Piper City Rehab & Living Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Piper City, Illinois.
- Location
- 600 Maple Street, Piper City, Illinois 60959
- CMS Provider Number
- 145489
- Inspections on file
- 26
- Latest survey
- November 19, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Piper City Rehab & Living Ctr during CMS and state inspections, most recent first.
A facility failed to provide a resident with the required notice of transfer/discharge, omitting the right to appeal and contact information for advocacy agencies. The resident, with mental health diagnoses and moderate cognitive impairment, was informed of the facility's closure without receiving the necessary written notice. The omission was confirmed by the Regional Director of Operations.
A facility failed to document discharge planning for a resident with moderate cognitive impairment and mental health diagnoses during an involuntary transfer due to facility closure. Despite discussions with the resident and their family, the discharge planning was not recorded in the medical record, leading to a deficiency in the process.
A resident with dementia physically abused another resident, who is blind and on blood thinners, by punching them in the face, causing a cut. The incident occurred during the night shift when the aggressor became agitated over perceived preferential treatment. The facility's policy on abuse prevention was not effectively implemented, resulting in a failure to protect the resident from harm.
The facility failed to employ a DON and did not provide RN services for eight consecutive hours daily, affecting all 36 residents. The Assistant DON confirmed the absence of a DON and inconsistent RN coverage. The nursing schedule documented multiple days without the required RN coverage, contrary to the facility's policy of maintaining 24/7 RN availability.
A facility failed to implement fall interventions and provide supervision for a resident at risk for falls, resulting in a hip fracture requiring surgery. Despite multiple falls and a care plan for 15-minute safety checks, there was no documentation of these checks being conducted. Observations showed the absence of a floor cushion, and staff were unaware of the need for fall mats, contrary to the facility's fall prevention policy.
The facility failed to address significant weight loss in three residents, leading to deficiencies in their nutritional care. One resident lost 24.68% of their weight over six months due to the facility's failure to implement the dietician's recommendations and notify relevant parties. Another resident's weight dropped from 150 to 122 pounds, with the facility not providing the recommended supplements. A third resident experienced an 11.87% weight loss, with the facility not following dietary recommendations. These failures resulted in significant nutritional deficiencies.
The facility failed to employ a DON for over a year and did not provide RN services for eight consecutive hours, seven days a week, potentially affecting all 36 residents. The nursing schedule showed gaps in RN coverage, and an LPN confirmed the absence of a DON and verified the schedule's accuracy. The facility's policy requires 24/7 RN coverage to ensure resident safety.
The facility failed to maintain proper food safety and sanitation standards, affecting all 36 residents. Unlabeled and expired items were found in an unclean refrigerator, and a greasy range hood had not been tested due to payment issues. A resident consumed moldy bread, highlighting lapses in food safety monitoring.
The facility did not ensure that key personnel, including the Administrator, DON, Infection Preventionist, and Medical Director, attended the required quarterly QAA committee meetings. This absence was confirmed by the Resident Care Coordinator, potentially affecting all 36 residents in the facility.
The facility failed to have an onsite certified Infection Preventionist working at least part-time, potentially affecting all 36 residents. The Resident Care Coordinator confirmed the absence of a part-time Infection Preventionist, with the Regional Nurse only filling in occasionally. Facility documents highlight the need for an Infection Control and Preventionist.
The facility failed to obtain informed consent for psychotropic medications for four residents, as required by their policy. Residents with conditions such as Bipolar Disorder, Dementia, and Depression were administered medications like Nortriptyline, Effexor, and Quetiapine without documented consent. The oversight was acknowledged by staff, indicating a systemic issue in consent documentation.
A resident's medications were not administered according to physician's orders and within the designated time frame, resulting in a 44% medication error rate. An LPN administered the resident's 6:00 AM medications too early, and the facility was out of Risperdal, leading to a missed dose. The resident had multiple medications for conditions like anemia and epilepsy, and the facility's policy allows for administration within one hour before and after the scheduled time.
A resident with Autism and other conditions missed five out of six doses of Risperdal due to the facility running out of the medication. This led to increased autistic-related behaviors. The issue was linked to improper handling of the medication bottle, causing spillage, and a denied refill request by insurance.
The facility failed to provide written Notices of Medicare Non-Coverage (NOMNC) for three residents who had leftover Medicare days when discharged from services. During a survey, it was found that the facility did not have any NOMNC notices available, and the Social Services Director could not locate them. The Administrator confirmed the absence of these notices, indicating a lapse in the documentation process for Medicare coverage notifications.
A facility failed to provide routine showers for a resident diagnosed with Cerebral Infarction and other conditions, who is dependent on staff for showering. Despite the facility's policy for weekly showers, the resident reported not receiving showers twice a week as preferred, with records indicating ten missed showers over a period. The Resident Care Coordinator confirmed the issue was due to staff call-offs, leading to insufficient staff to assist.
A facility failed to notify a physician or update the care plan for a resident with a pressure ulcer. The resident, with multiple diagnoses including cognitive decline and diabetes, had a pressure ulcer on the right heel that was not documented or treated. An LPN discovered the ulcer during an observation, and the care plan lacked necessary interventions, contrary to the facility's policy.
The facility failed to obtain ordered urinalysis tests for two residents due to a lack of proper collection tubes. Despite the arrival of specimen cups, the staff did not send the urinalysis for one resident, while the other resident's urine specimen showed organisms growing, and the facility awaited further physician orders. The Resident Care Coordinator acknowledged the issue and the residents' need for better care.
Two residents experienced deficiencies in oxygen therapy care. One resident had outdated oxygen tubing and water, contrary to weekly change orders, while another had an empty humidification bottle and incorrect oxygen flow rate. Both cases involved non-compliance with physician orders and facility policy.
A facility failed to label an open insulin pen with the date it was first opened, as required for medications with shortened expiration dates. An LPN was observed preparing an Admelog insulin pen for a resident without the necessary date, which was confirmed by the LPN and the Resident Care Coordinator. The facility's policy mandates dating such medications to ensure proper usage.
The facility failed to provide the correct consistency for pureed diets for three residents. The policy requires pureed food to be smooth and pudding-like, but the pureed ham served contained chunks, posing a choking risk. The dietary manager and dietician confirmed the inconsistency and the potential hazard.
Failure to Provide Adequate Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide adequate notice prior to the transfer or discharge of a resident, specifically omitting the resident's right to an appeal and the necessary contact information for advocacy and protection agencies. The facility's policy, revised in October 2022, mandates that all written notices of transfer or discharge include these details. However, the Notice of Closure letter sent to residents and their families did not contain this critical information. This oversight was identified in the case of a resident with a history of mental health issues, including Bipolar Disorder and Anxiety Disorder, who was discharged without receiving the required notice. The resident, who had moderate cognitive impairment, was informed of the facility's closure by the Regional Director of Operations. Despite the resident's request to involve their family in the decision-making process, there was no documentation that the family received the necessary written notice, including the right to appeal and contact information for advocacy agencies. The Social Services Director confirmed that corporate staff discussed the closure with residents and families, but the Regional Director of Operations acknowledged the omission of critical information in the written notice provided to the resident and their family.
Failure to Document Discharge Planning for Resident Transfer
Penalty
Summary
The facility failed to document coordination of discharge planning for a resident (R4) who was subject to involuntary transfer due to the facility's planned closure. The facility's closure and relocation plan indicated that they would meet with residents and their representatives to discuss alternative placements and assist with transfers. However, there was a lack of documented communication and coordination with R4 and their family (V11) regarding discharge planning. R4, who had moderate cognitive impairment and a history of Bipolar Disorder, Anxiety Disorder, and Cognitive Communication Deficit, was anxious about leaving the facility, as they had resided there for a long time. The facility's records show that the Regional Director of Operations met with R4 to discuss the closure, but subsequent communication with R4's family was not documented until a voicemail was left on 11/13/24. The Social Services Director and Resident Care Coordinator confirmed that discharge planning was not documented in R4's medical record, despite discussions with R4's family about potential placements. Ultimately, R4 was transferred to a sister facility, but the lack of documented discharge planning and coordination with the resident and their family constitutes a deficiency in the facility's discharge planning process.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident, R2, from physical abuse by another resident, R1. R1, who suffers from severe cognitive impairment due to dementia, punched R2 in the face, resulting in a cut above R2's eye. This incident occurred during the night shift when R1 became agitated after using the restroom and accused R2 of receiving too much attention from the nursing staff. R2, who is blind and on blood thinners, was unable to see the attack coming and subsequently bled from the injury. The incident was reported to the local sheriff's department, and a police report was filed. The report details that R2 informed the responding deputy that R1 hit R2 because R1 was upset about the attention R2 was receiving from the nurses. R1 admitted to the deputy that R1 hit R2, but due to R1's dementia, R1 was unable to provide a coherent explanation for the behavior. The facility's Assistant Director of Nursing (ADON) was informed of the incident and conducted interviews with the staff involved, confirming the details of the event. The facility's policy on 'Abuse Prevention and Reporting' emphasizes the residents' right to be free from abuse and outlines the facility's commitment to preventing such occurrences. Despite this policy, the facility did not prevent the physical abuse of R2 by R1, highlighting a failure in ensuring a safe environment for its residents. The staff's response involved removing R1 from the room and administering first aid to R2, but the initial failure to prevent the abuse remains a significant concern.
Failure to Maintain Required RN Coverage and Employ a DON
Penalty
Summary
The facility failed to employ a Director of Nursing (DON) and did not provide the services of a Registered Nurse (RN) for eight consecutive hours, seven days a week, which has the potential to affect all 36 residents residing in the facility. On a specific date, the Assistant Director of Nursing confirmed that the facility had been without a DON for a long time and lacked consistent RN coverage. The nursing working schedule from the beginning to the end of the month documented multiple days where the facility did not have RN coverage for the required hours. The facility's policy stated the need for RN coverage 24/7 to ensure resident safety and compliance with regulations, but this was not adhered to as per the documented schedule.
Failure to Implement Fall Interventions and Supervision
Penalty
Summary
The facility failed to implement resident-centered fall interventions and provide adequate supervision to prevent a fall for a resident identified as R187. Despite being at risk for falls due to multiple health conditions, including altered mental status and age-related cognitive decline, the facility did not initiate specific fall interventions following several falls. The resident experienced multiple falls, with the most recent resulting in a fractured hip that required hospitalization and surgical repair. The care plan included a 15-minute safety check intervention, but there was no documentation to support that these checks were initiated after the resident's readmission from hip surgery. Observations and interviews revealed that the resident did not have a floor cushion in place as recommended, and staff were unaware of the need for fall mats. The facility's fall prevention policy requires staff to observe residents for safety and document any new interventions following a fall. However, the policy was not followed, as evidenced by the lack of documentation and implementation of necessary interventions. The failure to adhere to the policy and provide adequate supervision contributed to the resident's fall and subsequent injury.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in three residents, leading to deficiencies in their nutritional care. Resident R23 experienced a 24.68% weight loss over six months, with the facility failing to implement the dietician's recommendations for nutritional supplements and not notifying the physician, dietician, or resident's representatives of the weight loss. The dietician noted that the facility did not provide accurate monthly weights, which hindered her ability to assess residents properly. Despite recommendations for increased nutritional support, the facility did not follow through, contributing to R23's continued weight loss. Resident R28 also suffered from weight loss, dropping from 150 pounds in March to 122 pounds in July. The facility did not implement the dietician's recommendation for a two-calorie supplement, and during an observation, R28 did not receive the prescribed protein at breakfast. The dietary manager confirmed that the supplement had not been provided, and the dietician expressed concern that the lack of supplementation could contribute to further weight loss. Resident R16 experienced a weight loss of 11.87% over six months. The dietician had recommended supplemental shakes and a med pass to address the weight loss, but these were not provided during observed meals. The dietician confirmed that the failure to follow dietary recommendations likely contributed to R16's ongoing weight loss. The facility's inability to document accurate weights and implement dietary interventions as recommended by the dietician resulted in significant nutritional deficiencies for these residents.
Failure to Maintain RN Coverage and Employ a DON
Penalty
Summary
The facility failed to employ a Director of Nursing (DON) for over a year and did not provide the services of a Registered Nurse (RN) for eight consecutive hours, seven days a week. This deficiency potentially affects all 36 residents residing in the facility. The resident roster dated July 14, 2024, confirms the presence of 36 residents. The nursing working schedule from July 1, 2024, to July 14, 2024, shows that the facility lacked RN coverage for eight consecutive hours on July 3, 5, 9, and 12, 2024. A Licensed Practical Nurse (LPN) confirmed the absence of a DON for about a year and verified the accuracy of the RN coverage documentation. The facility's policy, which is undated, states that RN coverage should be available 24/7 to ensure the health and safety of residents, in accordance with Illinois Department of Public Health regulations.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation standards, which could potentially affect all 36 residents. Observations revealed that refrigerated items, including chocolate syrup, ice cream toppings, a glass of milk, and a cup of sour cream, were not labeled with dates, and five packs of string cheese were expired. The refrigerator storing these items was found to be unclean, with dried spillage and old debris. The Dietary Manager acknowledged the issue and stated that the items had been disposed of and the refrigerator cleaned. Additionally, the range hood in the kitchen was observed to be greasy with dust and debris, and it had not been tested since a previous date due to a lack of payment to the fire suppression company responsible for its maintenance. A resident was observed eating a piece of moldy bread at the breakfast table, having consumed half of the slice before the mold was noticed. The Dietician confirmed that she had previously discarded moldy bread during a kitchen evaluation. The facility's Kitchen Sanitation policy mandates compliance with public health standards and the development of a cleaning schedule, while the Food Safety bulletin requires that expired food or beverages be discarded immediately and that all items be labeled and dated for safety monitoring.
Failure to Ensure Required Attendance at QAA Meetings
Penalty
Summary
The facility failed to ensure that the required personnel attended the quarterly Quality Assessment and Assurance (QAA) committee meetings, which are essential for maintaining and improving safety and quality within the facility. The QAPI Committee, as documented in the facility's agenda plan, should include the Administrator, Director of Nurses, Infection Preventionist, and Medical Director. However, the review of the meeting sign-in sheets for the past year revealed that these key members were absent from multiple meetings. Specifically, on three separate occasions, the Administrator, Director of Nurses, Infection Preventionist, and Medical Director were not present as required. This absence was confirmed by the Resident Care Coordinator, who verified the signatures and acknowledged the non-attendance of the necessary committee members. This deficiency has the potential to impact all 36 residents residing in the facility.
Lack of Onsite Infection Preventionist
Penalty
Summary
The facility failed to designate an onsite certified Infection Preventionist who works at least part-time, which has the potential to affect all 36 residents. During the survey conducted from July 14 to July 16, 2024, it was observed that there was no Infection Preventionist working part-time in the facility. On July 15, 2024, the Resident Care Coordinator confirmed that the facility had not employed a part-time certified Infection Preventionist for a long time. The Regional Nurse occasionally fills in but is only present two days a month, which is insufficient to fulfill the Infection Preventionist duties part-time. The facility assessment and the Long Term Care Facility Application for Medicare and Medicaid both document the need for an Infection Control and Preventionist to provide competent support and care for the resident population.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications for four residents, as required by their Psychotropic Medication Policy. The policy mandates that psychotropic medications should not be prescribed or administered without the informed consent of the resident, their guardian, or an authorized representative. Additionally, the policy requires behavior tracking for residents receiving such medications. However, the facility did not adhere to these requirements for residents diagnosed with various mental health conditions, including Bipolar Disorder, Dementia with Behavioral Disturbances, Depression, and other psychiatric disorders. Resident R18 was receiving Nortriptyline and Lamotrigine for Bipolar Disorder without consent until it was obtained belatedly. Similarly, R25 was administered Effexor and Lexapro for Dementia with Behavioral Disturbances and Depression without prior consent. R2's medical records lacked documentation of consent for Zolpidem Tartrate, Quetiapine, and Lorazepam, which were being administered. Lastly, R24's consents for Quetiapine, Clonazepam, and Trazodone were not located, and the Social Services Director acknowledged the oversight. These lapses indicate a systemic issue in obtaining and documenting informed consent for psychotropic medications.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications in accordance with physician's orders and within the designated time frame for a resident reviewed for medication administration. The facility's policy allows for medication administration within a window of one hour before and after the scheduled time. However, a Licensed Practical Nurse (LPN) administered the resident's 6:00 AM medications via a gastrostomy tube before 5:00 AM, which is outside the allowed time frame. Additionally, the facility did not have the resident's Risperdal medication available, resulting in a missed dose at 12:00 PM. The resident in question had multiple medications prescribed for conditions including anemia, seizures, epilepsy, and behaviors related to autistic disorder. The medication administration record indicated that all medications were scheduled for 6:00 AM. On the day of the survey, the LPN confirmed administering the medications too early and acknowledged the absence of Risperdal, which was not administered at the scheduled time due to being out of stock. The staff member responsible for coordinating resident care stated that in such cases, the pharmacy should be contacted immediately, and if the medication cannot be refilled, the physician should be notified.
Significant Medication Error Due to Insufficient Risperdal Supply
Penalty
Summary
The facility failed to ensure that a resident, identified as R33, was free from significant medication errors. R33, who has diagnoses including Autism, Epilepsy, and Traumatic Brain Hemorrhage, was prescribed Risperdal to manage behaviors associated with Autism. However, the Medication Administration Record revealed that R33 missed five out of six scheduled doses of Risperdal over a three-day period. This lapse in medication administration coincided with increased autistic-related behaviors, as R33 was observed hollering loudly on multiple occasions. The deficiency was attributed to the facility running out of Risperdal, as confirmed by a Licensed Practical Nurse (LPN) who stated that the medication was unavailable and that the pharmacy had been contacted for more. The Consultant Pharmacist noted that missing doses would increase R33's irritability. The Dispensing Pharmacist indicated that a 30 ml bottle of Risperdal had been sent and should have lasted 13 days, but an electronic request for a refill was denied by insurance as it was too soon. The Resident Care Coordinator suggested that the medication was running out because staff were not securing the bottle cap properly, leading to spillage.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a written Notice of Medicare Non-Coverage (NOMNC) for three residents who were reviewed for Medicare Non-Coverage notices. This deficiency was identified during a survey where it was found that the facility did not have any NOMNC notices available for these residents, despite them having leftover Medicare days when discharged from Medicare services. The Social Services Director was unable to locate any NOMNC notices in the building, and the Administrator confirmed that the notices were not available. This issue was identified through interviews and record reviews, highlighting a lapse in the facility's documentation process for Medicare coverage notifications.
Failure to Provide Routine Showers
Penalty
Summary
The facility failed to provide routine showers for a resident, identified as R12, who was reviewed for showers in a sample list of 30. According to the facility's Bath/Shower Policy dated January 2018, all residents are scheduled to receive at least one shower weekly, with staff required to report any pertinent observations or refusals to the Charge Nurse. R12, who is diagnosed with Cerebral Infarction, Seizures, Aphasia, Hemiplegia Right Side, and Unsteadiness of Feet, is cognitively intact and dependent on staff for showering. R12 reported not receiving showers twice a week as preferred, with staff either not offering or stating unavailability to assist. Records from 5/6/24 through 7/15/24 show R12 missed ten scheduled showers. The Resident Care Coordinator confirmed that showers were not completed due to staff call-offs, resulting in insufficient staff to assist, and acknowledged that R12's showers were scheduled for Tuesdays and Fridays, which should align with resident preferences.
Failure to Notify Physician and Update Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to notify the physician or seek treatment orders for a resident with a pressure ulcer. The resident, identified as R187, had a care plan updated on 6/29/24, which included diagnoses such as altered mental status, age-related cognitive decline, chronic kidney disease stage III, type II diabetes with polyneuropathy, depression, and anxiety. On 7/14/24, a roommate of the resident mentioned a sore on R187's right heel. A progress note from 7/13/24 documented the resident's arrival via ambulance and noted a pressure ulcer starting on the left heel, but there was no documentation of physician notification or treatment orders for the pressure ulcer. On 7/15/24, an LPN observed the resident in bed with heel protectors and discovered a purple unstageable pressure ulcer on the right heel, which was not previously documented. The LPN was unaware of the ulcer, and the resident's care plan did not include interventions for the pressure ulcer. The facility's policy on pressure ulcer prevention requires that skin risk and appropriate interventions be included in the care plan, and if a pressure ulcer develops, the care plan must be updated with interventions for healing and prevention. However, this was not done for R187.
Failure to Obtain Ordered Urinalysis Tests
Penalty
Summary
The facility failed to obtain ordered urinalysis tests for two residents, R22 and R34, who were reviewed for urinary tract infections. For R22, a physician's order for a urinalysis test was documented on 7/9/24. However, the progress notes on the same date indicated that the nurse was unable to obtain the specimen due to the lack of proper collection tubes on site. Despite the arrival of specimen cups on 7/12/24, the staff failed to send the urinalysis. As of 7/16/24, the specimen had still not been sent, as confirmed by the Resident Care Coordinator. Similarly, for R34, a physician's order for a urinalysis test was documented on 7/11/24. The progress notes indicated an attempt to collect the specimen, but proper tubes were not available in the facility. Although a urine specimen dated 7/12/24 showed organisms growing, the facility was still waiting for the physician to order an antibiotic based on the culture as of 7/16/24. The Resident Care Coordinator acknowledged the facility's dependency on the laboratory for supplies and expressed that the residents deserve better care.
Oxygen Therapy Deficiencies for Two Residents
Penalty
Summary
The facility failed to adhere to its own Oxygen Therapy Policy, which mandates that oxygen tubing, masks, and cannulas be changed weekly and dated. For one resident, identified as R22, the oxygen tubing and water were observed to be dated 7/2/24, despite the physician's order requiring weekly changes every Friday on the night shift. This discrepancy was confirmed by a Licensed Practical Nurse (LPN), who acknowledged that the tubing and water should be changed weekly. R22's medical history includes pneumonia, cognitive communication deficit, and hypoxemia, among other conditions, and the resident was receiving oxygen therapy at 1 liter per nasal cannula nightly. Another resident, R6, also experienced deficiencies in oxygen care. The treatment sheet indicated a physician's order for oxygen tubing and humidifier changes every Monday night shift, with a continuous oxygen flow of 3 liters per nasal cannula. However, the oxygen humidification bottle was found empty and dated 6/30/24, and the tubing was visibly dirty with white crust on the nasal tubes, lacking a date for the last change. Additionally, the oxygen flow was incorrectly set to 2 liters instead of the prescribed 3 liters.
Failure to Label Insulin Pen with Open Date
Penalty
Summary
The facility failed to properly label an open insulin pen with the date it was first opened, which is a requirement for medications with shortened expiration dates. This deficiency was identified during an observation of a Licensed Practical Nurse (LPN) preparing an Admelog insulin pen for a resident, referred to as R18, who was prescribed the medication for diabetes management. The insulin pen, which had already been opened and used, lacked a date indicating when it was first opened, contrary to the facility's policy and pharmacy's insulin storage recommendations. The incident was confirmed by the LPN during the observation and further verified when the insulin pen was found inside a medication cart without a date. The Resident Care Coordinator, also an LPN, acknowledged that nurses are supposed to date insulin pens upon opening. The facility's policy, revised in 2013, mandates that staff should enter the date opened on the label of medications with shortened expiration dates, such as insulin, to ensure proper storage and usage within the recommended timeframe.
Failure to Provide Correct Pureed Diet Consistency
Penalty
Summary
The facility failed to provide the correct consistency for a pureed diet for three residents who were reviewed for pureed diets. According to the facility's policy dated October 2012, pureed food should be blended to a smooth, pudding-like consistency. However, during an observation on July 14, 2024, the cook stated that the pureed ham was ready to serve, but upon testing, it was found to contain chunks of ham. The dietary manager confirmed the presence of chunks and acknowledged that the food needed to be corrected to prevent choking hazards. The dietician also emphasized the importance of maintaining a pudding consistency to avoid choking or aspiration.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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