River Bluff Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockford, Illinois.
- Location
- 4401 North Main Street, Rockford, Illinois 61103
- CMS Provider Number
- 145771
- Inspections on file
- 34
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at River Bluff Nursing Home during CMS and state inspections, most recent first.
A cognitively impaired, obese resident with impaired balance was transferred from bed to wheelchair using a sit-to-stand mechanical lift by two CNAs. After the resident was seated, one CNA left the room while the resident was still attached to the lift by a back strap. As the remaining CNA unhooked the strap, no one was holding the resident or stabilizing the wheelchair, and the resident leaned back, causing the wheelchair to flip backwards and the resident to fall onto the floor. This occurred despite facility policy and leadership expectations that two CNAs remain present and that one staff member stabilize the resident and wheelchair until fully disconnected from the lift. The resident later required hospital evaluation, where imaging showed an acute, unstable thoracic vertebral fracture related to the fall.
A cognitively impaired resident fell backwards from a wheelchair onto his back and was started on Tramadol for pain after a NP was notified by phone. Over the next two days, the resident’s back pain worsened, with documented yelling during movement, staying in bed, and refusing cares due to pain, yet nursing staff did not notify a physician or NP or obtain an in‑person assessment. The resident continued to experience severe pain and refusal of care until a NP and the resident’s POA were finally contacted, leading to transfer to the hospital, where imaging showed an acute, unstable thoracic vertebral fracture. The facility’s pain management policy requiring reassessment and revision of the pain regimen when pain is not adequately controlled was not followed.
A resident fell backwards from a wheelchair, developed lower back pain, and had a lumbar X-ray ordered by an NP. When the X-ray tech attempted the study, it could not be completed due to weight concerns, and the tech did not return with additional support as stated. Staff did not notify the physician, NPs, or the resident’s POA that the ordered X-ray was not completed, and there was no documentation of such notification. The resident’s back pain worsened and the resident was later sent to a hospital, where a thoracic vertebral fracture was diagnosed, revealing that the ordered lumbar X-ray had never been performed despite facility policy requiring appropriate diagnostic services.
A resident with severe cognitive impairment and total dependence for ADLs was found in bed with saturated linens, incontinence brief, and mattress due to delayed incontinence care. Staff were unaware of the last time the resident was checked or changed, and the resident expressed discomfort. The care plan and facility policy required frequent checks and changes, but these were not followed, resulting in the resident being left in a soiled state.
A resident with significant medical needs and a stage III pressure ulcer did not have the required physician-ordered dressing in place during a survey observation, despite documentation indicating the treatment was completed. Staff confirmed the absence of the dressing, representing a failure to follow wound care orders and facility policy.
Multiple residents at risk for falls did not have required safety interventions in place, including a bed alarm that was not properly positioned and call lights that were not within reach. These lapses occurred despite care plans and facility policies mandating such interventions, and resulted in at least one unwitnessed fall and residents being unable to call for assistance.
A resident with an indwelling urinary catheter was found with the catheter bag positioned above bladder level during wound care, causing urine to flow back toward the resident. Staff failed to reposition the bag and tubing below the bladder as required by the care plan and facility policy, resulting in a deficiency.
A resident with significant medical needs received medications and feeding through a gastric tube without proper verification of tube placement using an approved method. Nursing staff relied on outdated practices and were unable to locate a clear facility policy, while the DON acknowledged the policy was vague and under revision.
Two residents did not receive medications as ordered: one was left with medications at bedside without a documented self-administration assessment or care plan, and another did not receive a scheduled dose of lisinopril due to a change in administration time and lack of MAR verification by nursing staff.
Staff did not wear gowns, as required by enhanced barrier precautions, while providing incontinent care and performing a dressing change for a resident with a stage III pressure ulcer. Although gloves were used, the omission of gowns occurred despite clear signage, care plan instructions, and facility policy mandating both gloves and gowns for high-contact care activities.
A resident with Alzheimer's and severe dementia was involved in an abuse incident when a housekeeper attempted to restrain him by grabbing his wrists and walking him backwards, causing the resident to fall. Staff members confirmed that the appropriate response should have been to walk away and allow the resident to calm down. The facility's policy defines such actions as abuse, leading to the housekeeper's termination.
The facility failed to report and investigate an incident where a resident hit another resident, despite multiple staff witnessing the event. Statements were taken by a former ADON, but no formal investigation or report was completed. The administrator and current DON were unaware of the incident, indicating a failure in communication and adherence to the facility's abuse policy.
A resident with multiple health conditions filed grievances but only received verbal responses, contrary to the facility's policy requiring written decisions. The resident requested written responses, particularly for a grievance involving disrespectful staff interaction, but was informed that written resolutions were not provided.
A resident with severe cognitive impairment and a history of falls fell and fractured her hip due to the absence of a required chair alarm in her wheelchair. The chair alarm, intended to alert staff when the resident attempted to get up, was left in a recliner, leading to a delayed response from staff. The resident's care plan included the use of a chair alarm due to her risk factors, but it was not in place at the time of the incident.
A resident with a history of dementia and a left femur fracture experienced a fall and complained of hip pain. An X-ray was ordered but conducted nearly 36 hours later, revealing fractures. Staff indicated delays with the contracted X-ray company, and the resident's family was not informed of the delay or given the option for immediate evaluation. The facility's policy allowed for up to 24-hour delays, but this was not communicated to the family.
Failure to Safely Use Mechanical Lift During Transfer Resulting in Resident Fall and Spinal Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfer and adequate supervision during the use of a sit-to-stand mechanical lift, resulting in a resident fall and injury. The resident involved was cognitively impaired and care planned as being at risk for falls due to impaired cognition, obesity, and impaired balance. According to the incident report and staff interviews, two CNAs used a sit-to-stand lift to transfer the resident from bed to wheelchair. After the resident was placed in the wheelchair, one CNA left the room, even though the resident remained attached to the lift via a strap around his back. As the remaining CNA began to unhook the back strap from the lift, the resident leaned or laid back in the wheelchair, causing the wheelchair to flip backwards and the resident to land directly on his back. The facility’s Assistant DON stated that facility practice requires two staff members to remain with the resident until the resident is completely unhooked from the sit-to-stand lift and securely seated, with one staff operating the lift and the second stabilizing the resident and wheelchair. The facility’s written policy on “Safe Lifting and Movement of Residents, Including Mechanical Lifts” requires at least two CNAs for mechanical and stand lift transfers to safely move residents. In this incident, no one was holding the resident or the wheelchair while the strap was being disengaged, and one CNA had already left the room, contrary to facility expectations and policy. Following the fall, the resident complained of back pain over the next two days and was subsequently sent to the hospital, where a CT scan showed an acute, unstable hyperextension fracture of the eighth thoracic vertebra, attributed to the fall.
Failure to Notify Providers and Manage Worsening Pain After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to effectively manage and treat a cognitively impaired resident’s pain following a fall from a wheelchair. On 2/1/26, the resident fell backwards onto the floor while seated in a wheelchair during care, landing directly on his back. A nurse practitioner was notified by phone of the fall and ordered Tramadol 50 mg every four hours as needed for pain, in addition to the resident’s scheduled Tramadol three times daily. Progress notes for that day documented the fall and the new pain medication order but did not show that the resident was seen or assessed in person by a physician or nurse practitioner on 2/1/26. On 2/2/26, progress notes documented that the resident began complaining of increased back pain with movement, yelling when the head of bed was elevated or lowered or when staff assisted with repositioning. Nursing staff interviews confirmed that the resident stayed in bed, yelled with movement due to back pain, and refused cares because movement worsened his pain. Despite these observations of worsening pain and refusal of care, there was no documentation that the physician or nurse practitioner was notified on 2/2/26, and no evidence that the resident was seen or assessed by a provider that day. The nurse practitioner later stated she had been in the facility seeing other residents on that date but was not informed of the resident’s worsening pain. By 2/3/26, progress notes showed the resident continued to have back pain from the fall, was yelling out when staff attempted to provide care, and refused a shower, stating he hurt too badly. Nursing staff notified a nurse practitioner that morning regarding the resident’s condition and that he was yelling out in pain even when not being touched. The resident’s POA was also notified and requested that he be sent to the hospital. The resident was transferred by ambulance, and a hospital CT scan on 2/3/26 revealed an acute, unstable fracture of the eighth thoracic vertebra consistent with a hyperextension injury from the fall. The facility’s own pain management policy required reassessment and revision of the pain management regimen and plan of care when pain was not adequately controlled, but the record showed no timely provider notification or adjustment of treatment in response to the resident’s worsening pain on 2/1/26 and 2/2/26.
Failure to Complete Ordered Lumbar X-Ray and Notify Providers After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered radiology services were completed or alternative arrangements made after a resident sustained a fall with resulting back pain. The resident fell backwards from a wheelchair onto the floor, landing on his back, and subsequently complained of lower back pain. A nurse practitioner ordered a lumbar X-ray to be completed in the facility, with a physician order specifying 2–3 views of the lower lumbar area related to trauma and pain. When the X-ray technician arrived, the study could not be completed due to weight concerns and the technician stated that an additional tech and a special board would be needed to hold the resident. The X-ray staff did not return to complete the ordered study, and the lumbar X-ray was never performed in the facility. The resident continued to complain of back pain and was later transferred to a local hospital due to worsening pain, where he was diagnosed with a thoracic vertebral fracture. Facility progress notes for the day the X-ray attempt failed contained no documentation that the physician, nurse practitioners, or the resident’s POA were notified that the ordered X-ray was not completed. An LPN confirmed she did not notify the POA or either nurse practitioner that the X-ray was not done. The POA and both nurse practitioners reported they were not informed until the following day, shortly before or on the day the resident was sent to the hospital, that the X-ray had not been completed as ordered. This failure occurred despite a facility policy stating it will provide appropriate diagnostic services, including radiology, in accordance with state and federal guidelines.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A resident with severe cognitive impairment, chronic kidney disease, malnutrition, and other significant diagnoses was found to have not received timely incontinence care. The resident required total to substantial staff assistance for activities of daily living and was always incontinent of urine and bowel, with a documented risk for skin breakdown. During an observation, a certified nurse aide responded to the resident's request to be changed and discovered that the resident's bed linens, incontinence brief, blue pad, bed sheet, bed alarm safety pad, and mattress were all saturated with urine. The resident expressed discomfort, stating she was cold and uncomfortable, and could not recall when she was last changed. The aide was unaware of the last time the resident was checked or changed and noted that the situation was inappropriate, attributing it to possible inexperience among newer staff. The resident's care plan required staff to check and change her incontinence products upon waking, before and after meals, before bed, during nighttime checks, per request, and as needed. The Director of Nurses confirmed that residents should be checked at least every two hours and that being left in urine is a dignity issue and increases the risk for skin breakdown and infection. The facility's policy also stated that residents unable to perform activities of daily living should receive necessary services to maintain hygiene. Despite these protocols, the resident was left in a saturated state, indicating a failure to provide timely and adequate incontinence care.
Failure to Maintain Physician-Ordered Pressure Ulcer Dressing
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including cerebral palsy, chronic obstructive pulmonary disease, polyneuropathy, obesity, osteoarthritis, seizures, peripheral vascular disease, and heart failure, did not have a physician-ordered pressure ulcer dressing in place. The resident had a stage III pressure ulcer on the sacrum, with specific orders for wound care to be performed three times a week and as needed. Documentation indicated that the dressing change was signed off as completed, but during an observation by surveyors, no dressing was found on the resident's pressure wound, nor was it present in the brief. Certified Nursing Assistants confirmed that no dressing was in place during the provision of incontinent care. The resident's care plan and facility policy required adherence to physician orders for wound care and communication of interventions to all relevant staff. The resident was dependent on staff for activities of daily living, including repositioning and incontinence care, and was at high risk for pressure ulcers. Despite these documented needs and orders, the required dressing was not applied or maintained as ordered, resulting in a failure to provide appropriate pressure ulcer care.
Failure to Implement Fall Prevention Interventions and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that fall prevention interventions were consistently implemented for multiple residents identified as being at risk for falls. One resident with a history of stroke, hemiplegia, dementia, and other significant medical conditions was care planned to have a bed alarm in place due to her high fall risk. However, during observation, the bed alarm was found on top of the blankets and not under the resident, rendering it ineffective. This same resident had a recent unwitnessed fall in her room, and documentation indicated that the bed alarm was not activated at the time of the incident. Two additional residents, both with dementia and a history of falls, were observed in their rooms without their call lights within reach. One resident's call light was on an empty bed next to him, and he was unable to locate it, stating he had previously fallen while trying to get up. The other resident's call light was found on the floor, out of reach, and he was unaware of its location. Staff interviews confirmed that call lights should be accessible to residents at all times, and care plans for both residents specified that call lights should be within reach and that residents should be encouraged to use them for assistance. The facility's own policies on fall prevention and call light accessibility require that interventions such as bed alarms and accessible call lights be in place for residents at risk of falls. Despite these policies and individualized care plans, staff failed to ensure that these safety measures were consistently implemented, resulting in residents being left without necessary fall prevention interventions.
Catheter Bag Improperly Positioned Above Bladder Level
Penalty
Summary
A deficiency was identified when a resident with a history of stroke, dementia, and a stage IV pressure injury was observed with an indwelling urinary catheter bag positioned above the level of her bladder. During wound care provided by an LPN and a Unit Manager/RN, the resident was in bed with her feet elevated, and the catheter drainage bag was attached to the footboard, even with her feet and above her bladder. The drainage tubing was on the bed, and during repositioning, urine was seen flowing back toward the resident and away from the bag. After the wound care was completed, the staff exited the room without repositioning the catheter bag and tubing below the bladder level. Interview with the LPN confirmed that the catheter bag was incorrectly placed and acknowledged that it should have been hanging lower, off the bed frame, to prevent backflow. The resident's care plan specifically directed that the catheter bag and tubing be positioned below the level of the bladder, and the facility's catheter care policy also required this practice to discourage backflow of urine. The failure to follow these protocols resulted in the identified deficiency.
Failure to Verify Feeding Tube Placement Using Approved Method
Penalty
Summary
A deficiency occurred when staff failed to verify the placement of a gastric feeding tube using an approved method prior to administering medications and a bolus feeding to a resident. The resident in question had multiple diagnoses, including colon cancer, stroke, high blood pressure, and hemiplegia, and was dependent on staff for all care, including tube feeding. During observation, a registered nurse checked tube placement by injecting air into the tube and listening with a stethoscope, a method that is no longer considered best practice. The nurse then proceeded to administer medications and feeding through the tube. Interviews with nursing staff revealed uncertainty regarding the facility's policy for verifying tube placement, with both the nurse involved and another RN unable to locate a clear policy. The Director of Nursing acknowledged that the current policy was vague and in the process of being updated, and confirmed that air insufflation is not the best practice. Facility guidelines and care plans required verification of tube placement before administering feedings or medications but did not specify the method to be used.
Failure to Administer Medications as Ordered and Lacking Self-Administration Assessment
Penalty
Summary
The facility failed to ensure that physician-prescribed medications were administered as ordered for two residents. In the first case, a resident with multiple diagnoses including dementia, diabetes, and chronic kidney disease was found with four assorted pills left on her bedside table, which she identified as her morning medications. She reported that the nurse leaves her medications for her to take at her convenience, but she was unable to identify the pills or their purpose. Review of her records showed no assessment or documentation indicating she was capable of self-administering her medications, nor was there any care plan reflecting self-administration, contrary to facility policy. In the second case, a resident with colon cancer, stroke, and hemiplegia, who is dependent on staff for all care, did not receive a prescribed dose of lisinopril as ordered. The nurse prepared and administered several medications but omitted the lisinopril, which was scheduled for the morning medication pass. The MAR showed the time for lisinopril administration had recently changed, and the nurse was unsure if it had been given. The MAR was not signed for the administration of lisinopril, and the DON confirmed that the MAR should be referenced to ensure all medications are given as ordered. Facility policy requires verification of medications against the MAR prior to administration.
Failure to Use Required PPE During High-Contact Care Under Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow enhanced barrier precautions while providing care to a resident with multiple complex medical conditions, including a stage III pressure ulcer. During observed episodes of incontinent care and a dressing change, certified nursing assistants and a licensed practical nurse wore gloves but did not don gowns, despite clear signage and care plan instructions requiring both gloves and gowns for high-contact activities under enhanced barrier precautions. The care plan and posted signage specified that gowns and gloves were necessary for activities such as changing briefs, providing hygiene, and wound care for residents on these precautions. The facility's policies, as well as statements from the unit manager, confirmed that staff are required to wear gowns and gloves when providing high-contact care to residents on enhanced barrier precautions. Documentation showed that the resident had an active order for wound care and was assessed with a stage III pressure ulcer. Despite these requirements and the presence of clear instructions, staff did not comply with the expected infection control protocols during the observed care events.
Resident Abuse Incident Involving Physical Restraint
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse, as evidenced by an incident involving a resident with Alzheimer's disease, severe dementia with agitation, and other conditions. The resident, who has a history of becoming physically aggressive due to anger, dementia, and poor impulse control, was involved in an incident where a housekeeper, V9, attempted to physically restrain him. The resident was walking around the facility when V9 tried to direct him to a chair by grabbing his wrists and walking him backwards, resulting in the resident falling. Multiple staff members, including a CNA, LPN, and unit attendant, witnessed the incident and confirmed that V9 held the resident's wrists and forcefully walked him backwards, which led to the fall. The LPN and other staff members indicated that the appropriate response to the resident's agitation should have been to walk away and allow the resident to calm down, rather than physically restraining him. The incident was considered abuse by the staff, as it involved the willful infliction of physical harm and mental anguish on the resident. The facility's policy on abuse, neglect, and exploitation emphasizes the protection of residents from abuse by anyone, including staff. The policy defines abuse as the willful infliction of injury or unreasonable confinement, which aligns with the actions taken by V9 during the incident. The Director of Nursing and the Administrator both acknowledged that V9's actions were inappropriate and constituted abuse, leading to V9's termination.
Failure to Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that allegations of resident-to-resident abuse were immediately reported and investigated. Specifically, an incident occurred where one resident (R2) hit another resident (R3) in the dining room, which was witnessed by several staff members, including a Unit Attendant (V5) and a CNA (V7). Despite these observations, the incident was not reported to the facility's administrator or documented as required by the facility's abuse policy. The policy mandates that any incident, allegation, or suspicion of abuse must be reported immediately to the administrator or a supervisor, who must then inform the administrator. However, the administrator (V1) and the current Director of Nursing (V2) were unaware of the incident, indicating a breakdown in communication and reporting procedures. Interviews with staff revealed that statements were taken by the former Assistant Director of Nursing (V18), but no formal investigation or report was completed or submitted to the proper authorities. The facility's administrator confirmed that no abuse allegations or investigations had been reported in the past two months, despite the incident occurring in September. This lack of documentation and failure to follow the established abuse reporting protocol resulted in a deficiency, as the facility could not provide any reports or documentation of an investigation regarding the incident between R2 and R3.
Failure to Provide Written Grievance Decision
Penalty
Summary
The facility failed to ensure that a resident received a written grievance decision, as required by their grievance policy. The resident, who is diagnosed with peripheral neuropathy, Type 2 diabetes, obesity, heart failure, chronic kidney disease stage 3, and peripheral vascular disease, had filed grievances but only received verbal responses. During an interview, the resident expressed that he did not receive written responses to his grievances, despite requesting them. The facility's policy mandates that a written decision be provided to the resident at the conclusion of the grievance investigation. The resident's grievance dated 6/9/24 involved an incident of rude and disrespectful conversation with a staff member. The grievance specifically requested both a verbal and written response. However, the Director of Nursing informed the resident that written grievance resolutions were not provided, contradicting the facility's policy. The policy clearly outlines that the grievance official is responsible for issuing a written decision, including details such as the date received, investigation steps, findings, and any corrective actions taken.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure fall prevention interventions were in place for a resident with a history of falls, resulting in the resident falling and fracturing her left hip. The resident, who had severe cognitive impairment and was dependent on staff for transfers, was supposed to have a chair alarm in her wheelchair as part of her care plan. However, on the morning of the incident, the chair alarm was not in place, as it had been left in a recliner the previous night. The incident occurred when a CNA transferred the resident to her wheelchair and left her at the nurses' station without realizing the chair alarm was missing. Shortly after, the resident was found sitting on the floor with her back against another resident's wheelchair. The CNA and LPN on duty confirmed that the chair alarm was not in the wheelchair at the time of the fall, which was supposed to alert staff when the resident attempted to get up. The Director of Nursing and other staff members acknowledged the importance of chair alarms in preventing falls, especially during shifts with fewer staff. The resident's care plan clearly indicated the need for a chair alarm due to her risk factors, including confusion, weakness, and a history of falls. The lack of the chair alarm contributed to the delay in staff response, ultimately leading to the resident's fall and subsequent hip fracture.
Delay in Radiology Services for Resident Post-Fall
Penalty
Summary
The facility failed to provide timely radiology services for a resident who fell and was experiencing pain in her hip. The resident, who had a history of dementia, depression, and a left femur fracture, was found sitting on the floor with complaints of discomfort to her left hip. An X-ray was ordered after the fall, but it was not conducted until nearly 36 hours later, revealing acute fractures. Interviews with staff indicated that the contracted X-ray company typically takes 24 to 48 hours to perform X-rays, and the family was not informed of the potential delay or given the option to send the resident out for a quicker evaluation. The resident's Power of Attorney was not made aware of the delay in obtaining the X-ray and was not offered the option to have the resident sent out for immediate evaluation. The Director of Nursing acknowledged that ideally, X-rays should be done within 24 hours, but the facility had no control over the contracted imaging company's timeline. The facility's change in condition policy indicated that X-rays and labs might take up to 24 hours, but this was not communicated effectively to the resident's family, leading to a delay in diagnosis and treatment.
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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