these protocols were not followed for the two residents reviewed. The first resident, R84, was cognitively intact and required assistance with daily activities. The care plan specified that the head of the bed should be elevated to prevent aspiration. Observations revealed that R84's Jevity 1.2 calorie feeding was running while the resident was lying flat, and the feeding bottle was not properly labeled. The LPN acknowledged the labeling issue and noted that the feeding was started late, potentially causing stomach upset as it overlapped with the resident's meal times. The second resident, R321, also cognitively intact, had multiple medical diagnoses and required assistance with daily activities. The care plan instructed staff to keep the head of the bed elevated during feeding. Observations showed that R321's enteral feeding was running while the resident was lying flat, and the feeding bottle lacked proper labeling. The LPN confirmed the labeling deficiency and noted that the feeding was administered late, resulting in a discrepancy in the feeding schedule. The DON stated that feeding bottles should be labeled with necessary information and that the head of the bed should be elevated during feeding, although there was no formal policy on this practice.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications according to the physician's orders for one resident, resulting in a medication error rate of 7.69%, which exceeds the acceptable threshold of 5%. The resident, identified as R321, has multiple medical diagnoses including Diabetes Mellitus Type II, Chronic Diastolic Congestive Heart Failure, and an Implanted Cardiac Defibrillator, among others. The resident's physician orders included Dapagliflozin Propanediol (Farxiga) and Lansoprazole Suspension, which were not administered as prescribed. The nurse's progress note indicated that the Lansoprazole was not available due to pending insurance authorization, and the Farxiga was in the process of being reordered. On the day of the incident, the LPN was unable to locate the medications in the medication cart or supply room, confirming that the resident did not have access to the prescribed medications. The Director of Nurses acknowledged that all residents should have their medications available at all times, and noted that while pharmacy delays can occur, medications should generally be accessible. This deficiency highlights a failure in ensuring the availability and administration of necessary medications for the resident, as per the physician's orders.
Failure to Timely Notify Physician After Resident Fall
Penalty
Summary
The facility failed to notify a resident's physician in a timely manner following a fall with injury, affecting one resident out of five reviewed for falls. The resident, identified as R171, has multiple medical diagnoses including vascular dementia, unsteadiness on feet, and long-term use of anticoagulants, which contribute to a high fall risk. On 9/15/24, R171 was found on the floor with a laceration above the left eye and a small hematoma. Despite the injury, the physician was not notified until the following day, 9/16/24, at 1:05 AM. The facility's Director of Nurses acknowledged the lack of a specific policy for notifying physicians after a fall, stating that staff should notify the physician after a fall with a head injury. The resident's physician, V22, confirmed not being notified of the fall until the next day and emphasized that any resident on anticoagulants with a head injury should be sent to the emergency room immediately. R171 experienced another unwitnessed fall later the same day and was subsequently diagnosed with a closed head injury at the hospital. The physician expressed concern that the facility's delay in notification and failure to send the resident to the emergency room after the first fall may have contributed to the uncertainty regarding which fall caused the closed head injury.
Failure to Maintain Resident Privacy During Incontinence Care
Penalty
Summary
The facility failed to ensure the dignity and privacy of residents during incontinence care, affecting two residents out of a sample of eight. Resident R7, who is severely cognitively impaired and dependent on staff for various activities of daily living, was left exposed during incontinence care. Certified Nurse Aides V12, V15, and V17 did not pull the privacy curtain, leaving R7's perineal area fully exposed to R8, R7's roommate. R8 expressed discomfort at witnessing the incident, and V12 acknowledged the failure to provide privacy, which is against the facility's policy. Similarly, Resident R1, who is moderately cognitively intact and requires assistance for toileting and other activities, was also left exposed during incontinence care. While CNAs V20 and V23 were providing care, V25, an Infection Preventionist/RN, and V16, a Housekeeper, entered the room without ensuring privacy. V16 did not knock before entering, and V25 did not wait for a response after knocking, both actions leading to R1's exposure. These incidents highlight a breach in maintaining resident dignity and privacy as per the facility's policy.
Failure to Provide Adequate ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for two residents, R1 and R7, who were dependent on staff for personal care. R1, who has multiple medical diagnoses including Hypertension, Diabetes Mellitus Type II, and Chronic Kidney Disease, was observed with overgrown, ungroomed facial hair containing food debris. Despite being dependent on staff for grooming, R1 expressed a desire to be clean-shaven, which was not addressed by the facility staff. The Director of Nurses (DON) acknowledged that R1's family had expressed concerns about his grooming, indicating a lack of attention to R1's personal hygiene needs. Similarly, R7, who suffers from Alzheimer's Disease and Dementia, was observed with food debris on his face and clothing while eating lunch without assistance. R7's facial hair was also overgrown and ungroomed, and he was later found with phlegm on his clothing. The DON confirmed that R7's family requested grooming before a hospital visit, highlighting the facility's failure to provide necessary personal hygiene care. The facility lacks a formal ADL policy, but staff are expected to assist dependent residents, which was not adequately done for R1 and R7.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as R1, who was dependent on staff for toileting and other activities of daily living. R1's medical history included conditions such as hypertension, diabetes, chronic kidney disease, and urinary tract infection, among others. On the day of observation, R1 was seen sitting in a wheelchair from 8:30 AM to 9:18 AM without being offered incontinence care. It was noted that R1 was incontinent of both bladder and bowel, and had developed a small red open area on the scrotal area and beefy red buttocks, indicating a lack of timely care. The Certified Nurse Aide (CNA) on duty admitted that no care had been provided to R1 since the start of their shift at 6:00 AM, and acknowledged the need to check and provide care at least every two hours. The Director of Nurses confirmed that R1 was incontinent and emphasized the expectation for staff to provide incontinence care every two hours, although the facility's Perineal Care Policy did not specify timeframes. The lack of timely incontinence care led to the development of a Stage II pressure ulcer on R1, as confirmed by the Infection Preventionist.
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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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