Pavilion Of South Shore
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 7750 South Shore Drive, Chicago, Illinois 60649
- CMS Provider Number
- 145939
- Inspections on file
- 31
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Pavilion Of South Shore during CMS and state inspections, most recent first.
A resident with a seizure disorder, vascular dementia, and liver disease had physician orders and hospital discharge instructions for Valproic Acid level monitoring, but the facility failed to ensure these labs were obtained or documented over several months. No Valproic Acid results were found in the record, and progress notes lacked documentation of any lab refusals or physician notification, despite the care plan requiring therapeutic drug monitoring. The DON confirmed there were no recent lab results or refusal forms, while an LPN reported being told the resident was combative and that blood draws were unsuccessful, with no corresponding documentation to support these reports or show follow-up on the repeated lab orders.
A resident experienced a significant change in condition, including respiratory distress and hypoxia, but the family was not promptly notified by the assigned RN. The nurse prioritized notifying hospice and the physician, leaving family notification to the next shift, resulting in a delay of several hours before the family was informed. Facility policy requires immediate notification of both the provider and family when a change in condition occurs, which was not followed in this instance.
A facility failed to report allegations of misappropriation of property for a resident who was admitted with a diamond ring and bracelet that were not inventoried. The Social Services Director and Assistant Administrator were aware of the missing items, but there was no evidence of a formal report or investigation submitted to the Illinois Department of Public Health. The facility's policy requires documentation and reporting of such incidents, but the necessary documentation was not available.
A cognitively impaired resident's family reported missing jewelry upon admission, but the LTC facility failed to conduct a thorough investigation or provide documentation of reporting the incident to the state agency. The Assistant Administrator acknowledged the incident, but the former administrator who handled it was unavailable for further information.
The facility failed to maintain proper food handling and hygiene practices, affecting all residents receiving food from the kitchen. Observations revealed improper hand hygiene by staff when handling food trays and soiled dishes, and expired and unlabeled food items in the walk-in fridge. Personal items were also improperly stored in the fridge, increasing the risk of cross-contamination.
The facility failed to properly dispose of kitchen garbage and maintain a sanitary dumpster area. During a tour, surveyors found uncovered dumpsters with food waste and foul odors, contrary to facility policy. The maintenance staff acknowledged the issue, noting that open dumpsters could attract pests.
The facility failed to sanitize shared equipment between uses for multiple residents and did not post Enhanced Barrier Precautions (EBP) signage for a resident with a dialysis catheter. A staff member used a blood pressure device on different residents without cleaning it, and the necessary EBP signage was missing for a resident with serious health conditions, risking infection transmission.
The facility failed to ensure call lights were within easy reach for two residents, both with cognitive impairments and requiring assistance with transfers and toileting. One resident's call light was found under the bed, while another's was out of reach, preventing them from calling for help. Staff acknowledged the issue, and the DON emphasized the importance of keeping call lights accessible to prevent unmet needs and potential harm.
A facility failed to ensure a resident's code status was consistent with their care plan and physician orders. Despite the resident's POLST form indicating a DNR status, their care plan incorrectly documented them as Full Code. Interviews with facility staff highlighted the importance of consistent documentation to prevent confusion during emergencies.
A facility failed to follow its PICC line dressing change policy for a resident, as observed by a surveyor. The dressing was found halfway lifted and undated, and there were no physician orders for dressing changes or intravenous flushes. The RN acknowledged the issue but had not addressed it due to being busy. The DON confirmed the policy requires timely dressing changes and proper labeling to prevent infection risks.
A resident with a history of hemiplegia and other medical conditions was observed without a required hand splint, despite a physician's order to apply it daily for four hours. The facility's failure to follow the care plan and physician's order could potentially lead to further contracture of the resident's right hand.
The facility failed to ensure smoking materials were kept by staff, affecting three residents. One resident on oxygen therapy was found with a lighter near their oxygen concentrator. Another resident had a lighter in their pocket, and a third resident had both a cigarette and lighter. Facility policies require smoking materials to be turned over to staff, but observations showed these were not enforced, posing safety risks.
The facility failed to provide adequate respiratory care for residents on continuous oxygen therapy. A resident lacked required oxygen use and no smoking signage, another used oxygen without a humidifier, and a third had undated humidifier and nebulizer equipment, contrary to facility policies. These oversights were acknowledged by nursing staff and could lead to increased risks for residents.
A facility failed to assess the risks and benefits of bed rail use for a resident with heart failure and cognitive impairment before implementation. Observations showed a full bed rail in use without prior assessment or care plan inclusion, contrary to facility policy. The LPN confirmed assessments should precede use, but the resident's care plan lacked necessary details.
The facility failed to assess eligibility and offer the pneumococcal vaccine to three residents, despite having a policy requiring such actions. One resident with multiple diagnoses, including end-stage renal disease, lacked documentation of receiving the vaccine, and there was no record of screening questions or informed consent. Another resident with cerebral infarction and COPD also had no vaccine documentation, and the consent form did not reflect consent or refusal. A third resident with hypertensive heart disease similarly lacked vaccine documentation. The facility's policy required assessment and offering of the vaccine within 14 days of admission, but this was not followed.
The facility failed to assess and document COVID-19 vaccination eligibility for three residents, neglecting to perform necessary screenings and obtain informed consent. Despite having intact cognition, these residents did not have documented COVID-19 vaccinations or eligibility assessments, contrary to facility policy and CDC guidelines.
The facility failed to ensure call lights were accessible for two residents, as required by their care plans. One resident with severe cognitive impairment and another with mild cognitive impairment were unable to reach their call lights, which were found on the floor. This contravened the facility's policy that mandates call lights be within reach at all times.
The facility failed to implement fall prevention interventions for two residents with Dementia at risk for falls. During an observation, they were found wearing smooth-bottomed socks instead of non-skid socks, contrary to their care plans. The oversight was acknowledged by staff, and records confirmed the residents' fall risk and cognitive impairments.
A resident was attacked by another resident, resulting in a human bite, after confronting the latter for stealing food. The incident was not properly investigated or documented by staff, and occurred during a time when both the LPN and RN were on break, leaving residents unsupervised. The facility's policies on supervision and incident investigation were not followed.
Two residents in an LTC facility were involved in an altercation due to inadequate supervision, resulting in one resident sustaining a human bite. The incident occurred when key staff members were on break, leaving only one CNA to supervise the floor. The cognitively impaired resident, who was involved in the altercation, was unable to recall the event, and the incident was not documented by the staff present.
A resident with opioid dependence was not consistently transported to a methadone clinic due to the facility's transportation van being unavailable and lack of alternative arrangements. The resident missed several doses of Methadone and eventually left the facility against medical advice. The facility's policies on medication administration and transportation were not effectively implemented.
The facility failed to recognize and address a resident's significant weight loss, resulting in a 17% decrease in weight over several months. The resident's dissatisfaction with meals and the lack of a systematic process for evaluating and intervening in cases of weight loss contributed to the deficiency.
The facility failed to label and date food items, discard expired foods, maintain clean food storage areas, and ensure proper hand washing between handling dirty and clean items. Observations revealed multiple violations, including a contaminated cooling fan, expired food items, and improper hand hygiene by a Dietary Aide.
The facility failed to follow infection control policies, leading to deficiencies in PPE usage and medication administration. Staff and visitors entered isolation rooms without proper PPE, and nurses did not perform hand hygiene or wear gloves before opening sealed medications. Additionally, a resident's urinary catheter bag was found on the floor, and soiled linens were unsealed during transport.
The facility failed to maintain resident dignity by standing over residents during feeding assistance, contrary to policy requiring staff to sit and maintain eye level. One resident with multiple diagnoses and impaired cognition was observed being spoon-fed by a CNA in a standing position.
The facility failed to provide sack lunches or snacks to residents attending dialysis during mealtimes, despite having a policy in place. Multiple residents reported missing lunch and experiencing hunger during their dialysis days, as they only received breakfast and dinner. The facility's staff confirmed that no food was sent with the residents, citing a request from dialysis centers, although the dialysis center's dietitian indicated it would be acceptable for residents to eat before or after dialysis.
The facility failed to properly label, store, and dispose of insulin medications for multiple residents. Insulin pens were found without open dates, expired, or not refrigerated as required. LPNs admitted to not following procedures, leading to the use of potentially ineffective insulin.
The facility failed to ensure proper self-administration of medication for three residents, leading to medications being left at their bedside without proper authorization or assessment. The residents' records lacked documentation of self-administration assessments and physician orders, contrary to the facility's policy.
A resident with paraplegia and contracted hands was unable to reach their call light because it was tucked under a pillow instead of being strapped to their wrist as required. The resident had to call out verbally multiple times before a nurse responded and corrected the issue.
The facility failed to ensure the availability and proper functioning of low air loss mattresses for two residents with pressure ulcers. One resident did not have a low air loss mattress due to malfunction, and another resident's mattress was incorrectly set, causing them to sink into it. The facility's policies on pressure ulcer prevention and mattress usage were not followed.
The facility failed to ensure that the left-hand splint and left Ankle Foot Orthosis (AFO) were in place for two residents with limited range of motion. Observations revealed that both residents were without their prescribed devices on multiple occasions, despite care plans and physician orders requiring their application. The restorative nurse confirmed the importance of these devices in maintaining and improving contractures and deformities.
The facility failed to ensure fall precautions for a resident at risk for falls. Observations showed that floor mats were not laid flat and the bed was not in its lowest position, contrary to the care plan. Staff interviews confirmed these measures were not consistently implemented.
The facility failed to properly store oxygen cannula tubing for a resident with acute and chronic respiratory failure. Observations revealed the tubing was left uncovered and not stored in a plastic bag, contrary to facility policy. The LPN and DON confirmed the proper storage procedure, but the resident indicated frequent tubing changes.
The facility failed to obtain medication consents and care plan for the use of an antidepressant for a resident. The resident was prescribed Nortriptyline HCl 10 MG for depression and received the medication since admission. The facility did not provide the initial consent for Nortriptyline from admission or for the reorder on April 2, 2024, and did not include Nortriptyline in the resident's comprehensive care plan.
Failure to Complete and Document Ordered Valproic Acid Lab Monitoring
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests for monitoring an anticonvulsant medication were completed and followed up in a timely manner for one resident. The resident had medical diagnoses including seizures, vascular dementia, and liver disease, and a care plan intervention requiring lab tests for therapeutic monitoring of medication levels per MD orders, with MD notification of subtherapeutic or toxic levels. Hospital discharge instructions directed that a Valproic Acid level be obtained one week after discharge, and subsequent physician orders on multiple dates required Valproic Acid laboratory values. However, the resident’s medical record contained no documentation that these laboratory tests were ever obtained and no lab results were present. From the time of the resident’s hospital discharge through the review period, progress notes contained no documentation of the resident refusing blood draws or of physician notification regarding any refusals. The DON confirmed there were no lab results on file for the resident since several months prior and no documentation of refusals or reasons why the labs were not performed, despite a facility policy requiring that labs be completed per MD order and abnormal or immediate labs be relayed to the physician. An LPN reported that staff had informed her the resident was very combative and that blood specimens could not be obtained, and stated she notified the physician, who instructed staff to continue attempts; however, there was no corresponding documentation of these refusals or follow-up in the record. The facility was still attempting to determine why the ordered labs from December had not been completed.
Failure to Promptly Notify Family of Change in Resident Condition
Penalty
Summary
The facility failed to notify a resident's family member in a timely manner following a significant change in the resident's condition. On the morning of 4/13/2025, a resident was noted to have a change in condition, including hypoxia and respiratory distress, with an SPO2 of 89% that improved to 94% after oxygen was administered. The nurse on duty at the time notified hospice but did not promptly inform the resident's family member of the change. The nurse stated that notifying the family was not a priority and that the patient came first, and subsequently left the responsibility of notifying the family to the oncoming nurse at shift change. The oncoming nurse later discovered that the family had not been notified and subsequently called the resident's family member at 11:15 AM, several hours after the change in condition was first identified. The family member confirmed receiving the call late in the morning and expressed concern that the night shift nurse had left without providing notification. The facility's policy requires prompt notification of both the physician and the family when a change in condition occurs. The Director of Nursing confirmed that the nurse should have notified the family promptly as per facility policy.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report allegations of misappropriation of property for a resident, identified as R1, who was admitted with a diamond ring and bracelet that were not inventoried upon admission. The Social Services Director, V4, recalled a conversation with R1's family member, V9, about the missing items and the lack of an inventory list. Despite V9's insistence that R1 had these items, V4 could not find any documentation to support this. The Assistant Administrator, V3, was informed of the allegations and reimbursed V9 for the missing items, but there was no evidence of a formal report or investigation being submitted to the Illinois Department of Public Health (IDPH). The facility's policy requires that any allegations of misappropriation of property be documented and reported to the state agency. However, during the survey, V3 was unable to provide documentation proving that the initial and final reports were submitted to the state agency. Additionally, there was no inventory list for R1's belongings, which is a requirement upon admission according to the facility's policy. The former administrator, V8, who handled the incident, was no longer available for contact, and V3 could not locate the necessary documentation related to the investigation and reporting of the incident.
Failure to Investigate Misappropriation of Property
Penalty
Summary
The facility failed to adhere to its abuse prevention program by not conducting a thorough investigation into the alleged misappropriation of property involving a resident. The resident, who was cognitively impaired and had multiple diagnoses including Parkinson's Disease and neurocognitive disorder, was reported by a family member to have had a diamond ring and bracelet upon admission, which were not inventoried. The Assistant Administrator acknowledged the incident and stated that the former administrator reimbursed the family member for the missing items. However, there was no documentation to show that a comprehensive investigation was conducted, including interviews or statements from residents and staff. The Assistant Administrator was unable to provide documentation proving that the incident was reported to the state agency, as required by the facility's policy. The only documents available were a Petty Cash Reconciliation Form and a document titled 'Final investigation- Missing bracelet for R1,' but these did not include evidence of a thorough investigation or proof of submission to the state agency. The former administrator, who handled the case, was no longer employed at the facility, and there was no contact information available to obtain further details. This lack of documentation and investigation is a violation of the facility's abuse prevention policy.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food handling and hygiene practices, which could potentially affect all 110 residents receiving food from the facility's kitchen. During an inspection, it was observed that the facility did not perform proper hand hygiene when passing food trays, after handling soiled dishes, and before handling clean dishes. Specifically, a Certified Nursing Assistant (CNA) was seen passing lunch trays to residents without sanitizing hands between each resident, and dietary aides were observed not wearing gloves or washing hands when moving from the dirty to the clean side of the dishwashing area. These actions were contrary to the facility's policies, which emphasize hand hygiene as a primary means to prevent infection spread. Additionally, the facility failed to properly label perishable items and prevent personal food items from being stored in the walk-in fridge. Observations revealed expired apple sauce, unlabeled grape jelly, and personal items such as an energy drink and water bottle inside the fridge. The Director of Dietary acknowledged these issues, stating that all items should have an in and out date, and personal items should not be stored in the fridge to prevent cross-contamination. The facility's policies require refrigerated food to be labeled with a discard date and emphasize the importance of labeling and dating foods to decrease the risk of foodborne illness.
Improper Disposal of Kitchen Garbage
Penalty
Summary
The facility failed to properly dispose of kitchen garbage in a contained dumpster and maintain the dumpster area in a sanitary condition. During an initial facility tour, surveyors observed that the large dumpsters used for kitchen garbage disposal were uncovered, with lids left open. The area surrounding the dumpsters was littered with food garbage, papers, and emitted foul odors. The Director of Maintenance and Assistant Maintenance acknowledged that the dumpsters should be covered to prevent pests and raccoons from being attracted to the facility. The facility's policy on waste disposal, dated January 2014, requires that regulated waste be handled and disposed of safely, with the area around the dumpster kept clutter-free and lids closed after waste disposal.
Infection Control Deficiencies in Equipment Sanitization and EBP Signage
Penalty
Summary
The facility failed to ensure that shared equipment was cleaned and decontaminated between uses for multiple residents. On several occasions, a staff member used a manual blood pressure device on different residents without sanitizing it between uses. This occurred with four residents, where the device was placed on bed linens or directly on the residents' bodies without being cleaned. The staff member later acknowledged forgetting to sanitize the device, which could lead to the spread of infection. The Director of Nursing confirmed that all shared equipment must be sanitized between each resident to prevent potential infectious outbreaks. Additionally, the facility did not follow its infection control procedures by failing to post Enhanced Barrier Precautions (EBP) signage outside the room of a resident with an active dialysis catheter. This resident, who has multiple serious health conditions including end-stage renal disease and various malignancies, was observed without the necessary EBP signage. Staff members, including the Director of Nursing and the Infection Preventionist, confirmed that such signage is crucial to ensure that staff wear the appropriate personal protective equipment when providing care to prevent infection transmission.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within easy reach for two residents, R25 and R58, as per their policy. R25, a cognitively impaired male with multiple health issues including chronic obstructive pulmonary disease and a history of falls, was observed in bed unable to reach the call light. R25 requires extensive assistance with transfers and toileting, and the inability to reach the call light could prevent him from calling for help, potentially leading to skin breakdown. Similarly, R58, who is moderately cognitively impaired and has conditions such as hemiplegia and repeated falls, was found with the call light under the bed, making it unreachable. R58 also requires assistance with transfers and toileting. During the survey, staff members acknowledged the issue. A Registered Nurse (V8) confirmed that R58's call light was not reachable and should be within reach to prevent falls. A Certified Nursing Assistant (V11) noted that R25's call light was not within reach, which could prevent the resident from calling for help to use the washroom. The Director of Nursing (V2) stated that it is expected for staff to place call lights within reach of residents, as failure to do so could lead to unmet needs and potential harm such as falls or skin breakdown.
Inconsistent Code Status Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident's code status was consistent with their plan of care and physician orders, as required by their policy on advance directives. The resident in question, who had a moderately impaired cognition, was admitted with multiple diagnoses including chronic obstructive pulmonary disease, cerebral infarction, and chronic kidney disease. Despite having a POLST form indicating a Do Not Resuscitate (DNR) status with comfort-focused treatment, the resident's care plan incorrectly documented them as a Full Code, requiring all life-saving measures and CPR in emergencies. Interviews with the Director of Nursing and the Social Service Director revealed that the facility's policy mandates that a resident's code status should be clearly documented and consistent across their care plan and physician orders to prevent confusion during emergencies. The inconsistency in R29's documentation could lead to staff performing CPR on a resident who had opted for DNR, highlighting a significant lapse in adhering to the resident's documented treatment preferences.
Failure to Follow PICC Line Dressing Change Policy
Penalty
Summary
The facility failed to adhere to its policy regarding the management of a peripheral inserted central catheter (PICC) line dressing for a resident. During an observation, a surveyor noted that the dressing on the resident's midline intravenous catheter was halfway lifted and lacked a date label. The registered nurse, V8, acknowledged noticing the compromised dressing earlier in the day but had not yet changed it due to being busy. Additionally, there were no physician orders for the dressing change or intravenous flushes documented for the resident. The Director of Nursing confirmed that the facility's policy requires the dressing to be changed 24 hours after insertion, every seven days, or whenever it is not intact. The policy also mandates that the dressing be labeled with the date and time of the change. The absence of a date on the dressing and the lack of physician orders could lead to uncertainty about when the dressing was last changed, potentially increasing the risk of infection. The facility's failure to follow these procedures was observed and documented by the surveyor.
Failure to Apply Hand Splint as Ordered for Resident
Penalty
Summary
The facility failed to adhere to the plan of care and physician's order for a resident, identified as R29, who required a hand roll or splint on the right hand to prevent further contracture. R29 was observed sitting in a wheelchair with a contracted right hand and no device in place, despite the physician's order for the application of a hand roll or splint for four hours daily. The Director of Nursing confirmed the importance of following the plan of care to prevent further contracture, and the Restorative Nurse noted that the absence of the splint could potentially lead to further contracture. R29's medical history includes chronic obstructive pulmonary disease, dysarthria, ataxia, hemiplegia, osteoarthritis, osteoporosis, foot drop, chronic kidney disease, and hypertension. The Minimum Data Set indicated that R29 had moderately impaired cognition and required substantial assistance with daily activities. The care plan specified the need for a right hand splint daily for four hours, and the facility's policy required adherence to the physician's order for splint application. However, the failure to apply the splint as ordered was observed, indicating a lapse in following the prescribed care plan.
Failure to Secure Smoking Materials Poses Safety Risk
Penalty
Summary
The facility failed to ensure that smoking materials, such as cigarettes and lighters, were kept by staff for safety, potentially affecting three residents who were reviewed for smoking. Resident R28, who was admitted with conditions including interstitial pulmonary disease and chronic obstructive pulmonary disease, was observed with a lighter on their bedside table near an oxygen concentrator, despite being on continuous oxygen therapy. Resident R93, who has type 1 diabetes mellitus and hypertension, was found with a lighter in their pocket, although they stated that cigarettes were kept by facility staff. Resident R84, with diagnoses including osteoarthritis and opioid dependence, was observed with a cigarette and lighter in their possession, despite facility policy requiring these items to be turned over to staff. The facility's smoking safety policy and oxygen care and storage policy both emphasize the importance of keeping smoking materials away from residents, especially those using oxygen, to prevent potential fire hazards. Interviews with staff, including the Social Service Director and the Director of Nursing, confirmed that smoking assessments are conducted regularly, and smoking materials should be kept by staff for safety. However, observations revealed that residents were in possession of lighters and cigarettes, indicating a failure to enforce these policies effectively. This oversight could lead to significant safety risks, particularly for residents using oxygen therapy.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to ensure proper respiratory care for residents requiring continuous oxygen therapy. For one resident, there was no signage indicating oxygen use and no smoking on the door or over the bed, despite the resident being on continuous oxygen at 3 liters per minute (LPM) due to heart failure and chronic respiratory conditions. The Director of Nursing confirmed that such signage is required to prevent smoking near oxygen use, which was not adhered to in this case. Another resident was observed using oxygen at 2 LPM without a humidifier, which is necessary for continuous oxygen use to prevent nasal dryness. The resident confirmed experiencing dryness, and the Registered Nurse acknowledged the absence of humidification, which contradicts the physician's order for oxygen therapy at 3 LPM. The care plan also highlighted the need for oxygen therapy as ordered, which was not followed. Additionally, a third resident's humidifier bottle and nebulizer mask were not dated, contrary to the facility's policy requiring weekly changes and dating to prevent infection. The Licensed Practical Nurse and Director of Nursing both acknowledged the oversight, which could lead to an increased risk of infection due to the inability to track when the equipment was last changed. The facility's policies clearly state the need for dating and changing oxygen and nebulizer equipment weekly, which was not followed in this instance.
Failure to Assess and Plan for Bed Rail Use
Penalty
Summary
The facility failed to properly assess the risks versus benefits of using a bed rail for a resident, identified as R213, before its implementation. Observations on two separate occasions revealed that R213 was resting in bed with a full bed rail up on the right side, without a prior assessment being completed. The Restorative Licensed Practical Nurse (LPN), identified as V14, confirmed that bed rail assessments are necessary before use and should be explained to the resident or their representative, including potential complications. However, R213's comprehensive care plan did not address the use of the bed rail, nor did it identify any medical need or interventions to address potential complications. R213's clinical records indicate a history of heart failure, chronic obstructive pulmonary disease, and chronic respiratory failure with hypoxia, with moderate cognitive impairment noted in the Minimum Data Set. Despite these conditions, the Assist Rail Screening was only completed after the bed rail was observed in use, recommending two half rails instead of the full rail observed. The facility's policy on the proper use of side rails requires an assessment to determine the resident's symptoms, risk of entrapment, and reason for using side rails, which was not adhered to in this case.
Failure to Assess and Offer Pneumococcal Vaccine to Residents
Penalty
Summary
The facility failed to assess eligibility and offer the pneumococcal vaccine to three residents, which was identified during a survey. Resident 39, admitted with multiple diagnoses including end-stage renal disease and malignant neoplasms, had an intact cognition according to the Minimum Data Set (MDS) but lacked documentation of receiving the pneumococcal vaccine. There was no record of screening questions to determine vaccine eligibility, and the informed consent form did not indicate a refusal of the vaccine. Similarly, Resident 48, with conditions such as cerebral infarction and chronic obstructive pulmonary disease, also had no documentation of receiving the pneumococcal vaccine despite an active order allowing it unless contraindicated. The consent form for Resident 48 did not reflect that consent was obtained, nor was there documentation of screening questions to assess vaccine eligibility. Resident 72, admitted with diagnoses including hypertensive heart disease and chronic kidney disease, also showed no documentation of receiving the pneumococcal vaccine. The resident's order summary allowed for the vaccine unless contraindicated, but the consent form did not indicate that consent was obtained or refused. The facility's policy, dated March 2014, required that all residents be offered the pneumococcal vaccine and assessed for eligibility within 14 days of admission. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and assessment for the three residents. The Infection Preventionist confirmed that screening and informed consent should be documented, but this was not done for the residents in question.
Failure to Assess and Document COVID-19 Vaccination Eligibility
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding COVID-19 vaccination, specifically in assessing eligibility and offering the vaccine to three residents (R39, R48, R72) out of a sample of 23. These residents were not properly assessed for vaccine eligibility, and there was no documentation of screening questions to determine if they were appropriate candidates for the vaccine. Additionally, the facility did not document the COVID-19 vaccination status of these residents, nor did it obtain or document informed consent for vaccination. Resident R39, admitted with multiple serious health conditions, had an intact cognition according to the Minimum Data Set (MDS) but lacked documentation of COVID-19 vaccination or eligibility screening. Similarly, R48, with moderately intact cognition and a range of chronic health issues, also had no documented COVID-19 vaccination or consent. R72, with intact cognition and chronic health conditions, was in the same situation. The Infection Preventionist (V4) confirmed that the facility should offer the vaccine according to CDC guidelines and that proper documentation of consent and eligibility screening is necessary, but this was not done for the residents in question.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights of residents were accessible as stated in their care plans, affecting two residents. During an observation on the third floor, it was noted that one resident was in bed without the call light within reach. When asked, the resident indicated an attempt to use the call light, but it was found on the floor by a CNA. Another resident was observed sitting on the edge of the bed, trying to reach for the call light, which was also found on the floor behind the bed by a CNA. Both residents had care plans indicating they were at risk for falls and required the call light to be within reach. The first resident had a severe cognitive impairment with a BIMS score of 7, and the second resident had mild cognitive impairment with a BIMS score of 11. The facility's call light policy mandates that call lights be placed within reach and not on the floor, which was not adhered to in these instances.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for residents diagnosed with Dementia who are at risk for falls. During an observation on the third floor, two residents were found wearing smooth-bottomed socks instead of the required non-skid socks, which are essential for fall prevention. The Assistant Director of Nursing and a Certified Nurse Assistant were notified of the issue, acknowledging the oversight and the need for non-skid socks to prevent falls. Resident records revealed that both residents had been assessed as at risk for falls, with care plans specifying the need for shoes or gripper socks at all times. One resident had a severe cognitive impairment with a BIMS score of 4 out of 15, while the other had mild cognitive impairment with a BIMS score of 4 out of 11. The facility's Fall Management Program mandates the development of a care plan for residents at risk for falls, including specific interventions to ensure a safe environment, which was not adhered to in these cases.
Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident, R1, from abuse when another resident, R2, attacked R1, resulting in a human bite. This incident occurred after R1 found R2 stealing food from R1's and another resident's drawers. When R1 confronted R2, R2 attempted to hit R1 with a walker and subsequently bit R1's fingers. R1 required a tetanus shot and antibiotics as a prophylactic measure against infection. The incident highlights a lack of immediate staff response, as R1 reported calling for help without receiving timely assistance. Interviews with staff revealed a lack of thorough investigation into the cause of the altercation. The Social Services Director, V5, admitted to not following up on the incident or documenting it in the medical records of R1 and R2. The Director of Nursing, V2, also did not inquire about the cause of the altercation, citing R2's cognitive impairment as a barrier to communication. The staff's failure to investigate and document the incident properly indicates a breach in the facility's protocol for handling resident-to-resident altercations. The facility's staffing practices contributed to the incident, as both the LPN and RN were on lunch break simultaneously, leaving the residents unsupervised. This lack of supervision allowed the altercation to occur without immediate intervention. The facility's policies on staff breaks and supervision were not adhered to, as evidenced by the absence of sufficient staff on the floor during the incident. The facility's policies require that altercations be investigated and reported, but this was not adequately done in this case.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent an altercation between two residents, R1 and R2, which resulted in R1 sustaining a human bite. R1 required a tetanus shot and antibiotics as a prophylactic measure against infection. The incident occurred on the second floor, where 41 residents reside, and was attributed to insufficient staff presence at the time of the altercation. R1 was cognitively intact with a BIMS score of 14, while R2 had a severe cognitive impairment with a BIMS score of 7. On the day of the incident, R1 reported that R2 was stealing from their drawer and R3's drawer, leading to a confrontation where R2 attempted to hit R1 with a walker and subsequently bit R1's fingers. R2 was unable to recall the incident due to cognitive impairment. The facility's investigation revealed that key staff members, including two licensed nurses and two CNAs, were not present on the floor, leaving only one CNA to supervise the residents. The facility's policy on accidents and incidents requires sufficient staff based on residents' needs, which was not adhered to in this case. The staff's lunch breaks were not staggered appropriately, resulting in inadequate supervision. The incident was not documented by the staff present, and the Director of Nursing had to complete the documentation after being informed of the event. The physician familiar with both residents confirmed the need for separation and treatment following the altercation.
Failure to Provide Transportation for Methadone Clinic Visits
Penalty
Summary
The facility failed to provide necessary transportation for a resident who required daily visits to a methadone clinic. The resident, who had a history of opioid dependence and other medical conditions, was admitted to the facility with orders to receive Methadone daily. However, the facility did not ensure that the resident was transported to the methadone clinic consistently, resulting in the resident missing several doses of the medication. The Director of Nursing (DON) and the Registered Nurse (RN) confirmed that the resident was not transported to the methadone clinic on multiple occasions due to the facility's transportation van being unavailable and the lack of alternative transportation arrangements. The Transportation Coordinator, who was responsible for arranging transportation, stated that they were informed late about the resident's methadone clinic appointments and that the facility's transportation van was often booked. Additionally, the facility's policy required coordination of methadone services prior to admission, which was not adequately followed. The resident's Medication Administration Record (MAR) indicated that the resident did not receive Methadone on several days, and the resident eventually left the facility against medical advice. The facility's policies on administering medication and transportation were not effectively implemented, leading to the resident's unmet medical needs and subsequent discharge against medical advice.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to follow their policy to maintain acceptable parameters of nutritional status for a resident, resulting in a significant weight loss that went unrecognized and unaddressed. The resident experienced a 17% weight loss over several months, which was not identified or acted upon by the facility's staff. The resident expressed dissatisfaction with the meals provided, preferring specific foods that were not consistently offered, further contributing to the weight loss. The Registered Dietician (RD) at the facility did not have a systematic process for evaluating residents with significant weight loss. The RD relied on staff to notify her of any concerns, but there was no specific criterion for when a consult should be made. The RD was not involved in the care planning process and only reviewed weight loss reports monthly. The RD acknowledged that the resident's weight loss should have triggered an assessment and intervention, but this did not occur. The Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator also failed to identify and address the resident's weight loss. The DON stated that it was everyone's responsibility to identify weight changes, but there was no clear process for ensuring this happened. The MDS Coordinator did not include weight changes in the daily reports and relied on progress notes or assessments to document weight loss. As a result, the resident's significant weight loss was not included in the care plan, and appropriate interventions were not implemented in a timely manner.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food items were labeled and dated per facility policy, discard expired and/or rotten foods, keep food storage areas clean, and conduct proper hand washing between handling dirty and clean plateware/equipment. During an initial kitchen tour, the Dietary Manager (V5) explained the labeling policy, but observations revealed multiple violations. The cooling fan inside the walk-in cooler was covered in black material, which could contaminate food. Additionally, several food items in the reach-in cooler and on a metal cart were either not labeled or expired, including a container of green relish, a case of fresh tomatoes, and bottles of ground ginger and rosemary. The Dietary Aide (V6) was observed working in the dish machine area and failed to wash hands between handling dirty and clean items. V6 handled dirty insulated coffee and plastic juice pitchers, cleaned them, and then placed them into storage without washing hands. V6 continued to handle both dirty and clean items without washing hands, stating that keeping hands in soapy, bleach water was sufficient for sanitization. The Dietary Manager (V5) later confirmed that V6 should have been washing hands and changing gloves between handling dirty and clean items. The Maintenance Director (V9) confirmed the presence of accumulated dirt around the cooling fans, ceiling, and plastic stripping in the walk-in cooler. The facility's policies on labeling and dating foods, storage of refrigerated foods, and handwashing were not followed, leading to potential contamination and foodborne illness risks for the residents. The facility's diet order list indicated that one resident was receiving nothing by mouth (NPO).
Infection Control Deficiencies in PPE Usage and Medication Administration
Penalty
Summary
The facility failed to follow their infection prevention and control policies and procedures, leading to multiple deficiencies. Observations revealed that there was no signage outside of a resident's room indicating Enhanced Barrier Precaution (EBP), and personal protective equipment (PPE) supplies were not readily available. Staff and visitors were observed entering isolation rooms without wearing the required PPE, such as gowns and gloves, and not performing hand hygiene. This was noted in the cases of several residents who were on strict contact isolation due to infections like ESBL, CRE, and CRAB. Additionally, a resident's urinary catheter bag was found laying flat on the floor, contrary to the facility's policy that it should be placed in a urinary bag holder. Soiled linens were also found unsealed during transport, which is against the facility's linen and laundry policy. During medication administration, staff failed to maintain proper infection control practices. Instances were observed where nurses did not perform hand hygiene or wear clean gloves before opening sealed medication containers. In one case, a nurse used a dirty thumb to open a new bottle of Lactulose, and in another, a nurse used a key to cut a sealed packet of Buprenorphine HCL-Naloxone HCL. These actions were acknowledged by the staff as incorrect and potentially contaminating the medication, which could lead to infections. The facility's policies for Enhanced Barrier Protection and Contact Precautions were not adhered to, as evidenced by the lack of proper PPE usage and signage. The Infection Preventionist and Director of Nursing confirmed that staff are expected to wear gowns and gloves for high-contact care activities and that door signage should be posted to inform staff of the required precautions. The failure to follow these protocols was observed in multiple instances, including wound care for a resident with a stage IV pressure ulcer, where the nurse did not wear a gown. The facility's policies clearly state the need for PPE and proper signage to prevent cross-contamination and infection transmission, but these were not consistently implemented.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to maintain resident dignity by standing over four residents during feeding assistance. Observations included a CNA standing next to a wheelchair feeding a resident breakfast, another CNA standing while giving a resident liquid from a cup, and a CNA standing over a resident while assisting with lunch. These actions were contrary to the facility's policy, which requires staff to sit and maintain eye level while feeding residents to ensure dignity and respect. One resident's health record indicated multiple diagnoses, including osteoarthritis, COPD, Parkinson's disease, and schizophrenia. This resident was observed being spoon-fed by a CNA in a standing position, not at eye level, in the dining room. The Director of Nursing confirmed that staff are expected to assist residents with dignity by sitting down and maintaining eye level during feeding. The Minimum Data Set showed that this resident had impaired cognition and required substantial assistance with various activities, including eating.
Failure to Provide Meals for Dialysis Patients
Penalty
Summary
The facility failed to provide sack lunches or snacks to residents who were attending dialysis during mealtimes, despite having a policy in place that required it. This deficiency was observed in four residents who regularly attended dialysis sessions. These residents reported that they left the facility in the morning and did not return until late afternoon, missing lunch and any snacks in between. As a result, they experienced hunger and went without food for extended periods, from breakfast until dinner. The facility's Licensed Practical Nurse and Consulting Registered Dietitian confirmed that no food was sent with the residents to dialysis, citing a request from the dialysis centers not to send meals because patients could not eat during dialysis treatment. However, the dialysis center's Registered Dietitian indicated that it would be acceptable for residents to eat before or after their dialysis sessions, especially if they were hungry. One resident, who attended dialysis three times a week, stated that they left the facility at 10:00 AM and returned between 4:30-5:00 PM, only eating breakfast and dinner on those days. Another resident, who also attended dialysis three times a week, reported leaving the facility around 9:00 AM and returning between 3:00-4:00 PM, similarly missing lunch and snacks. Both residents expressed that they were hungry during these long periods without food. The facility's records and progress notes confirmed that no meals or snacks were sent with these residents on their dialysis days, despite the facility's policy requiring sack lunches for residents attending appointments during mealtimes. The facility's policy on transportation for dialysis and sack lunches clearly stated that residents requiring a meal should be provided with a sack lunch to take with them. Additionally, the Long Term Care Facility Outpatient Dialysis Services Care Coordination Agreement emphasized the importance of ensuring residents received proper nourishment before attending dialysis. Despite these policies, the facility did not adhere to them, resulting in residents missing meals and experiencing hunger during their dialysis days. The failure to provide sack lunches or snacks was consistent across multiple residents and documented over several weeks, indicating a systemic issue within the facility's operations.
Improper Labeling, Storage, and Disposal of Insulin Medications
Penalty
Summary
The facility failed to properly label, store, and dispose of insulin medications for multiple residents. During an inventory of the third-floor medication cart, it was observed that several insulin pens were either not labeled with an open date or had expired. Specifically, Resident 72 had an open Novolog Flex Pen and an open Lantus insulin pen without proper labeling. Resident 2 had an unopened Levemir Flex Insulin Pen that was not refrigerated as required. Resident 16 had an open Admelog Insulin pen without an open date. Licensed Practical Nurse V18 admitted to not paying attention to the dates on the insulin pens, and it was noted that night nurses were responsible for cleaning the cart and removing expired or undated insulin. However, this procedure was not followed, leading to the use of potentially ineffective insulin for residents. Further observations on the second and first-floor medication carts revealed similar issues. Resident 97 had an open Insulin Lispro without an open date, and Resident 49 had an unopened Humulin R Solution that was not refrigerated as required. Licensed Practical Nurses V23 and V10 confirmed that insulin should be dated for 28 days and refrigerated until opened, respectively. The facility's policy on medication storage and labeling, dated December 2017, mandates that medications requiring refrigeration must be stored in a refrigerator and that insulin pens should be dated when opened and disposed of if expired. These policies were not adhered to, resulting in the deficiencies observed during the survey.
Failure to Ensure Proper Self-Administration of Medication
Penalty
Summary
The facility failed to determine the appropriateness of self-administration of medication for three residents, leading to medications being left at their bedside without proper authorization or assessment. One resident was observed with a Colace capsule left on their bedside table, which they did not want to take. The nurse admitted to not staying with the resident to ensure the medication was taken and acknowledged that the medication should not have been left at the bedside. The resident's records showed no physician order for self-administration and no assessment confirming the resident's ability to self-administer medication safely. Another resident was found with an inhaler and a lidocaine patch on their bedside table. The resident stated they had been using the inhaler since an asthmatic attack a month ago and planned to apply the patch after a shower. The nurse confirmed that there were no orders for self-administration and that medications should not be left at the bedside. The resident's records also lacked documentation of a self-administration assessment and physician order. A third resident was observed with a medicine cup containing a yellow substance with pink flecks, later identified as Depakote mixed with applesauce. The resident's cognitive assessment indicated they were not cognitively intact, and there was no documentation of a self-administration assessment or physician order. The nurse confirmed that the medication had been signed off as administered, but it was left at the bedside without proper authorization. The facility's policy requires a physician's order and an interdisciplinary team assessment to determine if a resident can safely self-administer medication, which was not followed in these cases.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to place a resident's call light in a position that allowed the resident to utilize it. The resident, who has paraplegia and contracted hands, was found lying in bed with the call light cord tucked under a pillow, making it inaccessible. The resident stated that the facility usually straps the call light to their wrist, but staff forgot to do so that morning. As a result, the resident was unable to call for assistance and had to call out verbally multiple times before a nurse responded. The resident's comprehensive care plan indicated that the call light should be within reach and answered in a timely fashion. However, during the surveyor's observation, the call light was not attached to the resident's wrist strap as required. The facility's policy also mandates that call lights be placed within the resident's reach at all times. The deficiency was confirmed when a nurse eventually entered the room, repositioned the resident, and attached the call light to the resident's wrist strap, as per the care plan and facility policy.
Failure to Ensure Proper Use and Functioning of Low Air Loss Mattresses
Penalty
Summary
The facility failed to ensure the availability and proper functioning of low air loss mattresses for two residents with pressure ulcers. One resident, admitted with a Stage IV pressure ulcer, did not have a low air loss mattress in place because it was removed due to malfunctioning. The wound care nurse confirmed the absence of the mattress and noted that it was removed possibly on 4/15/24. The Director of Nursing acknowledged that the low air loss mattress is essential for distributing pressure and aiding in wound healing, and the resident's care plan included the use of such a mattress. Another resident, who had a history of a healed Stage III pressure ulcer, was observed lying on a low air loss mattress that was incorrectly set between 180 and 210 pounds, despite the resident weighing only 99.8 pounds. The mattress was malfunctioning, causing the resident to sink into it. The wound care nurse and licensed practical nurse confirmed the incorrect setting and malfunction, and the mattress was eventually replaced. The Director of Nursing stated that a malfunctioning mattress could create additional issues and emphasized the need for proper weight distribution. The facility's policies on pressure ulcer prevention and low air loss mattress usage were not followed, leading to these deficiencies. The policies required regular checks of the mattress to ensure proper functioning and setting the mattress according to the resident's weight. Both residents were at high risk for skin breakdown, and the failure to provide and correctly set the low air loss mattresses compromised their care and safety.
Failure to Apply Prescribed Splints and AFOs
Penalty
Summary
The facility failed to ensure that the left-hand splint and left Ankle Foot Orthosis (AFO) were in place for two residents, R38 and R54, who were reviewed for limited range of motion. Observations on multiple occasions revealed that both residents were without their prescribed splints and AFOs. Specifically, R54 was observed without her left-hand splint and left AFO while resting in bed and later while up in a wheelchair. Similarly, R38 was observed without his left-hand splint while sitting in a Geri chair. Both residents' care plans and physician orders indicated the necessity of these devices to be applied daily to prevent worsening of contractures and deformities, yet there was no documentation of refusal by the residents on the observed dates. R38's health record indicated multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction, chronic fatigue, and repeated falls, among others. His care plan required the application of a left-hand splint daily for four hours or as tolerated. R54's health record also documented multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction, chronic bronchitis, and age-related osteoporosis. Her care plan required the application of a left-hand splint and left AFO when out of bed. The facility's restorative nurse confirmed the importance of these devices in maintaining and improving contractures and deformities, yet the devices were not applied as required by the care plans and physician orders.
Failure to Implement Fall Precautions for At-Risk Resident
Penalty
Summary
The facility failed to ensure fall precautions were in place for a resident at risk for falls. The resident's Fall Risk Evaluation indicated a risk for falls, and the comprehensive care plan included interventions such as floor mats and keeping the bed in the lowest position. However, during observations, the floor mats were found folded and not laid flat, and the bed was not in its lowest position. These observations were made on two separate occasions, indicating a failure to implement the prescribed fall precautions consistently. Interviews with staff confirmed that the floor mats should be laid flat as a precautionary measure to prevent injury. The facility's Fall Management policy and Care Plans policy emphasize the need for implementing and adjusting fall prevention measures as needed. Despite these policies, the staff did not adhere to the prescribed interventions, leading to a deficiency in ensuring the resident's safety from fall hazards.
Failure to Properly Store Oxygen Cannula Tubing
Penalty
Summary
The facility failed to properly store oxygen cannula tubing for a resident, identified as R103, when not in use. On multiple occasions, surveyors observed the oxygen cannula tubing attached to both an oxygen concentrator and a portable oxygen tank hanging uncovered and not stored in a plastic bag. This was noted both when the resident was not in the room and when the resident was using the oxygen concentrator. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the tubing should be stored in a plastic bag to maintain cleanliness and prevent infection. Despite this, the resident stated that the tubing was changed frequently, implying it did not have time to get dirty. R103 has a medical history that includes acute and chronic respiratory failure with hypoxia, opioid dependence, psychoactive substance abuse, drug-induced myopathy, type 2 diabetes mellitus, hypertension, and long-term use of anticoagulants. The resident's care plan and medical orders indicate continuous use of oxygen therapy via nasal cannula at two liters per minute. The facility's policy on oxygen care and storage, dated December 2017, mandates that oxygen tubing must be stored in a bag when not in use, a protocol that was not followed in this instance.
Failure to Obtain Medication Consents and Care Plan for Antidepressant Use
Penalty
Summary
The facility failed to obtain medication consents and care plan for the use of an antidepressant for a resident, identified as R85, in a sample of 26 residents. R85 was prescribed Nortriptyline HCl 10 MG for depression and received the medication since admission. The medication was discontinued and reordered multiple times between January 2023 and April 2024. However, the facility did not provide the initial consent for Nortriptyline from admission or for the reorder on April 2, 2024. The only consent provided was dated November 29, 2023. Additionally, the facility did not include Nortriptyline in R85's comprehensive care plan, which is a requirement according to the facility's Psychotropic Medication policy dated November 2013. The surveyor requested R85's psychotropic consents multiple times on April 18, 2024, both verbally and via electronic mail, but the facility failed to provide the necessary documentation. The facility's policy mandates that an informed consent must be obtained prior to starting the medication and that a care plan should be developed and updated quarterly or more frequently as needed. The care plan should include resident goals, findings from the comprehensive assessment, non-pharmaceutical interventions, and potential adverse reactions. The facility's failure to adhere to these requirements led to the identified deficiency.
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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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