Ryze At Homewood
Inspection history, citations, penalties and survey trends for this long-term care facility in Homewood, Illinois.
- Location
- 19000 South Halsted, Homewood, Illinois 60430
- CMS Provider Number
- 146132
- Inspections on file
- 54
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Ryze At Homewood during CMS and state inspections, most recent first.
The facility failed to provide sufficient nursing and CNA staffing to meet residents’ assessed needs, resulting in multiple instances of unmet care, poor hygiene, and inadequate monitoring. A resident with wounds and an indwelling catheter was left on an improperly set low air loss mattress, with soiled clothing and abnormal urine in an undated bag, while an LPN did not clean the resident, adjust the mattress, or notify a physician. Other residents were observed with soiled clothing, long nails and facial hair, saturated briefs that were re-taped instead of changed, bare mattresses without fitted sheets, call lights out of reach, and inadequate assistance with feeding and catheter care. Residents reported sitting in urine and feces for hours, missing scheduled showers, and not receiving restorative care, while environmental areas such as a shower room and dining tables were found dirty and poorly maintained. Staff interviews and schedules showed that units routinely operated with one nurse for about 25 residents and limited CNAs, night CNAs were pulled from certain units, and restorative staffing was minimal, despite a facility assessment and staffing policy that called for higher staffing levels and specific nurse-to-resident and CNA-to-resident ratios.
A resident was left sitting in the dining room without a lunch tray while all other residents at the meal were served and some had already finished eating, despite the resident stating they were hungry and staff acknowledging that everyone should be served together. In a separate incident, a resident with continuous drooling during a meal accumulated a large puddle of thick sputum on the shared tabletop and clothing, which remained unaddressed for an extended period while four other residents at the same table were exposed to the situation. These events demonstrate failures to maintain resident dignity and to provide a clean, comfortable, and respectful dining environment as outlined in the facility’s resident rights materials.
Surveyors found multiple failures to accommodate residents’ needs and preferences, including soiled and damaged wheelchairs, unclean and unchanged bed linens, and lack of requested meal condiments. Several residents who required assistance with ADLs and were at risk for falls had call lights placed out of reach, despite care plans and policy requiring call lights to be accessible at all times. Another resident with significant ADL deficits was left with a foot resting in a puddle of water and wet socks after requesting help that was not promptly provided. These observations showed staff inaction and inadequate attention to basic comfort, cleanliness, and call light accessibility for multiple residents.
Surveyors identified multiple failures to maintain a clean, safe, and homelike environment, including a resident’s privacy curtain hanging improperly for about a week after staff pulled it from the track, dried spills and stains on a dining table used by two residents, and brown smeared substances on the wall, floor, and furniture in a resident room. In a shower room, sinks and counters had soap, food residue, and white buildup; soiled toilet paper with what appeared to be feces was on the floor; tiles around the drain were broken with pieces missing; a shower head was missing; a used washcloth was left on a shower chair; and a razor was left on the tub despite residents not being allowed unsupervised razors. In another room, human feces were found on the floor next to the bed of a cognitively impaired resident, and a housekeeper stated they had not yet cleaned that room. These conditions conflicted with facility policies requiring daily cleaning and a safe, sanitary, and comfortable environment.
Multiple residents who were dependent or partially dependent for ADLs did not receive appropriate hygiene, grooming, incontinence care, or feeding assistance as outlined in their care plans and facility policies. Some residents were observed with soiled clothing, long and broken fingernails, and unshaved facial hair despite having requested help or being unable to perform these tasks independently. Several incontinent residents reported or were observed sitting in wet or soiled briefs for extended periods, and scheduled showers were missed or infrequent despite twice-weekly shower schedules. In addition, a resident with severe cognitive impairment and dysphagia, ordered for 1:1 feeding assistance, received a meal tray without continuous one-to-one assistance, while staff stated the resident did not need such help even though clinical leadership identified the resident as a 1:1 feed.
Surveyors found that corridor handrails on two units were loose, shifting several inches, and in some areas pulling away from the wall with visible protruding screws and wall damage. The Maintenance Director confirmed that residents rely on these handrails for balance, safety, and wheelchair propulsion and acknowledged that only one unit’s handrails had been checked after problems were identified. Review of the facility’s preventative maintenance policy showed that routine inspection of handrails was not included.
A high fall-risk resident with dementia, severe cognitive impairment, multiple comorbidities, and a documented need for substantial/maximal assistance with transfers experienced two unwitnessed falls from bed within a short period, resulting in a large forehead hematoma and hospital evaluation, despite a care plan identifying high fall risk and the need for staff assistance and optimal visual access from the nurse’s station. The facility’s fall prevention policy required identification of high-risk residents and updating the care plan with new interventions after each fall based on root cause analysis. Separately, on a dementia unit housing 12 residents, an emergency exit door failed to alarm and remained locked when the push bar was held as instructed, only partially opening under full body weight and not fully unlocking even when the alarm eventually sounded, contrary to posted instructions and the preventative maintenance policy assigning the Maintenance Director responsibility for ensuring proper fire door operation.
Surveyors found that multiple residents with indwelling catheters and a nephrostomy tube did not receive care consistent with physician orders, care plans, and facility policy. One resident with a history including UTI had a catheter with cloudy urine, purulent material, and heavy sediment, with no date on the bag, no documentation of bag changes despite MAR orders, and no physician notification of the abnormal urine. Another resident with urologic diagnoses reported catheter bags were not changed as expected, and the MAR showed PRN bag-change orders with no documented changes, while staff could not clearly explain the significance of visible residue. A third resident with a nephrostomy tube was observed with the drainage bag resting on the abdomen rather than below kidney level, resulting in minimal drainage until a CNA lowered the bag, after which a large volume of urine drained, despite facility policy requiring the bag to remain below the kidney at all times.
The facility failed to ensure daily nurse staffing postings were complete and accurate. Over multiple days, the posting displayed behind the reception desk listed only the number of staff, while the sections for actual hours worked and total hours remained blank. The receptionist reported that the staffing coordinator prepared and delivered the postings each day and that older postings were stored in a drawer when replaced. The staffing coordinator confirmed responsibility for the postings and acknowledged overlooking the required entries for actual and total hours, affecting information available for all residents.
A resident with a history of substance abuse was repeatedly found in possession of illicit drugs and drug paraphernalia, and tested positive for multiple substances while under facility care. Despite documented incidents and hospitalizations, staff failed to consistently monitor, investigate, or implement effective interventions to prevent further drug use, and did not thoroughly document supervision or follow facility policy regarding contraband and substance abuse.
A resident with multiple complex medical conditions experienced an unwitnessed fall with potential head injury. Nursing staff assessed the resident and left a message for the physician but did not speak directly with them or document a physician assessment. The facility lacked clear protocols for managing unwitnessed falls, especially for residents not on anticoagulants, and staff in-service records on Fall Risk Assessments were incomplete, raising concerns about adequate staff training.
The facility failed to accurately complete Fall Risk Assessments for four residents with a history of falls, resulting in assessments that did not reflect relevant diagnoses, previous falls, or medications that increase GI motility. These inaccuracies were confirmed by the DON, and documentation showed that assessments did not align with residents' medical histories or observed incidents.
Two residents were not protected from physical abuse by peers, resulting in one sustaining blunt head trauma and a swollen, black eye, and another being slapped on the head. Both incidents involved individuals with known behavioral risks and prior care plans, but staff were unable to intervene in time to prevent the abuse, and police were notified in both cases.
A resident, dependent on staff for daily care and with intact cognition, had credit and debit cards stolen and used without consent by an LPN. The theft was discovered by the resident's family member, confirmed through police investigation and retail store surveillance, and resulted in the LPN's arrest. The incident caused the resident to feel unsafe and deprived of access to personal funds.
The absence of a Dietary Manager led to multiple issues in meal service, including residents not receiving meals according to their preferences or the facility's menu, food being served at improper temperatures, and unsanitary food storage practices. Staff reported being overwhelmed and unable to maintain inventory or ensure timely, accurate meal preparation, resulting in inconsistent and inadequate dietary services for all residents.
A resident with dementia and multiple comorbidities, who required one-to-one supervision during meals, did not have their fluid intake monitored or documented. Staff interviews and observations confirmed that fluids were not consistently provided or encouraged, and the electronic charting system lacked a place to record fluid intake. This failure resulted in the resident developing severe hypernatremia and acute kidney injury, requiring hospitalization and intravenous treatment.
A resident with a sacral pressure ulcer was not provided with the prescribed daily wound care treatments, leading to a worsening condition and hospitalization for septic shock. The facility failed to document wound care from the 8th to the 12th and on the 18th, and staff did not adequately monitor the wound for complications. The resident's condition deteriorated, resulting in a transfer to the hospital's ICU for five days. The Director of Nursing confirmed the lack of documentation and adherence to physician orders.
The facility's QAPI program failed to address repeated infection control deficiencies. Observations revealed an LPN not adhering to hand hygiene and PPE protocols, and a resident's catheter drainage bag touching the floor. Despite corrective actions, these issues persisted, highlighting gaps in infection control practices.
The facility failed to obtain physician orders for medications, oxygen, and enhanced barrier precautions for several residents. A resident was on enhanced barrier precautions without an order, and an unlabeled ointment was found at the bedside. Another resident used eye drops without a physician's order, while others received oxygen therapy without documented orders. Facility policies require physician orders for all treatments, which were not followed.
A facility failed to assess the appropriateness of self-administration of medication for a resident with multiple diagnoses, whose medication was left at the bedside. The resident expressed a preference to self-administer after completing personal business, and staff acknowledged the need for a medication-administration assessment. Facility policy requires an interdisciplinary team assessment for residents desiring to self-administer medications.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in accommodating their needs. One resident with a history of cerebral infarction and other conditions was found with the call light on the floor, confirmed by a CNA. Another resident, totally dependent on staff, also had the call light out of reach, verified by an LPN. The DON confirmed the importance of having call lights accessible and promptly answered.
The facility did not adhere to its policy of completing criminal history background checks within 24 hours for new admissions, affecting three residents. The admissions staff typically completed checks within 72 hours due to not working after hours or on weekends, and there was no policy to ensure timely completion. The administrator acknowledged the risk posed by this delay.
A facility failed to conduct the required Preadmission Screening and Resident Review (PASRR) for a resident with mental health diagnoses, including PTSD and major depressive disorder. The Unit Manager noted the resident's manipulative behavior, while the Administrator and Admissions Director were unaware of the need for Level 1 and Level 2 PASRR screenings. The Social Services Director was also unaware of the resident's mental illness diagnosis, leading to the oversight.
A facility failed to follow the manufacturer's recommendations for using a low air loss (LAL) mattress for a resident with a stage 4 pressure ulcer. The resident, with a history of pressure ulcers and immobility, was found lying on a LAL mattress with multiple layers of linen, contrary to guidelines that specify only a flat sheet should be used. This improper use was confirmed by the Wound Care Nurse and the Director of Nursing, highlighting a deficiency in pressure ulcer management.
The facility failed to implement fall prevention measures for two residents with a history of falls. One resident, with COPD and difficulty walking, fell while trying to use the bathroom, as her bed was not in the lowest position as required. Another resident, with hemiplegia and seizures, was found without a fall mat next to his bed, contrary to his care plan. Staff confirmed the need for these interventions, which were not followed.
A resident with chronic respiratory conditions was observed receiving oxygen at 6 LPM instead of the prescribed 4 LPM, and the oxygen tubing was not labeled or dated as required. This discrepancy was confirmed by a nurse and acknowledged by the DON, highlighting a failure to adhere to the facility's oxygen administration policy.
The facility failed to timely implement pharmacist recommendations for two residents prescribed Aricept, leading to a delay in changing the medication administration time from morning to bedtime. This delay, confirmed by the DON, was contrary to the facility's policy requiring same-day action. Observations showed one resident in a wheelchair due to fall risk and another in bed not in the lowest position.
A facility failed to ensure an appropriate diagnosis for a resident receiving Risperdal for vascular dementia with agitation. The resident's care plan did not address the anti-psychotic medication, and there was no qualifying diagnosis, as the appropriate diagnoses for Risperdal are schizophrenia and psychosis. Additionally, no baseline AIMS assessment was conducted, and the facility's revised policy on psychotropic medication management had not been implemented, with no documentation of behavioral symptoms monitoring.
A facility failed to coordinate and document hospice services for a resident with Alzheimer's and malignant neoplasm of the stomach. The resident's care plan lacked hospice interventions, and the hospice binder contained only nursing documentation. Staff interviews revealed missing hospice documentation and an unsigned hospice service agreement, indicating a lack of proper communication and documentation from the hospice provider.
The facility failed to follow infection control practices during enteral feeding and urinary catheter management. An LPN did not perform hand hygiene or wear the required PPE gown while assessing a resident with a gastrostomy tube. Additionally, a resident's urinary catheter drainage bag and tubing were observed touching the floor, contrary to infection control protocols. The DON and Infection Preventionist confirmed the need for proper PPE and hand hygiene, and the facility's policy mandates keeping catheter equipment off the floor.
A resident experienced an acute change in mental and respiratory status, but the facility failed to promptly notify the physician and delayed calling EMS. The resident was found unresponsive and in respiratory distress, leading to a hospital admission with aspiration pneumonia and sepsis. Staff interviews revealed delays in response and communication, contributing to the resident's adverse outcome.
A resident with dementia was pushed to the ground by another resident, resulting in severe head injuries, including skull fractures and brain hemorrhages. The incident occurred in the dining room and was witnessed by staff, who were unable to intervene in time. The resident who pushed did not provide a reason for the action, and there were no prior interactions or behaviors noted between the two residents.
Two residents suffered injuries due to inadequate safety measures during transport. One resident was not properly secured in a wheelchair, resulting in severe leg fractures, while another resident fell from a wheelchair due to the absence of footrests, causing a head laceration. The facility failed to provide necessary equipment and supervision to prevent these accidents.
A cognitively impaired resident exited a memory care unit without authorization due to inadequate supervision and failure to respond effectively to a door alarm. The resident, identified as high risk for elopement, was found by police nearly half a mile from the facility. Staff failed to conduct a headcount or verify the cause of the alarm, and the outside gate was left unsecured by landscapers.
Two residents in a LTC facility sustained head lacerations due to inadequate supervision and staffing. One resident, assessed as a high fall risk, was not properly monitored, resulting in a fall. Another resident, requiring two staff for ADLs, was assisted by only one CNA, leading to a fall from bed. Staff reported insufficient staffing levels, impacting their ability to provide necessary care.
A facility failed to notify a resident's representative and the Ombudsman of a discharge, violating its policy. The resident, with a history of medical conditions, was discharged to a community living home without medical care. The facility was unaware of the resident's State Guardian status, despite it being in the referral packet. The administrator later confirmed the oversight, acknowledging the need for notification.
The facility failed to maintain a clean and sanitary environment, affecting all thirty residents on the fifth floor. Observations included peeling paint, disarray in rooms, dust and debris on fans and lights, and dirty windows. Additionally, the dining room floor was sticky and inadequately cleaned. The Administrator acknowledged the issues and the facility's policy was not upheld.
A high fall risk resident with poor sitting balance fell out of a shower chair and sustained a laceration requiring seven sutures because the required two-person assist was not provided. The CNA did not check the care card and was unaware of the need for additional assistance, leading to the fall. The facility's policy on managing falls and fall risk was not followed.
Insufficient Nursing and CNA Staffing Leading to Unmet Care, Hygiene, and Monitoring Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff and related services to meet residents’ assessed needs, as reflected in multiple observations of unmet care needs, poor hygiene, and inadequate monitoring. On the 2nd floor, a resident with wounds and an indwelling urinary catheter was observed lying on a low air loss mattress set to static mode instead of alternate mode, with the LPN unable to explain or adjust the setting. The same resident had large white clumps of food on his chest and reported having eaten grits, yet the LPN did not clean the resident or change his soiled shirt. The resident’s catheter tubing and urine bag were cloudy with purulent material and heavy sediment, the bag was undated, and the LPN had not notified the physician and could not determine when the catheter or bag had last been changed. Another resident on the same floor had a shirt covered in white debris, long untrimmed facial hair and nails, and an indwelling catheter bag ordered to be changed as clinically appropriate, but there was no documentation of bag changes. Additional observations showed environmental neglect and lack of timely care. One resident’s privacy curtain was partially detached from the track, and the resident reported having notified staff about it about a week earlier without repair. A 2nd floor shower room was found with soiled sinks and countertop containing white residue, dried orange substance, and food debris; a large pile of soiled toilet paper with a brown smeared substance on the floor; broken ceramic tiles around the shower drain; a missing shower head; a wet, used washcloth hanging from a shower chair; and a razor left on the tub, despite staff acknowledging residents should not use razors unsupervised. Another resident was observed lying on a bare mattress with the fitted sheet at the foot of the bed and a modified call light dangling out of reach; the LPN attributed the missing sheet to the resident’s movement and left the room without replacing the sheet or positioning the call light. A different resident’s incontinence brief appeared saturated, and after confirming the brief was wet, the LPN re-taped it and left, stating someone would be sent to change the resident. The same resident’s enteral feeding (Jevity 1.5 Cal) had been hung with a documented start time many hours earlier, but only a small volume had infused compared to the ordered rate, and the LPN could not explain the discrepancy. Other residents reported delays and omissions in basic care and restorative services. Two residents were seated at a table with a large brown spill, likely coffee, that required scrubbing to remove and left a stain. One resident with flaccid right upper extremity was served lunch at the bedside and left to self-feed; when the resident attempted to eat carrots with a spoon, food fell off the plate due to difficulty using only one hand, and no assistance was provided. Another resident reported sitting in urine for extended periods at night, stating night staff typically changed residents only twice during the shift and expressing concern that there were not enough staff. A resident on the 100/200 unit reported not receiving scheduled showers on the days they were told they were scheduled, and another resident stated she had been waiting to be changed since after lunch, remained wet with a bowel movement, and said this happened frequently; she also reported being supposed to receive restorative care for left-sided weakness but not receiving it. A further resident stated she sometimes sat in urine and feces for hours before being changed and reported that on night shift there was only one CNA for both the 100 and 200 units, with one CNA being pulled to another unit when short. Staffing patterns and facility practices contributed directly to these deficiencies. On the 2nd floor, an LPN reported there were two nurses for the 500/600 and 700/800 units and five CNAs on day shift, but the daily assignment sheet showed only four CNAs assigned to the 500/600 units after one was crossed off. On the 100/200 units, an RN was observed as the only nurse passing medications for 25 residents with two CNAs, and later confirmed no additional nurse had arrived despite the schedule listing a second nurse; the DON confirmed there was only one nurse on those units and stated that having one nurse for 25 residents was their normal scheduling unless the unit was full. The DON also stated the facility had only two restorative aides and no restorative nurse, and was unsure if restorative care was being provided to a resident who reported not receiving it. The staffing coordinator described standard staffing based on census, with one nurse and two CNAs on the 100/200 units and one nurse and two CNAs on the 700 unit for all shifts, and acknowledged never scheduling more than one nurse on the 100/200 units and being unaware that one CNA was pulled from those units on night shift. The facility assessment, however, documented higher overall numbers of licensed nurses and nurse aides per day and specific nurse and CNA ratios (1:20 for nurses on post-acute units, 1:25 on long-term care units, and 1:12 for CNAs on all shifts), and the schedules and interviews showed the facility was not staffing according to its own facility assessment and staffing policy.
Failure to Maintain Resident Dignity and Clean, Respectful Dining Conditions
Penalty
Summary
The deficiency involves failures to honor residents' rights to dignity and respect during mealtimes. At the 12:15 PM lunch meal in the 300/400 dining room, one resident was observed at 12:45 PM sitting at a table watching other residents eat while not having been served any lunch. All other residents in the dining room had been served, and approximately 25% had already finished eating. The resident stated they were hungry and did not know why they had not received a tray. An activity aide confirmed the resident had not received a lunch tray while all others were eating and acknowledged this as a dignity concern. The dietary manager later confirmed awareness that the resident did not get a lunch tray and stated they believed a meal ticket had not printed for the resident, while also affirming that everyone should be served lunch at the same time and that tray passing begins at 12:00 PM. A separate dignity concern occurred during another lunch meal when one resident seated at a table with four other residents exhibited continuous drooling throughout the meal. The drooling accumulated on the tabletop and on the resident’s clothing, forming a visible puddle of thick sputum approximately a half foot long and a foot wide on the shared dining surface. The resident appeared unaware of or unable to manage the drooling independently and required staff support to maintain comfort and personal dignity, but the drooling remained on the table for an extended period while the other residents at the table were visibly exposed to the situation. The DON later stated that the described situation was not acceptable, described it as disgusting, noted the area was not cleaned immediately and that an odor could have been present, and stated it was not fair to the other residents. Facility resident rights materials state that residents must be treated with dignity and respect, cared for in a manner that promotes quality of life, and that the facility must be safe, clean, comfortable, and homelike, with reasonable arrangements made to meet residents’ needs and choices.
Failure to Maintain Call Light Access, Clean Equipment, and Timely ADL Assistance
Penalty
Summary
The deficiency involves multiple failures to reasonably accommodate residents’ needs and preferences related to call light access, cleanliness of equipment and linens, and timely assistance with basic comfort needs. Surveyors observed that one resident’s wheelchair was notably soiled with white debris on the wheels and had severely cracked armrests with most of the vinyl missing. When questioned, the Central Supply staff member described the wheelchair as “a little old,” and the Wound Care Coordinator acknowledged that the wheels were not clean and that the vinyl or fake leather on the armrests was peeling off. Another resident’s fitted sheet was observed to be soiled with a dried spill and corn flakes, and the Maintenance staff member stated that the CNA had not yet come to change the linens and that the soiling was probably waste food. Surveyors also identified repeated failures to ensure call lights and bed linens were properly in place and within reach for residents who required assistance. One resident was found lying directly on the mattress with the fitted sheet at the foot of the bed and a modified call light dangling from a rack out of reach; the resident was unable to reach the call light when asked. An LPN stated that the resident moved a lot so the sheet did not stay on the bed and did not address the sheet or call light before leaving the room. Another cognitively intact resident, care planned to require assistance with ADLs and bed mobility, had a call light wrapped around the bedside table and not within reach; the resident reported that the nurse had moved it and they could no longer reach it. An LPN later confirmed that the call light was attached in a way that the resident could not reach it. A further resident, care planned as high risk for falls with an intervention for the call light to be within reach and used for assistance, was observed with the call light behind the bed and not within reach; a housekeeper present in the room stated they did not know why the call light was behind the bed. Additional failures to meet residents’ expressed needs and preferences were documented. One resident received two hamburgers without condiments and specifically requested ketchup and mayonnaise, but was provided only a single ketchup packet. Another resident with Alzheimer’s disease, pain in the right hip, repeated falls, and substantial ADL deficits was observed in the dining room with a right foot resting in a puddle of water on the floor. The resident stated that their feet were cold and wet, requested new socks, and reported that someone had said they would get new socks but never returned. A CNA confirmed the liquid was water, acknowledged that the resident sometimes dropped water when drinking and that there was “a lot of water,” and stated they were unsure how long the water had been there before indicating they would take the resident to change socks. Facility policies and resident rights documents reviewed by surveyors required that call lights be within reach at all times, that ADL assistance be provided to maintain maximal functioning, that the facility be safe, clean, comfortable, and homelike, and that resident equipment and linens be kept clean and changed when soiled.
Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in resident rooms, common areas, and a shower room. Surveyors observed that one resident’s privacy curtain was dangling from the track with 23 hooks not attached; the resident reported that staff had pulled the curtain causing the hooks to come off and that they had requested repair about a week earlier. In the dining area, a large brown spill, described by the housekeeping manager as looking like coffee, was found on a table where two residents were seated; the substance was partially dried and adhered to the table, requiring scrubbing and leaving a stain. In another resident’s room, a brown smeared substance that a CNA described as looking like feces or food was present on the wall, floor, and dresser. On the 700 unit shower room, surveyors found multiple environmental and safety issues: double sinks with white residue, a countertop with dried orange substance and food debris, a large pile of soiled toilet paper with a brown smeared substance on the floor next to the toilet, broken ceramic tiles around the shower drain with missing pieces, a missing shower head, a wet soiled washcloth hanging from a shower chair, and a razor left on the tub. The health information manager confirmed the presence of soap, food, white residue, and what appeared to be feces, and acknowledged that staff should monitor residents while in the shower room. In another room, human feces were observed on the floor next to the bed of a resident with dementia and severe cognitive impairment (BIMS score of 6); the housekeeper stated they had not yet gotten to that room and were unsure what the substance was but would clean it. Facility documents, including the housekeeping aide job description and the safe and homelike environment policy, state that housekeeping and maintenance services are to maintain a sanitary, orderly, and comfortable environment and that resident rooms and bathrooms are to be wet mopped daily, which was not reflected in the observed conditions.
Failure to Provide ADL Assistance, Grooming, Incontinence Care, and Ordered 1:1 Feeding
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), grooming, incontinence care, and ordered feeding assistance to multiple dependent residents, despite documented care plans and policies. Several residents with documented ADL self-care deficits and cognitive or physical impairments were observed with unaddressed hygiene and grooming needs. One resident with hemiplegia and severe cognitive impairment was seen with large clumps of food on his chest after breakfast; the LPN acknowledged the spilled food but did not remove it or change the soiled shirt. Another resident with lumbar myelopathy, who required assistance with dressing and personal hygiene and was cognitively intact, was observed wearing a shirt covered in white debris, with a long beard and mustache and long, broken fingernails; the resident stated he needed help with shaving and that nobody cut his nails. A third cognitively intact resident who required assistance with personal hygiene had long, broken fingernails and reported he could not cut them himself and only picked at them. The facility also failed to provide timely incontinence care and scheduled showers as care planned and as required by policy. One cognitively intact resident, dependent on staff for toileting, was observed with a saturated incontinence brief; an LPN opened the brief, confirmed the resident was wet, stated she would send someone to change him, then re-taped the wet brief and left the room. Another resident, frequently incontinent of bowel and bladder and requiring assistance with most ADLs, reported sitting in urine for extended periods, especially on night shift, and stated that call lights were not answered and that CNAs made excuses when showers were requested; records showed the resident was scheduled for showers twice weekly but had not received a shower since the prior week, with the last documented shower several days earlier. A second resident, cognitively intact and requiring partial to moderate ADL assistance, reported issues with getting scheduled showers, stating staff did not provide them as planned; documentation showed only two showers since admission, despite twice-weekly scheduling. A further resident, frequently incontinent and requiring substantial to maximal assistance with toileting and hygiene, reported waiting to be changed since after lunch, remaining wet with a bowel movement while staff repeatedly told her to wait and did not return. Additional failures in grooming and feeding assistance were identified. One resident with facial hair on the chin reported repeatedly asking staff for a razor and a shaving basin so she could remove the hair herself, but the hair remained unaddressed at the time of observation; nursing leadership later told the resident they would shave and clean her up after medications, and the resident reiterated she had been asking for shaving supplies. Another resident with severe cognitive impairment, dysphagia, and significant weight loss risk had an active physician order for 1:1 assistance while eating or drinking. During a lunch observation period, the resident received a lunch tray but no staff member provided continuous one-to-one feeding assistance, prompts, or supervision, while staff assisted other residents in the dining room. A CNA stated this resident did not require 1:1 feeding and ate like everyone else, while the registered dietician and DON both identified the resident as a 1:1 feed and the DON affirmed staff are expected to follow physician orders and care plans. Facility policies and job descriptions required staff to assist with ADLs, keep residents clean and dry after incontinence, ensure dependent residents are dressed in clean clothing, keep nails trimmed, provide scheduled showers, and honor grooming preferences such as shaving facial hair, as well as to provide person-centered care consistent with residents’ rights and baseline care plans; these documented requirements were not followed in the observed instances. The facility’s own ADL, incontinence care, baseline care plan, and residents’ rights policies emphasized maintaining residents at their maximal level of functioning, providing assistance with ADLs and grooming (including shaving facial hair per preference), scheduling and documenting showers or bed baths, and keeping residents dry, comfortable, and odor free. Despite these written standards, multiple residents who were incontinent, dependent, or partially dependent for ADLs did not receive timely toileting, incontinence care, showers, nail care, grooming, or ordered feeding assistance. Staff interviews, including with CNAs, an LPN, the wound care coordinator, the registered dietician, and the DON, confirmed awareness of residents’ needs and expectations that staff follow care plans and physician orders, yet the observed care did not align with those requirements for the residents cited in the findings.
Unsecured Corridor Handrails on Two Units
Penalty
Summary
The facility failed to ensure that corridor handrails were firmly secured on the 300 and 400 units, potentially affecting all 32 residents residing on those units. Surveyors reviewed the facility census and observed that 12 residents lived on the 300 unit and 20 residents on the 400 unit. During an observation on the 300 unit, handrails outside several rooms were found to be loose and able to shift approximately 2 inches up or down, with one handrail shifting approximately 4 inches and showing visible loose screws coming out of the brackets. When light pulling pressure was applied to this handrail, it began to disconnect from the wall. The Maintenance Director observed these conditions, confirmed the findings, and stated that residents use the handrails for balance, safety, and to propel themselves down the hallway when in a wheelchair. On the 400 unit, additional observations showed loose, unsecured handrails outside multiple rooms, including areas across from the nurse's station and between various room pairs and a janitor closet. In one location, a hole approximately 5 inches tall by 3 inches wide was observed where the handrail bracket should be secured to the wall, and screws attaching the bracket to the wall were protruding approximately 1 inch from the wall. The Administrator and Maintenance Director observed and confirmed these conditions. When questioned, the Administrator asked if all handrails had been checked after the loose handrails were identified on the 300 unit, and the Maintenance Director stated that only the 300 unit handrails had been checked and fixed. Record review of the facility’s preventative maintenance policy dated 5/2025 showed that inspections of the facility’s handrails were not included as part of the preventative maintenance program.
Failure to Implement Fall Prevention and Maintain Functional Emergency Exit Door
Penalty
Summary
The deficiency involves the facility’s failure to implement fall prevention interventions and provide adequate supervision for a high fall-risk resident, as well as failure to maintain a functional, alarmed emergency exit door on a dementia unit. One resident, an elderly individual with dementia, metabolic encephalopathy, adult failure to thrive, muscle wasting/atrophy, lack of coordination, repeated falls, and a high fall risk score of 21, was admitted with severe cognitive impairment (BIMS score of 7) and required substantial/maximal assistance for bed-to-chair transfers, with walking not attempted. The resident’s care plan identified high fall risk and included an intervention to move the resident to a room with optimal visual access from the nurse’s station and to have staff assist as needed. On the date of the incident, progress notes documented that at 5:24 PM the resident was found on the floor on the right side of the bed in a prone position, with a raised area on the left forehead. The resident was assisted off the floor and returned to bed. At 5:54 PM, it was documented that the resident, who was alert to self only with confusion and unable to recall the event, again rolled out of bed and was found on the floor, still with a raised area on the left forehead and no bleeding or bruising noted. The incident report described the fall as unwitnessed, with predisposing factors including confusion, impaired memory, and antipsychotic use. EMS records noted a 3-inch hematoma on the left forehead and that the resident was taking Eliquis, and the hospital history and physical documented a moderate left frontal scalp hematoma and possible trace subdural hemorrhage on CT. The facility’s fall prevention policy required identification of high-risk residents, implementation of interventions, and updating the care plan with new interventions after each fall based on root cause analysis. A separate deficiency was identified regarding the 300 unit emergency exit door serving a dementia care unit with 12 residents. Observation showed that the emergency door alarm light at the top of the door was not illuminated despite posted instructions that the door would alarm and unlock after holding the push bar for 15 seconds. When the Maintenance Director tested the door by holding the push bar, no alarm sounded and, after 20 seconds, the door remained locked. The door only opened approximately 12 inches at the bottom when the Maintenance Director applied full body weight, and on a final attempt an alarm sounded but the lock still did not disengage. The Maintenance Director stated that the unit is a dementia care unit, that the alarm is intended to prevent elopement, and that the lock should disengage to allow staff and residents to escape in an emergency. The facility’s preventative maintenance policy assigned responsibility for checking the operation of fire doors to the Maintenance Director.
Failure to Provide Proper Catheter and Nephrostomy Care and Respond to Abnormal Urine
Penalty
Summary
The deficiency involves failures in catheter and nephrostomy care, including not implementing care plan interventions, not following physician orders, and not assessing and responding to abnormal urine. One resident with neuromuscular bladder dysfunction and a diagnosis including UTI had an indwelling catheter with tubing that was notably cloudy, with chunks of purulent substance and heavy sediment observed in the urine. The catheter bag was undated, and the resident was unsure when it was last changed. The MAR contained an order to change the urinary bag as needed when clinically appropriate every 8 hours, but there was no documentation of any bag changes. When questioned, an LPN acknowledged the discoloration and sediment, confirmed the bag was not dated, and stated that the physician had not been notified of the abnormal urine. The LPN was unsure when the catheter bag was last placed or changed, and the DON later could not confirm whether urinalysis or urine culture orders had been obtained in response to the abnormal urine. Another resident with obstructive and reflux uropathy had physician orders to change the urinary bag as needed when clinically appropriate. This resident, who was cognitively intact per a recent BIMS score, reported that the catheter bag was supposed to be changed once a week but that staff changed it only when they decided to. The January MAR included an order to change the urinary bag as needed when clinically appropriate, but again there was no documentation of any bag changes. When the wound care coordinator was asked about the appearance of the resident’s indwelling catheter, the coordinator described a white residue but did not explain what it indicated and then had to ask an LPN how often the order was to change the bag. A third resident had a care plan noting a nephrostomy bag with an intervention to observe for skin irritation and keep the skin clean, dry, and moisturized. This resident was observed in bed with the nephrostomy drainage bag resting on the abdomen, with only about one tablespoon of urine in the bag over a period of at least 15 minutes. A CNA stated she did not know what kind of urine bag it was but believed it should be hanging down on the side of the bed to allow proper drainage, and when she lowered the bag below the resident, approximately 200 ml of urine drained into the bag. An LPN initially was unsure what type of catheter it was and later confirmed it was a nephrostomy catheter connected directly to the kidney, acknowledging that the drainage bag should be placed below the resident to allow gravity drainage. The facility’s nephrostomy management policy required that the drainage bag be kept below the level of the kidney at all times, and the DON stated that backflow of urine could cause kidney infection.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information was complete and accurate as required. On 1/12/2026 at 9:00 AM, upon entrance, the surveyor observed the daily staffing posting on a board behind the reception desk and noted that only the column listing the number of staff was completed, while the columns for actual hours worked and total hours were left blank. The same incomplete postings were observed behind the reception desk on 1/13/2026 and 1/14/2026. On 1/14/2026 at approximately 2:30 PM, the receptionist stated that the staffing coordinator was responsible for the staffing posting, that the coordinator brought it down every day, and that the receptionist placed the prior day’s posting in a drawer when a new one was provided. On 1/14/2026 at 4:18 PM, the staffing coordinator confirmed she was in charge of the nursing staff posting since February 2025 and acknowledged that the two columns on the posting for actual hours worked and total hours had been overlooked. This failure to complete all required sections of the daily nurse staffing postings had the potential to affect all 131 residents residing in the facility.
Failure to Monitor and Investigate Resident Illicit Drug Use
Penalty
Summary
The facility failed to implement an effective system to monitor and investigate how a resident with a known history of substance abuse was able to obtain and use illicit drugs while residing in the facility. Despite the resident being cognitively intact and having no independent outside pass privileges, there were multiple documented incidents where the resident was found in possession of illicit substances and drug paraphernalia, and subsequently tested positive for cocaine, fentanyl, and opiates. Staff discovered a white powdered substance and a crack pipe in the resident's room on more than one occasion, and hospital records confirmed the resident's admission of drug use within the facility. There was a lack of consistent documentation and follow-through regarding the monitoring and supervision of the resident after each incident. Although the resident's care plan and behavior contract addressed substance abuse, there were no additional interventions documented after repeated hospitalizations for drug use. The facility's own policies required immediate assessment, drug screening, and restriction of passes, but there was no evidence of a thorough investigation into how the drugs were obtained or brought into the facility. Staff interviews revealed uncertainty about the process for handling contraband, inconsistent communication, and a lack of clarity regarding the involvement of law enforcement or addiction specialists. Furthermore, there was insufficient documentation of frequent monitoring and supervision of the resident following each incident, as required by facility policy. Staff did not consistently document monitoring on various shifts, and there was no evidence of a substance abuse assessment, psychiatric evaluation, or referral for addiction treatment after the resident's repeated positive drug screens and hospitalizations. The facility's failure to investigate the source of the drugs and to implement effective interventions contributed to the ongoing risk and ultimately resulted in the resident requiring multiple hospital transfers due to drug use while in the facility.
Removal Plan
- Regional Director of Operations in-serviced the Administrator regarding the facility's Resident Possession & Use Policy and the Illicit Drug Use Program.
- Administrator will be responsible for overseeing the Social Service Director in ensuring all residents identified with a history of substance abuse and drug seeking behaviors are closely monitored with appropriate and effective interventions.
- Regional Nurse Consultant in-serviced the Director of Nursing regarding the facility's Resident Possession & Use Policy and also the Illicit Drug Use Program.
- Director of Nursing will be responsible for overseeing nursing staff in ensuring all residents identified with a history of substance abuse and drug seeking behaviors are closely monitored with appropriate and effective interventions.
Failure to Notify Physician and Inadequate Staff Training Following Unwitnessed Fall
Penalty
Summary
The facility failed to notify the physician in a timely manner following an unwitnessed fall with potential head injury involving a resident with multiple complex medical conditions, including quadriplegia, diabetes, and acute kidney failure. The resident was found on the floor by a registered nurse, who performed an assessment and left a message for the physician but did not speak directly with them. The nurse also notified the resident's guardian and monitored the resident throughout the shift, but did not follow up with the physician after the initial message, as there were no observed changes in the resident's condition at that time. The facility's policy required physician notification after an accident or incident, but documentation in the medical record did not show direct communication or a physician assessment regarding the fall. The facility's policies and protocols did not provide clear guidance on the management of unwitnessed falls, particularly regarding residents not on anticoagulant therapy. Interviews with staff, including the DON and the administrator, confirmed that there was no specific written policy addressing unwitnessed falls or the protocol for sending residents out for evaluation based on anticoagulation status. The only available policy, "Fall Prevention and Management," did not address these scenarios, and staff relied on state guidelines and their own clinical judgment. The lack of a clear protocol contributed to inconsistent practices and uncertainty among staff regarding appropriate actions following unwitnessed falls. Additionally, the facility failed to properly in-service staff on Fall Risk Assessments. The in-service documentation provided did not include the date, time, or specific educational content covered, making it unclear whether staff received adequate training on fall risk identification and management. This deficiency in staff education, combined with the lack of clear protocols, had the potential to affect all residents in the facility, as proper fall risk assessment and response are critical for resident safety.
Inaccurate Fall Risk Assessments for Residents with Fall History
Penalty
Summary
The facility failed to accurately complete Fall Risk Assessments for four residents with a history of falls. For one resident with multiple diagnoses including hypertension, quadriplegia, and a recent fall, the assessment did not reflect the presence of hypertension or the recent fall, both of which should have increased the fall risk score. The documentation showed that the resident was found on the floor and was unable to describe the incident, but the assessment failed to account for these risk factors. Another resident with a history of falls and a recent traumatic fracture was not properly assessed for previous falls or for medications that increase gastrointestinal motility, which should have contributed to a higher fall risk score. The resident had experienced a fall prior to admission and another incident in the facility, but the assessment recorded no history of falls or relevant medications. Similarly, a third resident with Parkinson's disease and a documented unsteady gait was incorrectly assessed as having independent mobility with a steady gait, despite care plan documentation and observed incidents indicating otherwise. A fourth resident with cerebral infarction and seizures, who was receiving multiple medications known to increase gastrointestinal motility, was also inaccurately assessed as not receiving such medications. The DON confirmed that the Fall Risk Evaluations for these residents were inaccurate and acknowledged that assessments were not being fully completed. The facility's in-service training on Fall Risk Assessments lacked documentation of date, time, and educational content, further contributing to the deficiency.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by other residents, resulting in one resident sustaining blunt head trauma and a swollen, black eye. In the first incident, a female resident with a history of confusion, memory loss, wandering, and lack of safety awareness was punched in the right eye by a male resident who was known to have persistent anger, poor judgment, psychotic symptoms, and a history of aggressive and abusive behaviors. The incident occurred in the activity room during a group activity, where only one activity aide was present. The male resident became upset, was not redirectable, and struck the female resident before staff could intervene. The injured resident was sent to the emergency department for evaluation and treatment of blunt head trauma, and the incident was reported to the police and the state health department. In the second incident, a resident with a history of cerebral infarction and diabetes was slapped on the head by a roommate who had a history of substance abuse, poor judgment, and aggressive behaviors. The altercation occurred when the resident entered the bathroom connected to their shared room, leading to a confrontation in which the aggressive resident slapped the other on the head. The victim reported previous verbal aggression from the roommate but stated this was the first physical incident. Staff were alerted by the altercation, and the police were called, resulting in a citation for the aggressor. The aggressive resident was placed on 1:1 monitoring until discharge, and the incident was documented in nursing and social service notes. Both incidents involved residents who had been previously identified as at risk for abuse, with care plans in place noting their vulnerabilities and behavioral histories. Despite these assessments and care plans, the facility did not prevent the physical altercations, and staff were unable to intervene in time to stop the abuse. The facility's abuse prevention policy affirms the right of residents to be free from abuse, but the events described demonstrate a failure to ensure this protection for the residents involved.
Staff Misappropriation of Resident Property
Penalty
Summary
A resident with chronic respiratory failure, encephalopathy, and generalized anxiety disorder, who was cognitively intact and dependent on staff for multiple activities of daily living, experienced misappropriation of personal property while residing in the facility. The resident's niece, who managed the resident's finances, discovered unauthorized charges on the resident's credit and debit cards, as well as the disappearance of these cards from the resident's room. The resident reported never giving staff permission to use the cards and expressed feelings of being targeted, unsafe, and trapped as a result of the incident. The facility's internal investigation began after the resident's family member reported the suspicious charges and missing cards. Despite initial interviews with staff and the resident, the facility was unable to substantiate the theft internally. However, law enforcement became involved, and through collaboration with retail store loss prevention and review of surveillance footage, a staff LPN was identified as the individual using the resident's credit card. The LPN admitted to finding and using the card multiple times and was arrested at the facility. The police found receipts for purchases made with the resident's card in the LPN's possession. The facility's abuse prevention policy prohibits misappropriation of resident property and outlines procedures for screening, training, and reporting. Despite these policies, the LPN, who had a prior felony conviction and disciplinary history, was able to access and use the resident's financial property without consent. The resident's inventory of personal effects included the missing cards, and the facility's cameras were not operational at the time of the thefts. The incident resulted in significant emotional distress for the resident, who no longer felt safe and was deprived of access to personal financial resources.
Failure to Provide Adequate Dietary Oversight Results in Meal Service Deficiencies
Penalty
Summary
The facility failed to provide sufficient support personnel in the food and nutrition service, specifically by not having a Dietary Manager available to oversee daily operations. As a result, residents did not consistently receive meals according to their preferences, requests, or the facility's menu. Multiple residents reported not receiving requested meal substitutions, such as cheeseburgers or salads, and instead were served items not matching their preferences or the posted menu. Residents also reported that food was often served lukewarm or cold, and some meal components, such as milk for cereal or yogurt, were missing due to inventory issues. Observations revealed that meal trays were sometimes left uncovered or covered only with plastic wrap, and not all trays had meal tickets, particularly for newly admitted residents. Staff reported challenges in maintaining inventory, preparing meal tickets, and ensuring timely and accurate meal service in the absence of a Dietary Manager. The lack of oversight led to inconsistencies in meal preparation, serving times, and food temperatures. Additionally, dry food storage practices were not consistently sanitary, with scoops left inside or on top of bulk bins and bin lids left open, contrary to facility policy. Interviews with dietary staff and the Dietary Regional Consultant confirmed that the absence of a Dietary Manager resulted in increased workload, overlooked tasks, and difficulty maintaining proper kitchen operations. Staff expressed being overwhelmed and unable to keep up with inventory, cleaning, and ensuring all supplies were available. The facility's own policies and job descriptions for the Dietary Manager outlined responsibilities that were not being met, including ensuring food quality, safety, proper storage, and compliance with resident preferences and dietary needs.
Failure to Monitor and Document Fluid Intake Leads to Resident Dehydration and Hospitalization
Penalty
Summary
The facility failed to monitor and document the fluid intake of a dependent resident who required one-to-one supervision during meals, and did not assess for signs and symptoms of dehydration. The resident, who had multiple diagnoses including dementia, diabetes, and a history of cerebral infarction, was at risk for fluid imbalance and required assistance with eating and drinking due to cognitive and visual impairments. Despite care plan interventions that included encouraging fluid intake and monitoring for dehydration, there was no documentation of the resident's fluid intake in the electronic charting system, and staff interviews confirmed that the system did not provide a place to record fluid intake. Observations revealed that water was not consistently provided during meals, and staff did not always encourage or assist residents with drinking fluids. Staff interviews indicated that the resident needed significant assistance with feeding and drinking, but the amount of fluid consumed was not tracked or documented. The facility's own assessment and job descriptions required monitoring and recording of intake, but this was not implemented in practice. The dietician and acting Director of Nursing were unaware that fluid intake was not being documented, and no facility policy on meal and fluid intake documentation was provided for review. As a result of these failures, the resident experienced a significant decline in condition, presenting with lethargy and abnormal vital signs, and was emergently transferred to the hospital. Hospital records indicated severe hypernatremia and acute kidney injury, suspected to be secondary to dehydration, requiring intravenous fluids and antibiotics. The resident was hospitalized for five days and later died in the facility. The lack of fluid intake monitoring and documentation, combined with insufficient assessment for dehydration, directly contributed to the resident's adverse outcome.
Failure to Perform and Document Wound Care Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that physician orders for daily wound care treatments were completed as ordered for a resident with a sacral pressure ulcer. The resident, who was cognitively intact, had a history of cerebral infarction, obesity, type 2 diabetes mellitus, and hypertension. Upon admission, the resident had a community-acquired unstageable sacral wound. Despite the care plan interventions to assess the wound with each dressing change and monitor for signs of infection, the facility did not document the completion of wound care treatments from the 8th to the 12th and on the 18th. This lack of documentation indicates that the treatments were not performed as ordered. The resident's condition worsened, with the wound showing signs of infection, including purulent drainage and a significant increase in size. The wound care nurse and other nursing staff failed to monitor the wound for possible complications or signs of infection adequately. The resident was eventually transferred to a hospital with a diagnosis of septic shock due to the pressure wound infection and required intensive care for five days. Interviews with the wound care nurse and other staff revealed inconsistencies in the documentation and execution of wound care treatments, with some staff unaware of the resident's condition or the need for aggressive interventions. The Director of Nursing confirmed that the treatment administration record was missing documentation of the resident's wound care treatments, and the treatments were not performed as ordered by the physician. The facility's policy on skin management and monitoring of wounds was not followed consistently, leading to the resident's decline and hospitalization. The lack of proper documentation and adherence to physician orders contributed to the resident's worsening condition and subsequent transfer to the hospital.
Infection Control Deficiencies Persist Despite QAPI Efforts
Penalty
Summary
The facility failed to ensure its Quality Assurance Performance Improvement (QAPI) program effectively identified and addressed repeated deficiencies in infection control practices. The survey history revealed non-compliance with Federal tag F880 for infection control in November 2021, October 2022, and September 2023. Despite corrective actions such as re-educating nursing staff and conducting facility-wide infection control audits, deficiencies persisted. During an observation, a Licensed Practical Nurse (LPN) entered a resident's room with Enhanced Barrier Precautions signage without performing hand hygiene or wearing the required PPE gown. The LPN assessed the resident's tube feeding stoma and surrounding area, directly touching the resident's skin, and exited the room without performing hand hygiene. Another observation noted a resident with an indwelling catheter drainage bag and tubing in contact with the floor, which was confirmed by an LPN as a breach of infection control protocols. The Director of Nursing (DON) acknowledged the expectation for staff to adhere to infection control practices and stated that ongoing education and monitoring should be implemented. The facility's policy on QAPI emphasized the need for a comprehensive, data-driven program to address all systems of care and management practices, including infection control.
Failure to Obtain Physician Orders for Medications and Treatments
Penalty
Summary
The facility failed to obtain physician orders for the administration of medication, oxygen, and enhanced barrier precautions for several residents. Resident R177 was placed on enhanced barrier precautions due to an indwelling catheter without a physician's order until after the surveyor's inquiry. Additionally, an unlabeled medication ointment was found at R177's bedside, which the LPN identified as likely being barrier cream left by the treatment nurse, contrary to the facility's policy that no medication should be left at the bedside. Resident R14 was using Polyethylene glycol 400 1% lubricant eye drop solution for dryness and irritation without a physician's order. The LPN stated that they administered the medication upon the resident's request and did not document it, as they believed it was acceptable to have eye medication at the bedside. However, the resident's other glaucoma medications were kept in the medication cart with proper physician orders and documentation. Residents R56, R41, and R108 were all receiving oxygen therapy without documented physician orders. R56 was observed using oxygen at 3 LPM, and R41 was on oxygen at 3 LPM and enhanced barrier precautions due to enteral feeding, both without prior orders. R108 was also on oxygen therapy at 3 LPM, and the LPN and DON acknowledged the absence of a physician's order for this treatment. The facility's policies require that all medications and treatments, including oxygen and enhanced barrier precautions, have a physician's order, which was not adhered to in these cases.
Failure to Assess Appropriateness of Self-Administration of Medication
Penalty
Summary
The facility failed to determine the appropriateness of self-administration of medication for a resident, identified as R20, whose medication was left at the bedside. R20 has multiple diagnoses, including atrial fibrillation, mood disorder, hypertensive heart and chronic kidney disease, cardiopulmonary disease, asthma, chronic respiratory failure, major depressive disorder, GERD, diabetes mellitus, and peripheral vascular disease. The resident's care plan, dated July 18, 2024, includes an intervention to administer medications as ordered by a physician and to monitor and document for side effects and effectiveness. On December 3, 2024, R20 expressed a preference to self-administer medication after completing personal business, indicating a reluctance to take a water pill at that time. An LPN acknowledged the need to stay until R20 consumed the medication and recognized the necessity for a medication-administration assessment. The Unit Manager confirmed that R20's medication should not be left at the bedside without a completed self-medication assessment. The Director of Nursing stated the expectation for all residents with bedside medication to have a self-administration assessment. The facility's policy requires an interdisciplinary team assessment to determine the safety of self-administration for residents who wish to do so.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, leading to a deficiency in accommodating their needs. Resident R72, who has a history of cerebral infarction, asthma, and congestive heart failure, was observed in bed with the call light on the floor behind the privacy curtain, out of reach. This was confirmed by a Certified Nurse Aide, who acknowledged that the call light should be next to the resident to allow her to call for help if needed. Similarly, Resident R46, who is totally dependent on staff due to conditions such as lymphedema, congestive heart failure, and impaired vision, was found with the call light behind the bed on the floor. A Licensed Practical Nurse verified that the call light was not within reach and emphasized the importance of having it accessible since the resident is unable to ambulate. The Director of Nursing confirmed that all call lights should be within reach and answered promptly, as per the facility's policy.
Failure to Timely Complete Background Checks for New Admissions
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent resident abuse, specifically regarding the timely completion of criminal history background checks for new admissions. Three residents were admitted without the Criminal History Information Response Process being completed within the required 24-hour timeframe. The admissions staff, V18, stated that background checks are typically done within 72 hours due to not working after hours or on weekends, and there was no policy in place to ensure these checks are completed within 24 hours. The facility's administrator, V1, acknowledged that the failure to complete these screenings in a timely manner could put other residents at risk. The facility's undated Abuse Policy and Prevention Program indicated that criminal history background checks should be requested within 24 hours after a new resident's admission, but this was not adhered to in practice.
Failure to Conduct Required PASRR Screenings for a Resident
Penalty
Summary
The facility failed to submit the necessary information for the Preadmission Screening and Resident Review (PASRR) for a resident, identified as R20, who was part of a sample of 26 residents reviewed. R20 has diagnoses including Post Traumatic Stress Disorder, Unspecified Mood Disorder, insomnia due to another mental disorder, and major depressive disorder. The Unit Manager acknowledged R20's manipulative behavior, and the Administrator admitted to not having the required Level 1 or Level 2 PASRR screenings for R20, despite knowing that all residents under a certain age should have these screenings. The Admissions Director mistakenly believed R20 was exempt from the requirement and was unaware of the need for a Level 2 PASRR. Additionally, the Social Services Director was not aware of R20's mental illness diagnosis, which contributed to the oversight in obtaining the necessary screenings.
Improper Use of Low Air Loss Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to adhere to the manufacturer's recommendations for the use of a low air loss (LAL) mattress for a resident with a stage 4 pressure ulcer. The resident, who has a history of pressure ulcers and immobility, was observed lying on a LAL mattress with multiple layers of linen, including a cloth pad and flat sheet, which is contrary to the manufacturer's guidelines. The guidelines specify that only a flat sheet should be used over the LAL mattress to ensure its effectiveness in promoting wound healing. This deficiency was identified during an observation by a Licensed Practical Nurse (LPN) and confirmed by the Wound Care Nurse (WCN) and the Director of Nursing (DON), who acknowledged the improper use of the mattress. The resident, identified as having dementia, type 2 diabetes mellitus, peripheral vascular disease, and an acquired absence of the left leg below the knee, was at risk for pressure sores as indicated by the Braden scale assessment. The most recent wound assessment by the wound care physician confirmed the presence of a stage 4 pressure wound on the right hip and a non-pressure wound on the right lateral buttocks. Despite the facility's policy on mattress use, which is based on the manufacturer's literature, the staff did not have access to the manufacturer's recommendations for the LAL mattress, leading to improper care and management of the resident's pressure ulcers.
Failure to Implement Fall Prevention Measures for At-Risk Residents
Penalty
Summary
The facility failed to implement fall preventive measures for two residents, R56 and R21, who have a history of falls. R56, who was admitted with conditions including COPD and difficulty walking, was identified as being at risk for falls. Despite this, an incident occurred where R56 experienced an unwitnessed fall while attempting to use the bathroom, resulting in hospitalization. Observations revealed that R56's bed was not in the lowest position, contrary to the fall prevention measures outlined in her care plan, which included the use of bilateral floor mats and keeping the bed at its lowest position. Similarly, R21, who has a history of repeated falls and conditions such as hemiplegia and seizures, was found without the required fall mat next to his bed. Instead, the mat was placed between the clothes cabinet, not serving its intended purpose. Staff interviews confirmed that R21 is a fall risk and that the fall mat should have been positioned beside the bed. The facility's policy on managing falls emphasizes the need for staff to implement interventions to minimize fall risks, which was not adhered to in these cases.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to adhere to a physician's order for oxygen administration for a resident diagnosed with chronic obstructive pulmonary disease, asthma, chronic bronchitis, hypoxemia, and dependence on supplemental oxygen. The active physician order specified that the resident should receive oxygen at 4 liters per minute (LPM) via nasal cannula continuously, and that the oxygen tubing should be changed weekly during the night shift. However, during an observation, the resident was found in the dining area receiving oxygen at 6 LPM, which was not in accordance with the physician's order. Additionally, the oxygen tubing lacked a date or label, indicating non-compliance with the facility's policy on oxygen administration. The deficiency was confirmed by a registered nurse who verified the discrepancy between the physician's order and the actual oxygen administration. The Director of Nursing acknowledged that administering higher levels of oxygen than prescribed could potentially put the resident at risk for elevated carbon dioxide levels. The facility's policy, revised in March 2024, outlines the necessity of following physician orders and ensuring proper labeling and dating of oxygen equipment, which was not followed in this instance.
Delayed Implementation of Pharmacist Recommendations
Penalty
Summary
The facility failed to act upon and implement medication recommendations in a timely manner, affecting two residents. Resident R114, diagnosed with Alzheimer's disease and other conditions, was prescribed Aricept (Donepezil) to be administered at 9 AM daily. However, a pharmacist's review on 11/11/24 recommended changing the administration time to bedtime due to potential adverse effects like syncope and dizziness, which could contribute to falls. The attending physician agreed to the recommendation on 12/4/24, indicating a delay in response. On 12/3/24, R114 was observed in a wheelchair near the nursing station, closely supervised due to a high risk of falls. Similarly, Resident R56, with diagnoses including chronic obstructive pulmonary disease and cognitive communication deficit, was also prescribed Aricept at 9 AM. The pharmacist's review on 11/11/24 suggested changing the administration time to bedtime for the same reasons as R114. The physician agreed to this recommendation on 12/4/24, again showing a delay in action. On 12/3/24, R56 was observed lying in bed, which was not in the lowest position, with a floor mat on the right side. The Director of Nursing confirmed that the pharmacist's recommendations were not acted upon immediately, as they should have been within the same day according to the facility's policy.
Inappropriate Use of Anti-Psychotic Medication Without Qualifying Diagnosis
Penalty
Summary
The facility failed to have an appropriate diagnosis for a resident receiving anti-psychotic medication, specifically Risperdal (Risperidone), which was prescribed for vascular dementia with agitation. The resident, identified as R110, was admitted with multiple diagnoses including hemiplegia, aphasia, vascular dementia with agitation, anxiety disorder, and depression. However, the comprehensive care plan did not address the use of Risperdal, and there was no qualifying diagnosis for its use, as the appropriate diagnoses for Risperdal are schizophrenia and psychosis. Additionally, there was no baseline AIMS assessment conducted upon admission, and the most recent psychotropic note did not address the use of Risperdal or document any gradual dose reduction (GDR). Interviews with facility staff revealed that the Unit Manager/Psychotropic Nurse and the MDS/Resident Assessment Coordinator were responsible for managing psychotropic medications and ensuring appropriate diagnoses. However, the MDS Coordinator admitted that the resident did not have a qualifying diagnosis for Risperdal. Furthermore, the facility's policy on behavior and psychotropic medication management, revised in September 2024, had not yet been implemented, and there was no documentation of behavioral symptoms monitoring as required by the policy. This deficiency was identified through observation, interview, and record review, affecting one of the three residents reviewed for psychotropic medication management.
Failure to Coordinate and Document Hospice Services
Penalty
Summary
The facility failed to ensure that hospice services were properly coordinated and documented for a resident receiving end-of-life care. The resident, who was admitted with Alzheimer's disease and malignant neoplasm of the stomach, was on hospice care upon admission. However, the comprehensive care plan did not include any interventions related to hospice care. During observations, the resident was found to be confused, requiring total care for activities of daily living and transfers, and was receiving oxygen therapy. Despite being on hospice care, the hospice binder for the resident contained only nursing documentation, with no other hospice-related documents available. Interviews with facility staff revealed a lack of communication and documentation from the hospice provider. The social services representative acknowledged the absence of necessary hospice documentation and indicated a need to follow up with the hospice services. Additionally, the medical records staff had not uploaded any hospice documents to the resident's electronic medical records. The facility's administrator confirmed that the hospice binder should contain several key documents, including the hospice plan of care and medication list. Furthermore, the hospice service provider agreement was not fully executed, as it lacked the hospice representative's signature, contrary to the facility's policy requiring both parties' signatures before hospice care is provided.
Infection Control Lapses in Enteral Feeding and Catheter Management
Penalty
Summary
The facility failed to adhere to proper infection control practices during the assessment of enteral feeding and urinary catheter management. In the case of a resident with a gastrostomy tube, a Licensed Practical Nurse (LPN) entered the resident's room, which required Enhanced Barrier Precautions (EBP), without performing hand hygiene or wearing the necessary personal protective equipment (PPE) gown. The LPN proceeded to assess the resident's tube feeding stoma and surrounding area, directly touching the resident's skin. After the assessment, the LPN removed her gloves and exited the room without performing hand hygiene, despite the availability of a hand sanitizer dispenser in the hallway. The Director of Nursing and the Infection Preventionist confirmed that PPE should be worn in an EBP room and hand hygiene should be performed before and after care. In another instance, a resident with an indwelling urinary catheter was observed with the catheter drainage bag and tubing touching the floor, which is against infection control protocols. A Licensed Practical Nurse acknowledged that the urinary catheter tubing and drainage bag should not be touching the floor. The Director of Nursing reiterated that for infection control, the urinary drainage bag and tubing should be kept off the floor. The facility's policy on urinary catheter care, revised in September 2005, also indicates that the catheter tubing and drainage bag should be kept off the floor to prevent infection of the resident's urinary tract.
Failure to Notify Physician and Delay in Emergency Response
Penalty
Summary
The facility failed to immediately notify the physician and obtain an order to transport a resident experiencing an acute change in mental and respiratory status to the hospital. This deficiency affected a resident who was found unresponsive and in respiratory distress, with a diagnosis of aspiration pneumonia and sepsis secondary to pneumonia upon hospital admission. The delay in notifying the physician and calling EMS resulted in a significant lapse in the resident's care. The report details that the resident was last seen eating breakfast and was alert and oriented at their baseline. However, shortly after, the resident was found unresponsive with vomit on their clothes and mouth, and in respiratory distress. Despite these critical changes, the facility staff did not notify the physician or call EMS until several hours later. The resident's condition deteriorated significantly, with medical assessments revealing severe respiratory issues and a poor prognosis. Interviews with facility staff revealed a lack of immediate action and communication regarding the resident's condition. Several CNAs observed the resident's decline and attempted to alert nursing staff, but there was a delay in response. The RN on duty eventually assessed the resident and called EMS, but the physician was not notified as per the facility's protocol. This failure to follow the change in condition protocol and notify the physician promptly contributed to the resident's adverse outcome.
Resident-to-Resident Physical Assault Incident
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident physical assault, which affected two residents. Resident R10, who was cognitively intact with a Brief Interview for Mental Status score of 13/15, pushed resident R9, who had a diagnosis of dementia and was rarely understood, to the ground unprovoked. This incident occurred in the dining room area when R9 was standing in the pathway of R10. As a result, R9 sustained extensive injuries, including intraparenchymal and subarachnoid hemorrhages, hemorrhagic contusions, and extensive skull fractures. The incident was witnessed by staff members V19 and V22, who were monitoring the dining room at the time. Despite their presence, they were unable to prevent the assault. R9 was assessed immediately after the fall and was found with a laceration to the posterior scalp and skin tears on the left elbow. R9 was alert but confused and was subsequently sent to the hospital for further evaluation, where the severe nature of the injuries was confirmed. Interviews with staff and review of video footage revealed that R10 pushed R9 without any apparent reason and continued walking towards a window. R10 later stated that she did not know why she pushed R9 and was looking for something. The facility's abuse prevention policy, which prohibits abuse and neglect, was not effectively implemented to prevent this incident, as there were no previous interactions or noted behaviors between R9 and R10 that could have indicated a risk of such an event.
Failure to Ensure Resident Safety During Transport
Penalty
Summary
The facility failed to ensure safety measures were in place to prevent avoidable accidents for two residents. One resident, R7, was not properly secured in a wheelchair during transport to a dialysis center. The wheelchair was not equipped with a seat belt, and the leg rest was not fully functional. As a result, R7 slid out of the wheelchair, sustaining severe fractures to both legs, which required surgical intervention and immobilization. The transportation personnel, V26, attempted to reposition R7 during the journey but was unable to secure him adequately, leading to the resident's injuries. Another resident, R8, who has severe cognitive impairment and a history of wandering, was being transported in a wheelchair without footrests. While being redirected by staff, R8 placed his feet on the ground, abruptly stopping the wheelchair and causing a fall. This resulted in a laceration above the left eye, requiring sutures. The incident report noted that R8's wheelchair was not appropriately fitted for his height and lacked necessary support, contributing to the fall. Both incidents highlight the facility's failure to provide adequate supervision and equipment to prevent accidents. The lack of proper restraints and functional equipment during transportation and the absence of footrests for R8's wheelchair were significant factors in the accidents. These deficiencies resulted in serious injuries to the residents, indicating a need for improved safety protocols and equipment maintenance.
Resident Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a cognitively impaired resident, leading to the resident's unauthorized exit from the memory care unit. The resident, who had a history of severe cognitive impairment and was identified as a high risk for elopement, managed to leave the facility through a dining room door. The door alarm was triggered, but staff failed to locate the resident in the area and reset the alarm without conducting a thorough search or headcount. The incident occurred when the resident exited the facility after the dining room door alarm was triggered. Staff members were aware of the alarm but did not take immediate action to verify the cause or conduct a headcount. The resident was later found by local police nearly half a mile from the facility, highlighting a significant lapse in supervision and response to the alarm. The facility's failure to secure the outside gate after landscapers left also contributed to the resident's ability to leave the premises. The facility's policies and procedures for responding to door alarms and ensuring resident safety were not effectively followed. Staff statements indicated a lack of consistent headcounts and a history of frequent false alarms due to weather conditions, which may have contributed to the oversight. The delay in notifying the Director of Nursing and the police further exacerbated the situation, resulting in the resident being outside the facility for an extended period before being located.
Inadequate Supervision and Staffing Lead to Resident Injuries
Penalty
Summary
The facility failed to adequately supervise a resident in the locked unit who was assessed as a high fall risk, resulting in the resident sustaining a head laceration. The resident, a female with a history of dementia and other medical conditions, was observed walking around the dining room with improper footwear, which was against her fall care plan that required constant supervision and a clutter-free environment. Despite the presence of staff, the resident was not adequately monitored, leading to an injury that required hospital treatment. Another deficiency involved a resident who required two staff members for assistance during activities of daily living (ADLs) but was only assisted by one, resulting in a fall and a head laceration requiring stitches. The resident, who was dependent on staff for most activities and had an air mattress, was not provided the necessary assistance as per her care plan. The CNA assisting the resident at the time of the fall was unable to find additional help, leading to the resident rolling off the bed during care. Interviews with staff revealed that the unit was understaffed, with only one nurse and three CNAs available, which was deemed insufficient for the level of supervision required. The staff expressed concerns about the staffing levels and the challenges in providing adequate supervision and assistance to residents, particularly those at high risk of falls. The facility's policies on fall prevention and ADLs were not effectively implemented, contributing to the incidents.
Failure to Notify Resident's Representative and Ombudsman of Discharge
Penalty
Summary
The facility failed to notify a resident's representative and the local Ombudsman of the resident's discharge, which is a violation of the facility's transfer and discharge policy. The resident, a male with a history of abdominal aortic aneurysm, hypertension, diabetes, and other conditions, was discharged to a community living home without medical care. The discharge was scheduled, and the resident was transferred with his belongings and medication, but there was no documentation that the resident's family, Power of Attorney, or Ombudsman were informed of the discharge. The facility's social services staff were unaware that the resident had a State Guardian, despite the information being included in the referral packet from the hospital. The State Guardian was not notified of the discharge, and the facility did not follow up with the resident after the discharge. The facility's administrator later confirmed that the resident was a ward of the state and acknowledged that the Office of State Guardian should have been notified of the discharge. The facility's policy requires that residents or their authorized legal representatives be notified verbally and in writing at least thirty days prior to discharge.
Environmental and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the environment in good repair and failed to maintain a clean and sanitary environment, which has the potential to affect all thirty residents residing on the fifth floor. During facility rounds, several deficiencies were observed, including peeling paint on the walls, disarray in rooms with clean and dirty clothes mixed, dust and debris on wall fans and overbed lights, and dirty glass windows. Additionally, multiple room doors had peeling wood on the lower part of the doors. These observations were confirmed by the Administrator and the Maintenance Director during the surveyor's visit. In the fifth-floor dining room, an accumulated grayish-black sticky substance was found on parts of the floor, along with scattered brownish liquid in other areas. The floor was sticky to walk on, indicating inadequate cleaning. The Administrator acknowledged that housekeeping usually mops the floor after meals but admitted that they did not do a good job of cleaning on this occasion and was unsure if mopping was done daily. The facility's undated Housekeeping Services Policy states that the environment should be clean, odor-free, comfortable, and orderly, which was not upheld in this instance.
Failure to Provide Adequate Assistance During Shower
Penalty
Summary
The facility failed to prevent an avoidable fall for a high fall risk resident with poor sitting balance by not providing the required two-person assist during a shower. This resulted in the resident falling out of the shower chair, being transported to the local hospital, and receiving seven sutures to the left eyebrow area. The resident's care card and ADL functional analysis indicated the need for a two-person assist during bathing, which was not followed by the CNA at the time of the incident. The CNA involved in the incident did not check the resident's care card before providing care and was unaware that the resident required a two-person assist. The CNA was alone while giving the resident a shower and was bending down to dry the resident's legs when the resident suddenly fell out of the shower chair. The Director of Nursing confirmed that the resident's care plan was not updated to reflect the need for a two-person assist during showers, despite the resident's known jerky movements and high fall risk. Interviews with the Restorative Manager and Therapy Director further confirmed that the resident required a two-person assist for safety reasons due to poor sitting balance and cognitive deficits. The facility's policy on managing falls and fall risk was not adhered to, as the staff failed to provide the necessary level of assistance to prevent the fall. The incident report and progress notes detailed the events leading to the fall and the immediate actions taken to address the resident's injury.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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