Robings Manor Rhc
Inspection history, citations, penalties and survey trends for this long-term care facility in Brighton, Illinois.
- Location
- 502 North Main, Brighton, Illinois 62012
- CMS Provider Number
- 146011
- Inspections on file
- 19
- Latest survey
- October 24, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Robings Manor Rhc during CMS and state inspections, most recent first.
The facility failed to provide an RN for at least eight hours a day, seven days a week, and lacked a full-time DON. The only full-time RN worked night shifts, and PRN RNs rarely worked, leaving gaps in coverage. The Administrator acknowledged the ongoing issue of not having a full-time DON, affecting all 29 residents.
The facility failed to maintain and check food temperatures during meal service, affecting all 29 residents. Staff did not ensure food reached the required 165 degrees Fahrenheit before serving, with observed temperatures below the safe holding level. Resident feedback indicated ongoing issues with cold food, and the facility's policy requires daily monitoring to prevent foodborne illness.
The facility failed to ensure proper food storage and preparation, risking contamination for all 29 residents. Observations revealed an unclean ice machine, undated and expired food items, and a malfunctioning freezer. Staff actions, including improper cleaning practices and lack of beard net use, contributed to the deficiency. The Dietary Manager was unaware of these issues, violating the facility's storage policy.
The facility failed to ensure safe transfer practices for four residents, including those with Alzheimer's and brain injuries. Staff did not use gait belts or properly secure mechanical lifts, leaving residents swinging freely during transfers, contrary to care plans and facility policies.
The facility failed to provide adequate incontinence and catheter care for several residents, leading to deficiencies in hygiene and infection control. Residents with cognitive impairments and urinary catheters were not properly cleaned, and staff did not adhere to hand hygiene protocols. The facility's policies on perineal and catheter care were not followed, resulting in incomplete care and potential risks for the residents.
The facility failed to properly prepare pureed diets for residents, as observed when a staff member prepared pureed broccoli without following a recipe, resulting in a thick mixture with small pieces of broccoli. This did not meet the required smooth, pudding-like consistency, posing a potential choking hazard. A dietician confirmed the importance of smooth purees for residents on such diets.
The facility failed to maintain proper hand hygiene and PPE protocols, leading to deficiencies in infection control. CNAs and an LPN were observed assisting residents with meals, medications, and incontinence care without performing necessary hand hygiene. Enhanced barrier precautions were not followed for residents with specific needs, as PPE was not used appropriately. These actions indicate significant gaps in the facility's infection prevention and control program.
A resident in a facility was found to have untreated wounds on the toes, with no dressings or treatments applied, despite being at high risk for pressure ulcers. The facility's policy requires documentation and treatment of such wounds, but these procedures were not followed, resulting in a deficiency in pressure ulcer care.
The facility did not maintain current daily nursing staff postings for four consecutive days, affecting all 29 residents. Staff, including an LPN and the Administrator, confirmed the absence of the staffing sheet, which was previously posted by the time clock. The Administrator admitted there was no policy for posting staffing information.
The facility did not provide the required 80 square feet of floor space per resident in multiple resident bedrooms for 17 residents. The administrator acknowledged the issue and provided a list of undersized rooms, stating that a room waiver was in place. The Regional Maintenance Director confirmed that some rooms were measured and found to be below the required size.
The facility failed to implement timely COVID-19 testing and reporting, affecting all 29 residents. A CNA tested positive but continued working after informing two LPNs, who did not report it. The infection preventionist was unaware of this case, delaying the response. Another staff member also tested positive after working one day. The facility's protocols for testing after exposure were not followed, contributing to the outbreak.
The facility failed to maintain an effective pest control system, leading to the presence of insects in residents' living and common-use areas. Observations and resident interviews confirmed sightings of large black bugs, identified as water bugs and German cockroaches, in various locations. The facility's Administrator acknowledged the issue but could not provide documentation of recent pest control activities, despite the policy requiring monthly treatments. Staff confirmed the presence of bugs, particularly during rainy conditions.
The facility failed to conduct the admission/initial comprehensive assessment for four residents, resulting in missing Admission/Initial MDS in their medical records. Staff cited technical difficulties with the electronic medical record system as the cause.
The facility failed to maintain 15 months of resident assessments in the medical records for six residents. The MDS assessments were either missing or not updated, and technical difficulties with the electronic medical record system were cited as the cause. CNAs did not refer to the residents' Care Plans or MDS for information, relying instead on verbal instructions and their own assessments.
The facility failed to develop comprehensive care plans for four residents, despite having baseline care plans indicating various health issues and assistance needs. Technical difficulties with printing care plans and MDS assessments were cited as the reason for this deficiency.
The facility failed to update care plans and conduct fall risk assessments for four residents with multiple falls and complex medical conditions. Despite documented falls, care plans were not revised to address the residents' current needs, and comprehensive care plans were missing for some residents.
The facility failed to complete quarterly assessments for two residents, resulting in missing Minimum Data Sets (MDS) in their medical charts. Staff acknowledged issues with printing the MDS and care plans, which were not resolved despite multiple attempts.
Deficiency in RN Coverage and Lack of Full-Time DON
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for at least eight hours a day, seven days a week, and did not have a Director of Nursing (DON) on a full-time basis. This deficiency was identified through interviews and record reviews. The Director of Nursing stated that the facility only had one full-time RN who worked from 6:00 PM to 6:00 AM, which did not cover the required eight hours per day. Additionally, there were two other RNs listed as PRN (as needed), but they rarely worked. The facility's nursing schedule confirmed that there were days without any RN coverage, specifically on 10/5 and 10/6/24. The facility's Administrator acknowledged the ongoing issue of not having a full-time DON, despite having the position posted for nearly a year. The lack of sufficient RN coverage and a full-time DON has the potential to affect all 29 residents in the facility. The facility's Nurse Staffing Policy emphasizes the need for sufficient licensed nursing staff to maintain the highest practical physical, mental, and psychosocial well-being of each resident, but the current staffing levels do not meet these requirements.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain and check food temperatures during meal service, which could potentially affect all 29 residents. On multiple occasions, staff member V3 did not take the temperatures of hamburgers and pizza burgers after removing them from the oven, nor did she ensure they reached the required 165 degrees Fahrenheit before placing them on the steam table. Observations showed that the pizza burgers were not hot, and V3 attempted to reheat them in an oven that was not turned on. Subsequent temperature checks revealed that the food items were below the safe holding temperature of 135 degrees Fahrenheit, with the pureed pizza burger at 126.0 F, broccoli at 72.0 F, and pizza burger at 90.0 F. The facility's Monitoring Food Temperature for Meal Service Policy requires that food temperatures be monitored daily to prevent foodborne illness and ensure palatable serving temperatures. The policy specifies that hot foods should be reheated to at least 165 degrees Fahrenheit for a minimum of 15 seconds if they are not at 135 degrees Fahrenheit or higher when checked. Resident Council Meeting Minutes from several months indicated ongoing issues with food being served cold, and a grievance from a resident noted that the food was never hot and lacked flavor. The dietary manager and dietician both stated that they expect all hot food on the steam table to be at least 135 degrees Fahrenheit or higher.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage and preparation, leading to potential contamination risks for all 29 residents. During a kitchen inspection, it was observed that the ice machine had brown grooves indicating it needed cleaning, and there was no record of it ever being cleaned. The refrigerator contained undated and unlabeled cheese slices, an open container of bologna past its use-by date, and cereal labeled with an outdated date. The walk-in refrigerator had a dusty fan, and the freezer had a broken door handle and seal, preventing it from closing properly. Additionally, a crate of frozen vegetables was found sitting directly on the floor, and ice buildup was noted on a black hose and food items in the freezer. Staff actions further contributed to the deficiency. V3, a staff member, was observed using a single glove and a rag to clean counters, leaving the rag on the counter, and not washing hands after handling potentially contaminated items. V4, a dietary aide, was not wearing a beard net while cleaning dishes, acknowledging the oversight. The Dietary Manager, V15, admitted to being unaware of the ice machine's cleaning status and the freezer's ongoing issues. The facility's storage policy mandates cleanliness and proper labeling, which were not adhered to, as evidenced by the observations and staff interviews.
Unsafe Transfer Practices in LTC Facility
Penalty
Summary
The facility failed to provide safe transfers for four residents, leading to deficiencies in accident prevention and supervision. For one resident with a total brain injury, a Licensed Practical Nurse (LPN) assisted the resident from a wheelchair to a bed and back without using a gait belt, contrary to the care plan that required its use for all transfers. This resident was identified as high risk for falls, with a care plan intervention specifying the need for a gait belt and one staff assist during transfers. Another resident with Alzheimer's disease was transferred using a mechanical lift by two Certified Nursing Assistants (CNAs). However, during the transfer, the resident was left swinging freely in the air without anyone holding onto her, which is against the care plan that required two staff members to ensure safety during transfers. The care plan also emphasized the need for reassurance and proper handling during transfers, which was not adhered to during the observed incident. Two additional residents, both dependent on staff for all activities of daily living and requiring mechanical lift transfers, were also transferred unsafely. In both cases, the mechanical lift's wheels were not locked, and the residents were left swinging freely in the air without proper guidance or support from the staff. These actions were in direct violation of the facility's mechanical lift policy, which mandates locking the lift's wheels and guiding the resident during transfers to ensure safety.
Inadequate Incontinence and Catheter Care in LTC Facility
Penalty
Summary
The facility failed to provide complete incontinent care and urinary catheter care for six residents, leading to deficiencies in hygiene and infection control. Resident R9, who has vascular dementia and severe cognitive impairment, was observed receiving inadequate incontinence care. The CNAs did not perform hand hygiene before or during the care process, and R9's perineal area was not thoroughly cleaned, leaving feces in the brief and failing to clean the penis and groins. Resident R10, with a history of cerebral vascular accident and moderate cognitive impairment, was also subjected to insufficient incontinence care. The CNAs did not check R10 for incontinence every two hours as required, and during care, they used a soiled brief to wipe feces and did not clean or dry the resident properly. The Director of Nursing acknowledged the lapse in care, noting that R10 should have been cleaned before lunch. Resident R12, who has multiple sclerosis and a urinary catheter, received improper catheter care. The CNA did not perform hand hygiene and failed to clean the catheter tubing properly. Similar deficiencies were observed in the care of residents R17, R4, and R5, where CNAs did not follow proper hygiene protocols, such as drying the residents after cleaning and performing hand hygiene. The facility's policies on perineal and catheter care were not adhered to, contributing to the deficiencies observed.
Improper Preparation of Pureed Diets
Penalty
Summary
The facility failed to ensure that food was prepared appropriately to meet the needs of residents on pureed diets. During an observation, it was noted that a staff member, identified as V3, was preparing pureed broccoli without following a recipe or using a recipe book. The preparation process involved placing a large quantity of broccoli into a food processor along with a pre-made brown liquid containing a thickener. The food processor was overcrowded, and the resulting puree was thick and contained small pieces of broccoli, which did not meet the required smooth, pudding-like consistency. The facility's policy on pureeing food specifies that pureed items should be smooth and free of lumps to prevent choking hazards. A dietician, identified as V15, confirmed that the presence of lumps in pureed food could pose a choking risk to residents. The facility had a list of residents on pureed diets, including four residents who were affected by this deficiency. The failure to adhere to the facility's policy and the improper preparation of pureed food led to the deficiency identified during the survey.
Inadequate Hand Hygiene and PPE Use in LTC Facility
Penalty
Summary
The facility failed to adhere to proper hand hygiene and personal protective equipment (PPE) protocols, leading to multiple deficiencies in infection control practices. During meal assistance, certified nursing assistants (CNAs) were observed feeding residents without performing hand hygiene before, between, or after assisting them. Similarly, a licensed practical nurse (LPN) was seen administering medications to residents without performing hand hygiene before, between, or after the medication pass. Incontinence and wound care procedures were also compromised due to inadequate hand hygiene and PPE use. CNAs were observed performing incontinence care on residents without washing their hands before donning gloves or after doffing them. In some instances, CNAs used soiled gloves to handle residents and their personal items, further increasing the risk of infection. Additionally, enhanced barrier precautions were not followed for residents with specific needs, such as those with urinary catheters or open wounds, as PPE was not available or used appropriately. The facility's failure to implement its own policies on hand hygiene and PPE use was evident in the observations and interviews conducted. Staff members, including CNAs and LPNs, did not consistently follow the established protocols, leading to potential exposure to infections for both residents and staff. The lack of adherence to these critical infection control measures highlights significant gaps in the facility's infection prevention and control program.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to properly identify, assess, and treat pressure areas for a resident, leading to a deficiency in pressure ulcer care. During an observation, it was noted that the resident had wounds on the right foot's first, second, and third toes, with the first toe having an open area surrounded by redness. Despite these findings, there were no dressings or treatments present, and the Licensed Practical Nurse (LPN) stated that they were just monitoring the wounds. The Treatment Administration Record (TAR) documented scabs on the toes but failed to include any measurements or treatments. The resident's care plan indicated a high risk for pressure ulcers due to decreased mobility and incontinence, yet there was no documentation of the wounds on the wound log. The facility's policy on Decubitus Care/Pressure Areas requires that upon notification of skin breakdown, a Quality Assurance form should be completed, and the pressure area should be assessed and documented. This includes documenting the size, stage, site, depth, drainage, and treatment of the pressure ulcer, and notifying the physician for treatment orders. Additionally, nursing personnel are required to notify dietary personnel for nutritional support. However, these procedures were not followed, as evidenced by the lack of documentation and treatment for the resident's wounds, leading to a failure in providing appropriate pressure ulcer care and prevention.
Failure to Post Daily Nursing Staff Information
Penalty
Summary
The facility failed to ensure that the daily nursing staff posting was current for all four days of the survey, potentially affecting all 29 residents residing in the facility. On multiple occasions, staff members, including a Licensed Practical Nurse (LPN) and the Administrator, acknowledged the absence of the staffing sheet, which was previously posted by the time clock near the front door. The LPN/Minimum Data Set (MDS) Nurse was unaware of the current location of the staffing sheet, and the Administrator confirmed that there was no policy in place for posting staffing information. During the survey conducted from October 23 to October 24, 2024, no staffing information was observed to be posted anywhere in the facility.
Failure to Provide Adequate Room Size
Penalty
Summary
The facility failed to provide the required 80 square feet of floor space per resident in multiple resident bedrooms for 17 out of 17 residents reviewed in a sample of 29. During the survey, the administrator acknowledged that several rooms did not meet the 80 square feet requirement and provided a list of rooms that were undersized. The rooms identified as not meeting the space requirement included rooms 100 through 111 and 324 through 334. The administrator mentioned that the facility had a room waiver for these undersized rooms. Additionally, the Regional Maintenance Director confirmed that rooms 101 and 325 were measured and found to be approximately 75 square feet, which is below the required size.
Failure to Implement Timely COVID-19 Testing and Reporting
Penalty
Summary
The facility failed to follow CDC guidance and implement an effective infection control program for the timely and accurate assessment of COVID-19 symptoms and testing. This deficiency was identified through a review of records and interviews, revealing that the facility did not conduct timely COVID-19 testing for residents and staff, potentially affecting all 29 residents. The infection preventionist, V2, stated that mass swabbing began after the initial positive case of a resident on August 6, 2024. However, it was discovered that a staff member, V9, tested positive on August 4, 2024, but this was not reported to the infection preventionist, leading to a delay in response. Interviews with staff revealed that V9, a CNA, felt unwell and tested positive for COVID-19 at the facility but continued to work her shift after informing two LPNs, V4 and V15. V15 did not report the positive test result because she had not seen the test herself. Additionally, another staff member, V17, who worked at the facility for one day, later reported testing positive for COVID-19. The facility's COVID-19 control measures required testing for residents and staff after exposure, but these protocols were not followed, contributing to the outbreak.
Facility Fails to Maintain Effective Pest Control System
Penalty
Summary
The facility failed to maintain an effective pest control system, resulting in the presence of insects in residents' living and common-use areas. Observations included sightings of large black bugs in various locations, such as the hallways and shower rooms, which are used by residents for bathroom needs. The facility's Resident Meeting minutes documented ongoing concerns about bugs, indicating that this issue had been raised multiple times without resolution. Interviews with residents revealed that they were aware of the bug problem, with some residents identifying the insects as water bugs and German cockroaches. Residents expressed discomfort and dissatisfaction with the presence of bugs in their rooms and common areas. One resident mentioned that the facility had lost their maintenance man, which may have contributed to the lack of effective pest control measures. The facility's Administrator acknowledged the issue, stating that an exterminator company was contracted to address the problem, but was unable to provide documentation of any recent pest control activities. The facility's Insect and Pest Control Policy required monthly preventative treatments, but there was no evidence that these treatments were being conducted as per the policy. Staff members also confirmed the presence of bugs, particularly during rainy conditions, and noted that traps were placed in some areas, but this did not seem to be sufficient to control the infestation.
Failure to Conduct Admission/Initial Comprehensive Assessments
Penalty
Summary
The facility failed to conduct the admission/initial comprehensive assessment for four residents (R1, R4, R5, R6) upon their admission. Each resident's medical record lacked the required Admission/Initial Minimum Data Set (MDS), which is essential for developing a comprehensive care plan. The absence of these assessments was confirmed during a survey on 4/24/24, where the facility could not provide the necessary documentation for the residents in question. R1 was admitted with multiple diagnoses including Vascular Dementia, Alzheimer's, and COPD, among others. Similarly, R4 had significant health issues such as Neoplasm of Brain/Meninges and Parkinson's Disease. R5's medical history included Parkinson's Disease, Multiple Fractures, and Dementia, while R6 had conditions like Bipolar Disorder, Diabetes Type 2, and Coronary Artery Disease. Despite these complex medical histories, none of these residents had their Admission/Initial MDS completed and documented in their medical records. Interviews with facility staff revealed that the issue stemmed from technical difficulties with the electronic medical record system, which prevented the printing of Care Plans and MDS. The Assistant Director of Nursing, the MDS Nurse, and the previous MDS Nurse all acknowledged the problem, citing that the issue had been reported but not resolved. The Regional Director of Operations/Interim Administrator was unaware of the problem until the survey and stated that an audit would be conducted to ensure compliance moving forward.
Failure to Maintain 15 Months of Resident Assessments
Penalty
Summary
The facility failed to maintain 15 months of resident assessments in the medical records for six residents. The survey revealed that the Minimum Data Set (MDS) assessments were either missing or not updated for the residents. For instance, one resident's MDS had not been updated since September of the previous year, and another resident's MDS had not been updated since July. Additionally, some residents had no MDS available in their medical records at all. The Assistant Director of Nursing and the MDS Nurse acknowledged the issue, citing problems with printing the documents due to technical difficulties with the electronic medical record system. Despite attempts to resolve the issue, including reporting it to the Regional MDS Coordinator and the Previous Administrator, the problem persisted, and the necessary documents were not printed and placed in the residents' charts. The Regional Director of Operations/Interim Administrator was unaware of the issue until the survey and stated that an audit of all resident charts would be conducted to ensure compliance. Interviews with Certified Nursing Assistants (CNAs) revealed that they did not refer to the residents' Care Plans or MDS for information on the care required, relying instead on verbal instructions from nurses and their own assessments. The facility's policy mandates that 15 months of OBRA MDS be kept in a resident's active clinical record, but this was not adhered to, leading to the deficiency. The facility's Comprehensive Assessment/MDS Policy emphasizes the importance of maintaining updated assessments to develop comprehensive care plans for residents, which was not followed in this case.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan for four out of six residents reviewed. Resident 1, who was admitted with multiple diagnoses including Vascular Dementia and Alzheimer's, had a baseline care plan indicating high fall risk and various assistance needs but lacked a comprehensive care plan based on a thorough assessment. Similarly, Resident 4, admitted with conditions such as Parkinson's Disease and Hyperlipidemia, had an incomplete baseline care plan and no comprehensive care plan in place. Resident 5, with diagnoses including Parkinson's Disease and Dementia, also had a baseline care plan but no comprehensive care plan documented. Resident 6, admitted with multiple health issues including Bipolar Disorder and Coronary Artery Disease, had no comprehensive care plan in their medical record either. The Assistant Director of Nursing (ADON) and the MDS Nurse acknowledged the absence of comprehensive care plans and attributed the issue to technical difficulties with printing care plans and MDS assessments. The previous MDS Nurse confirmed that she had to handwrite certain information due to these technical issues but did not complete comprehensive care plans for all aspects of care. The Regional Director of Operations/Interim Administrator was unaware of the issue until recently and stated that an audit of all resident charts would be conducted to ensure updated care plans and MDS assessments are in place. The facility's policy mandates that a comprehensive care plan be developed within seven days of completing the Resident Assessment Instrument (RAI) and be updated regularly. However, due to the technical issues and lack of proper documentation, the facility failed to meet these requirements, resulting in incomplete or missing comprehensive care plans for the residents reviewed.
Failure to Update Care Plans and Conduct Fall Risk Assessments
Penalty
Summary
The facility failed to complete and revise care plans to address the current needs of four residents. Resident 2, who has diagnoses including Anxiety, Depression, and Type 2 Diabetes Mellitus, had falls documented on 2/3/24 and 4/13/24, but no fall risk assessments or updates to the care plan were completed after these incidents. Similarly, Resident 3, diagnosed with Alzheimer's Disease and Dementia, experienced falls on 2/13/24, 3/21/24, and 3/25/24, yet the care plan was not updated with new interventions to address these continued falls. Resident 4, with diagnoses including Neoplasm of Brain/Meninges and Parkinson's Disease, had a partially completed baseline care plan and no comprehensive care plan. After a fall on 3/11/24, there was no fall risk assessment or update in the care plan. Resident 5, who has multiple diagnoses such as Parkinson's Disease, Dementia, and Osteoporosis, had a baseline care plan indicating a high risk for falls but no comprehensive care plan. Following a fall with injury on 4/3/24, there was no update to the care plan with new interventions. The facility's policies require comprehensive assessments and periodic reassessments to develop person-centered care plans, which should be revised as necessary to reflect the resident's current needs. However, the facility did not adhere to these policies, as evidenced by the lack of updated care plans and fall risk assessments for the residents mentioned. The previous MDS nurse admitted to handwriting notes due to computer issues but did not update the care plans comprehensively. The administrator acknowledged the expectation for timely and accurate care plan updates and has started auditing records for compliance.
Failure to Complete Quarterly Assessments
Penalty
Summary
The facility failed to complete quarterly assessments for two residents, R2 and R3, as required. R2's admission record shows that R2 was admitted to the facility and has a moderate cognitive impairment, being independent in all Activities of Daily Living (ADLs) and always continent of bowel and bladder. However, there were no quarterly Minimum Data Sets (MDS) available in R2's medical chart for review. Similarly, R3, who has multiple diagnoses including Alzheimer's Disease and Dementia, had an MDS dated 7/13/23, but no subsequent quarterly MDS was available for review. The facility did not provide the required quarterly MDSs for either resident by the time of the surveyor's review on 4/24/24. Interviews with facility staff revealed that there were issues with printing the MDS and care plans, which were not resolved despite multiple attempts to address the problem. The Assistant Director of Nursing (ADON) and the MDS Nurse acknowledged the absence of printed MDSs and care plans in the resident charts. The previous MDS Nurse mentioned that the computer system had issues, and despite reporting the problem to the Regional MDS Coordinator and the Previous Administrator, the issue remained unresolved. The Regional Director of Operations/Interim Administrator confirmed that the problem was not reported to them and stated that an audit of all resident charts would be conducted to ensure updated care plans and MDSs are included in the charts.
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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