Sharon Health Care Pines
Inspection history, citations, penalties and survey trends for this long-term care facility in Peoria, Illinois.
- Location
- 3614 North Rochelle, Peoria, Illinois 61604
- CMS Provider Number
- 14E322
- Inspections on file
- 38
- Latest survey
- September 3, 2025
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at Sharon Health Care Pines during CMS and state inspections, most recent first.
A resident with multiple psychiatric diagnoses, poor safety awareness, and a documented restriction from unsupervised community access was able to call a taxi, exit through the front door, and leave the premises despite staff and security presence, and was returned without any documented assessment, elopement precautions, or 15‑minute checks being initiated or added to the care plan. Multiple CNAs, RNs, and security staff reported they did not know which residents had restricted passes, relied on a front‑desk binder they could not memorize, and were not informed of the elopement, citing poor communication and staffing issues. Two other residents with restricted passes later exited through a side door that had been propped open by an outside vendor, further demonstrating that staff were not consistently preventing unsupervised exits or following the facility’s elopement and pass policies.
The facility failed to provide sufficient licensed nursing staff in accordance with its own staffing policy and staffing calculator, which required specific numbers of nurses and licensed nursing hours on each shift based on census and acuity. Timecard reviews showed that on multiple shifts there were fewer nurses working than required, including shifts with only one nurse on duty where more were indicated. The DON acknowledged ongoing staffing shortages, lack of awareness of the calculator’s required nurse numbers, and reported that nurses complained they could not complete their work. An RN stated she was unable to complete resident charting because the unit was too busy and understaffed, and the DON noted holes in MAR and TAR documentation that nurses attributed to low staffing, affecting care for approximately 110 residents.
The facility did not ensure that an RN was on duty for eight consecutive hours within a 24-hour period as required. Review of nurse timecard reports for a specified timeframe showed no RN coverage for the required continuous eight-hour period on one of the days reviewed, and the DON confirmed that no RN worked that day. At the time, the facility’s CMS LTC application documented that 110 residents were residing in the facility.
Surveyors found multiple failures in food storage, labeling, and kitchen sanitation, including undated and expired food items, thawed pre‑cooked meats and waffles stored without dates, and an opened, undated container of gravy mix powder. A freezer was operating at 42°F with thawed, sealed bologna that had not been discarded, and the unit had not been taken out of service despite the temperature issue. Additionally, heavy black, stringy dust was observed on a ceiling vent and surrounding tiles directly over an uncovered beverage preparation area. The Dietary Manager confirmed these conditions were inconsistent with facility policy and that Maintenance had been aware of the ceiling and vent condition, with these issues having the potential to affect all residents.
The facility failed to implement an effective pest control program for flies despite having a written pest control policy and regular pest control invoices that showed no treatment for flies. Multiple flies were observed in the kitchen near the juice machine, preparation sink, cup storage area, and on the steam table and food-contact surfaces during a meal. A resident in a wheelchair reported flies constantly landing on her while eating, and another resident reported flies swarming an uncovered trash can used for soiled disposable undergarments at the entrance of a hall, which surveyors observed on more than one occasion. The Dietary Manager acknowledged the flies and lack of known preventative measures, and the Administrator confirmed the facility had not been treated by pest control for flies, while 110 residents were documented as residing in the facility.
The facility did not provide mandatory annual Quality Assurance and Performance Improvement (QAPI) training to its staff. Review of in-service records over a one-year period showed no documentation of QAPI training for any staff members, despite the presence of 110 residents in the facility. This was confirmed by an administrative assistant, who stated that no staff had received the required annual QAPI education.
Surveyors identified that nursing staff failed to document medication administration on MARs for multiple residents, despite a facility policy requiring immediate documentation and prohibiting pre‑ or post‑signing. Review of August MARs showed numerous missing entries for ordered medications, including insulin, cardiovascular drugs, psychotropics, inhalers, pain medications, and other chronic therapies, with some medications lacking documentation 5–10 or more times. One resident with Type 2 DM had both mealtime and twice‑daily insulin not recorded as given on multiple days, and an RN who worked that weekend could not explain the lack of documentation. The DON confirmed the missing entries and attributed the problem to inadequate staffing, resulting in a pattern of undocumented medication administration across the residents reviewed.
A resident with psoriasis and excoriation had physician orders for triamcinolone 0.1% cream to affected areas on weekdays and antifungal powder to abdominal folds three times daily, with the care plan reflecting these treatments. Observation showed multiple red, raised, flaky skin lesions and the resident reported worsening psoriasis and eczema. MAR review revealed the triamcinolone cream was never administered after being ordered and the antifungal powder was missed for the majority of scheduled doses, which a RN and the DON confirmed as not given.
Surveyors identified that staff did not follow physician orders and professional standards during medication administration, resulting in a 12% medication error rate. An LPN administered an Albuterol inhaler without shaking it or instructing a resident to rinse and spit as ordered. Another LPN administered fewer units of Insulin Lispro than required by a sliding scale for a resident with an elevated blood glucose. An RN administered Insulin Aspart to a resident using an expired vial and in a total dose that did not align with the ordered regimen and sliding scale.
Surveyors found that staff failed to date opened insulin vials before administering Insulin Lispro per sliding scale to two residents. An LPN drew 18 units from an opened, undated vial for one resident, and an RN drew 2 units from another opened, undated vial for a second resident; both nurses stated they did not know when the vials were first accessed. The DON reported that facility policy requires insulin vials to be dated when first opened and used only for a defined 28-day period before disposal.
A resident with DM had physician orders for twice-daily fingerstick blood glucose monitoring and Insulin Lispro per sliding scale based on pre-meal blood glucose results. Review of the MAR showed multiple missed entries where staff did not document the resident’s fingerstick blood glucose results on several days, despite the standing orders. The DON confirmed the orders and stated that staff were responsible for performing and recording the blood glucose testing so the physician could monitor the resident’s blood sugar levels.
Staff failed to follow the facility’s glucometer cleaning policy requiring disinfection with a disinfecting wipe and a 5-minute dry time after each use. An LPN performed finger-stick blood glucose tests on two residents using the same shared glucometer, cleaning it only with an alcohol pad between uses and immediately returning it to the medication cart. The DON later confirmed that shared glucometers were required to be disinfected with a disinfecting wipe after each use, not an alcohol wipe.
A resident with cognitive impairment was physically pushed by another resident with a history of aggression, resulting in a fall. Facility staff did not notify the administrator or implement interventions after the incident, and an investigation was delayed until the administrator was later informed.
A resident was pushed by another resident, resulting in a fall, but the incident was not reported to the administrator or the State Agency as required by facility policy. Documentation confirmed the altercation, but no investigation or external reporting was completed because the administrator was not notified.
A physical altercation occurred between two residents, resulting in one resident being pushed and falling to the floor. Facility policy requires immediate reporting and investigation of such incidents, but the administrator was not notified, and no investigation or reporting took place.
Two residents with behavioral and psychiatric diagnoses engaged in a verbal and physical altercation on the smoking patio, during which one resident was pushed out of a wheelchair by another, resulting in a complex hip fracture that required surgery. Witnesses confirmed the escalation from verbal conflict to physical abuse, and another resident was also struck during the incident. The facility did not prevent the physical abuse as required by its policies.
A resident sustained a complex left hip fracture after a physical altercation with another resident on the smoking patio. Despite facility procedures requiring law enforcement notification for resident-to-resident physical abuse resulting in injury, the police were not contacted following the incident.
Staff failed to investigate or document an incident where a resident and others were exposed to a toxic chemical in the dining room. Despite symptoms such as coughing and eye irritation, no nursing assessments or incident reports were completed, and the facility could not identify all affected residents or provide required documentation.
A CNA engaged in taunting, derogatory, and threatening behavior toward a resident, including making disparaging remarks and physical gestures, which caused emotional distress and fear. Multiple staff and residents reported a pattern of confrontational and abusive conduct by the CNA, and the facility failed to protect residents by allowing the CNA to return to work after an initial suspension.
A resident with severe cognitive impairment and poor impulse control physically assaulted another resident, resulting in a facial laceration requiring sutures. The incident occurred in the TV area, where both residents were present, and staff intervention was not timely enough to prevent the altercation. The facility's abuse prevention policy failed to protect the resident from this incident.
Two residents with TBI diagnoses were involved in a physical altercation in the dining room, resulting in one resident sustaining a scratch. Despite staff presence, they could not intervene before the incident escalated from a verbal to a physical confrontation. The facility's abuse policy emphasizes prevention, but the incident highlights a failure to protect residents from physical abuse.
The facility did not respond to repeated Resident Council concerns about small meal portions and limited administrative availability, affecting all 96 residents. Despite consistent documentation of these issues in meeting minutes, the Dietary Manager and Administrator failed to address the grievances, contrary to the facility's policy of prompt resolution.
The facility failed to implement Enhanced Barrier Precautions (EBP) to prevent the spread of multi-drug resistant organisms (MDROs) among its 96 residents. Despite having a policy for EBP, observations showed no residents in isolation or signs indicating EBP implementation. The Director of Nursing confirmed that EBP had not been implemented, even though two residents had open wounds requiring dressing changes, and only standard precautions were used.
The facility failed to prevent and monitor abuse among residents, resulting in physical altercations. One resident with a history of aggression was involved in two incidents on the smoking patio, despite requiring supervision. Another altercation occurred in the dining room, escalating from a verbal to a physical confrontation. These incidents highlight lapses in adherence to the facility's abuse prevention policy.
A resident, recently hospitalized and with a changed diet order, was treated dismissively by a staff member when addressing a meal discrepancy. The staff member, V10, instructed the resident to speak with their nurse and turned away, leaving the resident upset. V10 perceived the resident as aggressive, though no specific aggressive behavior was noted during the interaction. This incident violated the facility's Resident Dignity policy.
A resident expressed a desire to return to a previous LTC facility, but the current facility failed to assist in the transfer process. Despite the resident's repeated requests and the facility's policy on discharge planning, no attempts were documented to facilitate the transfer, and the previous facility confirmed no requests for rescreening were received.
The facility did not update the PASARR for two residents who were diagnosed with psychiatric conditions after admission. One resident was diagnosed with Schizoaffective Disorder, Bipolar Type, and another with Other Schizoaffective Disorders. The Quality Assurance staff confirmed the absence of updated screenings to determine the need for Level II PASARR.
A resident's chart was not updated to reflect a change from Full Code to Modified DNR, resulting in the resident receiving unwanted CPR, including chest compressions, after being found unresponsive. The POLST indicated no chest compressions, but the care plan was not updated until after the resident's death. The LPN and CNA involved were unaware of the change, leading to EMS performing full resuscitation efforts.
A resident with limited range of motion did not receive ordered therapy services for six weeks, despite having a physician's order for speech, physical, and occupational therapy. The resident and his Power of Attorney had to arrange therapy themselves, as the facility failed to send referrals to the outside therapy department. The Restorative Nurse confirmed the delay in treatment and acknowledged that the resident was not on a formal restorative program to prevent further decline.
A resident experienced significant weight loss over several months due to the facility's failure to implement the registered dietician's dietary recommendations. Despite documented weight decline and specific dietary suggestions, the resident did not receive the necessary supplements, and staff were unaware of any special dietary interventions. The facility's weight policy was not followed, leading to a deficiency in maintaining the resident's nutritional health.
The facility failed to provide residents with easy access to three years of survey results, including complaint and certification inspections. Residents were unaware of where to find these results, and the survey book, located behind the reception desk, contained only the 2023 annual survey. The Quality Assurance representative confirmed the book's limited contents and explained that it was kept in a room that was not always unlocked.
A resident with a history of Traumatic Brain Injury and susceptibility to overstimulation was involved in two physical altercations with other residents due to the facility's failure to maintain required 15-minute checks and provide adequate supervision. The incidents resulted in injuries to the resident, highlighting deficiencies in the facility's abuse prevention measures.
Failure to Prevent Elopement and Implement Required Safety Measures for Residents With Restricted Passes
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision to prevent elopement for multiple residents with restricted community passes. One resident with a history of disorganized and paranoid schizophrenia, bipolar II disorder, delusional disorder, personality disorder, anxiety, poor insight and judgment, scattered thought process, poor decision-making skills, and poor safety awareness had been assessed as not capable of unsupervised outside community passes and did not know the facility address or how to contact someone in an emergency. Despite this, the resident’s care plan did not include safety interventions related to restricted community pass status and did not document the pass restriction. On the day of the incident, the resident independently called a taxi using a personal cell phone, walked out the front door, and entered the taxi while staff and security attempted to stop the departure, and the resident instructed the driver to leave. The resident was later returned by the taxi company, but there was no documented assessment after return, no initiation of elopement precautions, and no 15‑minute checks or other monitoring documented in the medical record. Staff interviews revealed that the nurse who was aware of the elopement did not document the incident, stating that the DON said she would chart it and citing staffing shortages and workload. Security staff reported seeing the resident outside on a cell phone and then entering a taxi, yelling for the resident to stop because there was no pass, and then notifying facility staff after the taxi left. Another security staff member assigned to the front entrance that day, who usually worked in housekeeping, stated he did not know the resident, did not recall any residents leaving, and was unaware the resident had exited while he was on duty. Multiple CNAs and nurses reported they did not know which residents had passes or restricted passes, relied on a binder at the front desk that listed pass status, and stated they could not memorize all residents’ pass restrictions. Several staff members, including CNAs and an RN, stated they were not aware that the resident had eloped, that the information was not passed on to them, and that communication in the facility was poor, with management not informing them of such incidents. Additional deficiencies were identified when two other residents with restricted community passes exited the facility unsupervised through a side door that had been propped open by an outside vendor working on the heating and cooling unit. One resident was observed outside near the main entrance and was escorted back into the facility, while another resident reported following the first resident outside to make sure he did not leave and then yelling for staff. Staff interviews confirmed that both of these residents had restricted passes and were not to leave without staff. The facility’s own elopement and missing person policy required that upon a resident’s return after elopement, staff initiate an assessment, notify family, complete documentation, place the resident on elopement precautions, review sign‑out procedures, and implement monitoring such as 15‑minute checks for at least 24 hours, with IDT reassessment. However, for the resident who left by taxi, these required steps were not implemented or documented, and the resident’s care plan and electronic medical record continued to lack updated safety interventions and monitoring strategies even days after the elopement. The cumulative failures in care planning, staff education on pass status, monitoring, communication, and adherence to the elopement policy resulted in an Immediate Jeopardy determination.
Insufficient Licensed Nursing Staff and Unmet Staffing Calculator Requirements
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient licensed nursing staff to meet residents’ needs and to follow its own staffing policy and staffing calculator requirements. The facility’s Staffing Policy dated 4/30/25 states that minimum numbers of nursing staff must be established and maintained based on census and resident acuity. The facility’s staffing calculator for multiple dates in August 2025 documented that four nurses (32 licensed nursing hours) were required on day shift, three nurses (24 licensed nursing hours) on evening shift, and two nurses (16 licensed nursing hours) on night shift. However, timecard reports for 8/5/25 through 8/24/25 showed that on several dates the actual licensed nursing hours fell below these calculated requirements. For example, on some days only one nurse worked the day shift, one to one-and-a-half nurses worked the evening shift, and one nurse worked the night shift, instead of the higher numbers required by the staffing calculator. The Director of Nursing confirmed multiple staffing shortages on specific dates and stated that staffing is an issue and that she was not aware the staffing calculator required four nurses on days, three on evenings, and two on nights. A registered nurse reported that she did not chart on her residents on one of the cited dates because things were too busy and there was not enough staff. The DON also stated that nurses complain about staffing numbers, report they cannot get things done, and that the MARs and TARs have holes in charting, which nurses attribute to not having enough time due to low staffing. At the time of the survey, the facility’s CMS LTC application documented a census of 110 residents, all of whom had the potential to be affected by these staffing shortages.
Failure to Provide Required RN Coverage for Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours in a 24-hour period, as required. During a survey on 8/28/25 at 8:30 AM, the Director of Nursing (V2) provided nurse timecard reports covering 8/5/25 through 8/24/25, which showed no documentation of an RN working eight consecutive hours on 8/12/25. At 10:15 AM the same day, V2 confirmed that there was no RN working on 8/12/25. The facility’s Centers for Medicare & Medicaid Services Long Term Care Application, dated 8/25/25 and signed by the Administrator (V1), documented that 110 residents were residing in the facility at the time.
Improper Food Storage, Labeling, and Kitchen Sanitation Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own Labeling and Dating and Food Policy and cleaning practices. During a kitchen tour with the Dietary Manager, an opened five‑pound tub of cottage cheese was found in a three‑door refrigerator, one‑quarter full, undated, and past its printed expiration date. Three gallon‑sized plastic bags of thawed, pre‑cooked chicken and a gallon bag of thawed, pre‑cooked hamburger patties were stored without dates, and two boxes of waffles labeled by the manufacturer to be kept frozen were observed thawed and undated in the refrigerator. On a preparation table next to the stove, a plate containing a piece of ham and two pancakes covered in plastic wrap was undated, and on a dry storage rack, an opened, half‑full 24‑ounce container of gravy mix powder was undated. The Dietary Manager confirmed that these items should have been labeled and dated in accordance with the facility’s policy and that the expired cottage cheese should have been discarded. Additional deficiencies were observed in equipment maintenance and environmental cleanliness in the kitchen. In the kitchen freezer, the thermometer registered 42°F, and the Dietary Manager stated the unit had failed that morning and that maintenance had been notified, further acknowledging that the freezer should have been taken out of service and that three sealed, undated packages of bologna found thawed in the freezer should have been discarded. During drink preparation, surveyors observed a heavy accumulation of black, stringy dust hanging from a ceiling vent and surrounding tiles directly over an uncovered prepared beverage area. The Dietary Manager verified the presence of the black dust on the ceiling vent and tiles and stated that Maintenance was responsible for cleaning the kitchen ceiling and vents and had been aware of the condition. The facility’s CMS LTC application documented that 110 residents resided in the facility at the time of the survey.
Failure to Implement Effective Pest Control for Flies in Resident and Food Service Areas
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its Pest Control Policy dated 4/25/25, which calls for prevention, sanitation, and integrated pest management across all buildings and grounds. Pest control invoices for March through August 2025 did not show any evidence that the facility was being treated for flies. During a kitchen tour, multiple flies were observed near the juice machine, preparation sink, and cup storage area. The Dietary Manager acknowledged the presence of flies, attributed them to frequent opening of the dining room door, and stated she was unaware of any pest control measures being used to keep flies out of the kitchen. A resident in a wheelchair reported that flies constantly landed on her while she ate in the dining room, and during the interview two flies were observed landing on her arm, which she swatted away. Another resident reported that a trash can without a lid at the beginning of C-Hall, used for disposal of soiled disposable undergarments, was constantly swarmed by flies and described them as very annoying. Surveyors observed this uncovered trash can filled with soiled undergarments at the entrance of C-Hall with a swarm of flies, and later again observed the same trash can filled with soiled undergarments with multiple flies present. During a noon meal, a fly infestation was observed in the kitchen, with flies landing on the steam table and food-contact surfaces. The Administrator confirmed the facility had not been treated by a pest control service for flies. The facility’s CMS LTC application documented that 110 residents resided in the facility at the time of the survey.
Lack of Annual QAPI Training for All Staff
Penalty
Summary
The facility failed to ensure that all staff received mandatory annual training on the facility’s Quality Assurance and Performance Improvement (QAPI) program. Review of the facility’s CMS Long Term Care Application, dated 8/25/25 and signed by the Administrator, documented that 110 residents resided in the facility. A review of the facility’s List of Staff In-services, covering the period from 8/8/24 through 8/25/25, showed no documentation that facility staff had received the required annual QAPI training. In an interview on 8/28/25 at 12:55 PM, the Administrative Assistant confirmed that no staff at the facility had received the annual QAPI training.
Widespread Failure to Document Medication Administration on MARs
Penalty
Summary
The deficiency involves the facility’s failure to document medications at the time of administration in accordance with its own Medication Administration policy, which requires staff to initial the Medication Administration Record (MAR) immediately after administering medications and prohibits pre‑signing or post‑signing. Surveyors’ review of MARs for multiple residents in August 2025 showed numerous missing documentation entries for ordered medications over multiple days. The Director of Nursing verified the missing documentation and stated that insufficient staffing contributed to staff not documenting medications administered. For one resident with Type 2 Diabetes Mellitus without complications, physician orders required Humulin R insulin with meals and Lantus SoloStar insulin twice daily. The MAR for this resident from August 1–27, 2025, showed that both Humulin R and Lantus SoloStar were not recorded as given on six separate dates. A registered nurse later stated that she had been the nurse for that resident on one of the affected weekends and did not know why she had not recorded administering those insulins. For eight additional residents, MARs dated August 2025 showed that numerous routine and PRN medications, including cardiovascular agents, psychotropics, inhalers, insulin, pain medications, and other chronic disease therapies, were not documented as administered multiple times throughout the month. For several of these residents, individual medications were not documented as given 5 or more times, and in many cases 7–10 or more times, between August 1 and August 25, 2025. These findings collectively demonstrate a pattern of failure to document medication administration as required by facility policy for all nine residents reviewed for medication administration.
Failure to Administer Ordered Topical Treatments for Skin Conditions
Penalty
Summary
The facility failed to provide physician-ordered topical treatments for a resident with psoriasis and excoriation. During observation, the resident was noted to have multiple round, red, raised, and flaky areas on both upper and lower extremities, and the resident reported having psoriasis and eczema that had recently worsened. The resident’s care plan documented psoriasis and directed staff to apply Nystatin powder to abdominal folds and triamcinolone as ordered. Physician orders included triamcinolone acetonide 0.1% cream to affected areas twice daily on weekdays for psoriasis and an antifungal powder to the abdominal folds three times daily for excoriation. Review of the MAR for August showed that the triamcinolone cream had not been administered at all since it was ordered and that the antifungal powder was not documented as given for 50 out of 73 scheduled doses. A RN and the DON confirmed that the blank MAR entries indicated the medications were not administered as ordered.
Medication Administration Errors Resulting in Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered, resulting in a 12% medication error rate (3 errors out of 25 opportunities), exceeding the 5% threshold. Facility policy on Medication Administration requires adherence to the seven rights and compliance with manufacturer specifications and professional standards, including shaking medications when indicated and following specific inhaler instructions. For one resident with asthma, the physician’s order for Albuterol Sulfate inhalation aerosol specified 2 puffs four times daily, with directions to shake well before administration and to have the resident rinse and spit afterward. During observation, an LPN handed the resident the Albuterol inhaler without shaking it, allowed the resident to take 2 puffs, and then returned the inhaler to the cart without instructing the resident to rinse and spit, despite the inhaler label including these directions. For a second resident with diabetes mellitus, the physician’s order for Insulin Lispro included a detailed sliding scale directing that a blood glucose of 356 or higher required administration of 20 units and a call to the MD. An LPN obtained a blood glucose result of 389 for this resident and administered only 18 units of Lispro insulin in the abdomen, later confirming that 20 units should have been given. For a third resident with diabetes mellitus, the physician’s orders included a fixed dose of 6 units of Insulin Aspart three times daily and a separate sliding scale that required 8 units for a blood glucose of 301–350. An RN obtained a blood glucose result of 348 and administered 14 units of Aspart insulin into the resident’s left upper arm using a vial that was confirmed to be expired. These observed deviations from physician orders and professional standards formed the basis of the cited medication administration deficiencies.
Failure to Date Opened Insulin Vials for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that opened insulin vials were dated in accordance with facility policy and accepted professional standards. For one resident, whose physician order sheet for August 2025 included Insulin Lispro 100 unit/mL to be given per sliding scale, an LPN prepared and administered 18 units of insulin from an opened insulin vial that had no date indicating when it was first accessed; the LPN confirmed she did not know when the vial was opened. For a second resident, also ordered Insulin Lispro 100 unit/mL per sliding scale, an RN prepared and administered 2 units of insulin from another opened, undated insulin vial and likewise stated she did not know when that vial was first accessed. The Director of Nursing later stated that the facility’s policy required insulin vials to be dated when first accessed and used for a period of 28 days, after which any remaining insulin should be discarded. The observations of staff administering insulin from undated vials, combined with staff statements that they did not know when the vials were opened, demonstrate that the facility did not follow its own policy for labeling and managing opened insulin vials for these two residents.
Failure to Accurately Document Ordered Blood Glucose Monitoring
Penalty
Summary
Facility staff failed to maintain an accurate medical record by not documenting physician-ordered blood glucose testing for a resident with Diabetes Mellitus. The resident’s current Physician Order Sheet dated August 2025 included an order for Insulin Lispro 100 Unit/mL to be administered per sliding scale based on blood glucose monitoring before each meal, with a current order for fingerstick blood glucose monitoring twice daily. Review of the resident’s Medication Administration Record for August 1–25, 2025 showed that staff did not document the resident’s fingerstick blood glucose results on multiple dates, specifically August 6, 8, 10, 15, 17, 20, 21, 22, 23, and 24, 2025. During an interview on August 27, 2025 at 8:40 A.M., the DON confirmed the physician’s order for twice-daily fingerstick blood glucose monitoring and stated that staff were expected to perform the testing and record the results in the medical record for the physician to monitor the resident’s blood sugar levels. This lack of documentation of ordered blood glucose testing for a resident with Diabetes Mellitus constituted a failure to maintain an accurate medical record in accordance with accepted professional standards.
Failure to Properly Disinfect Shared Glucometer Between Residents
Penalty
Summary
Facility staff failed to follow the facility’s Glucometer Cleaning Policy and Procedure, dated 6/5/25, which requires disinfection of shared blood glucose monitoring equipment with a disinfecting wipe after each use and a 5-minute dry time. The deficiency involved two residents with physician orders for blood glucose monitoring three times daily (R8 and R103). On 8/25/2025 at 11:52 A.M., an LPN (V4) performed a finger-stick blood glucose test on R8 and then cleaned the shared glucometer with an alcohol pad instead of a disinfecting wipe, immediately placing the device in the top drawer of the medication cart without allowing the required disinfectant dry time. Seven minutes later, at 11:59 A.M., the same LPN used the same glucometer to perform a finger-stick blood glucose test on R103 and again cleaned the device only with an alcohol pad before returning it to the medication cart. On 8/27/2025 at 11:34 A.M., the DON (V2) confirmed that shared glucometers were required to be disinfected with a disinfecting wipe after each use, not an alcohol wipe. These observations, interviews, and record reviews showed that the facility did not implement its infection prevention and control program as written for disinfection of shared blood glucose monitoring equipment for two of two residents reviewed for blood glucose monitoring in a sample of 40.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
A resident with cognitive impairment was involved in a physical altercation with another resident who is alert and oriented but has a history of emotional regulation issues and aggressive behavior. The incident occurred when the cognitively impaired resident attempted to cut in line, prompting the other resident to push them, resulting in a fall. Both residents' care plans documented their respective behavioral and cognitive challenges, including poor impulse control and a tendency toward aggression. Despite the altercation, facility staff failed to notify the administrator or implement any interventions following the incident. The registered nurse did not report the event, and an investigation was not initiated until the administrator was informed at a later date. This lack of timely response and failure to follow abuse prevention protocols resulted in the facility not protecting the resident from physical abuse as required by policy.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident physical abuse to the State Agency as required by its Abuse Prevention Program policy. According to the facility's policy, any suspicion or allegation of abuse, neglect, or exploitation must be immediately reported to the administrator or a designated individual in their absence, and the Department of Public Health's regional office must be informed. On 8/6/25, one resident was pushed by another resident, resulting in a fall and landing on the left side. Progress notes for both residents documented the altercation. However, the administrator confirmed that he was not notified of the incident, and as a result, no investigation or reporting to authorities occurred.
Failure to Investigate Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident physical abuse involving one of four residents reviewed for abuse. According to the facility's Abuse Prevention Program policy, the administrator or designee is required to initiate an incident investigation upon learning of any allegation of abuse. Progress notes for two residents documented that one resident pushed another, resulting in the second resident falling to the floor and landing on his left side. The administrator confirmed that he was not notified of the incident, and as a result, no investigation or reporting was conducted. The administrator also stated that all such incidents are supposed to be reported to him or his designee immediately, regardless of the time or day.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in one resident sustaining a complex left hip fracture that required surgical intervention. One resident, who had diagnoses including schizophrenia, major depression, dementia, and chronic kidney disease, was involved in an altercation with another resident on the smoking patio. The altercation began with verbal exchanges and escalated when one resident pushed the other out of his wheelchair, causing him to fall onto the concrete and sustain a serious hip injury. Witnesses confirmed that the incident involved bickering, followed by one resident tipping the other out of the wheelchair. The injured resident was unable to stand due to pain and was subsequently sent to the emergency room, where a complex fracture was confirmed. The resident who initiated the altercation had a documented history of socially inappropriate behaviors, including verbal and physical aggression, and a delusional thought process affecting his awareness of safety for himself and others. The facility's Abuse Prevention Program defines abuse as the willful infliction of injury, and the incident was described by staff as an impulsive act rather than abuse. However, the event resulted in significant harm to the resident, and another resident was also struck in the face during the altercation. The report documents that the facility did not prevent the physical abuse between residents, as required by their policies.
Failure to Notify Law Enforcement After Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to notify local law enforcement following a physical altercation between two residents that resulted in injury. According to the facility's Abuse Prevention Program Facility Procedures, law enforcement must be contacted in cases of physical abuse involving injury, except when the behavior is associated with dementia or developmental disability. In this incident, one resident was found lying on the smoking patio, unable to stand due to pain, and was subsequently diagnosed with a complex fracture of the left hip. Progress notes indicated that the altercation stemmed from a verbal exchange, and the injured resident required emergency room evaluation. Despite these circumstances, the facility's Administrative Quality Assurance/Grievance/Abuse Coordinator confirmed that the police were not notified of the incident.
Failure to Investigate and Document Resident Exposure to Toxic Chemical
Penalty
Summary
The facility failed to investigate and document an incident in which residents were exposed to a toxic chemical in the dining room. According to the facility's policy, any incident or accident that could result in physical harm or emotional upset must be documented in the resident's medical record, and a nursing assessment should be completed. On the date of the incident, a registered nurse accidentally discharged a can of a chemical substance in the dining room, causing residents and staff to cough and experience eye irritation. Residents were evacuated, and emergency services were called, but no nursing assessments were performed or documented for the residents involved, including a cognitively intact resident who reported symptoms but was not assessed by a nurse. Multiple staff members, including RNs and an LPN, confirmed that no incident reports, resident assessments, or investigations were completed following the exposure. The Director of Nursing acknowledged that nursing assessments should have been completed and documented but were not. The facility was unable to identify which residents were present in the dining room at the time of the incident and could not provide any documentation of an investigation, witness statements, or incident reports related to the event.
Failure to Protect Resident from Verbal and Mental Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from mental and verbal abuse by a Certified Nursing Assistant (CNA), resulting in emotional distress and persistent fear for the resident. The CNA engaged in taunting behavior, including making derogatory remarks about the resident's significant other, sticking her tongue out at the resident, and making threatening gestures such as raising her fists and challenging the resident to a fight. Multiple staff and residents reported that the CNA was confrontational, demeaning, and had a pattern of inappropriate interactions with both residents and staff. The incident occurred in a public area of the facility, and the CNA's behavior was witnessed by other staff members, who described her actions as unprofessional and abusive. Despite the initial suspension of the CNA following the incident, her termination was rescinded due to union involvement, and she was allowed to return to work. This decision left residents and staff fearful, as the CNA continued to work in various areas of the facility, including the dining room and multiple halls. Interviews with several residents revealed that they felt intimidated, bullied, and harassed by the CNA, with some expressing fear of being around her and reluctance to report her behavior due to intimidation. Staff members also reported feeling uncomfortable and scared, with some stating that the CNA's behavior extended to her interactions with employees as well. The facility's own policies affirm the right of residents to be free from abuse and outline expectations for staff conduct, including the prohibition of verbal abuse and mistreatment. However, the facility failed to enforce these policies effectively, as evidenced by the CNA's continued employment and the lack of immediate protective measures for residents. The deficiency resulted in an Immediate Jeopardy situation, as residents experienced emotional harm and ongoing fear due to the CNA's actions and presence in the facility.
Removal Plan
- V3 completed Abuse training and Behavior De-escalation training and was monitored continuously on Second Shift.
- V3 was immediately terminated by V1 (ADM) and V2 (Director of Nursing/DON).
- V1 (ADM), V2 (DON) and V4 (Abuse Coordinator) completed an entire whole house audit to evaluate Facility Residents at risk for potential abuse and no evidence was noted.
- An all-Staff in-service by V1 (ADM) and V4 (Abuse Coordinator) was conducted on Resident Abuse and Reporting. A tracking sheet was expected to be completed.
- A sign was placed by the Facility timeclock to ensure employees complete the Abuse training prior to work on floor and direct care with Residents.
- A checklist was developed to ensure one-hundred percent compliance with the mandatory training for employees/staff that are on vacation and as needed basis (PRN).
- A current employee list was audited and over seen by V1 (ADM), V2 (DON) and V3 (Abuse Coordinator) to evaluate potential staff requiring one-on-one review and said employees to have additional training on Abuse and Mandatory Behavioral De-escalation courses.
- An Abuse training module through the Facility computer program was initiated with trainings on Abuse prevention, sensitivity and respect to be scheduled and implemented for part of the progressive disciplinary process.
- V1 (ADM), V4 (Abuse Coordinator) and Department Heads to monitor for compliance.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident, R2, from physical abuse by another resident, R1, resulting in R2 receiving sutures for a facial laceration. The incident occurred in the TV area where both residents were present. R1, who has a history of psychotic disorder, mood disorder, unspecified dementia, anxiety, and traumatic brain injury, is noted to have severe cognitive impairment and poor impulse control. R1's care plan acknowledges the potential for verbal and physical aggression due to these conditions. On the day of the incident, R1 and R2 were involved in an altercation. R2, who also has unspecified dementia, anxiety, and schizoaffective disorder, is moderately cognitively impaired and prone to verbal and physical aggression. According to the progress notes, R2 and R1 began arguing, and as staff attempted to intervene, R1 stood up and struck R2 in the face, causing a laceration that required hospital treatment. The facility's abuse report confirms that R1's action was intentional, and video footage corroborates the sequence of events leading to the altercation. Staff interviews reveal that R1 becomes agitated by loud noises and yelling, which may have contributed to the incident. Despite staff presence, the intervention was not timely enough to prevent the physical altercation. The facility's abuse prevention policy emphasizes the protection of residents from abuse by anyone, including other residents, but in this case, the measures in place were insufficient to prevent the incident.
Failure to Prevent Physical Abuse Between Residents
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents with Traumatic Brain Injury (TBI) diagnoses. The incident occurred in the main dining room, where a verbal altercation between the two residents escalated into a physical confrontation. The altercation involved name-calling, slapping, scratching, and hair-pulling, resulting in one resident sustaining a scratch on the forehead. Despite multiple staff members being present, they were unable to intervene before the physical altercation occurred. The facility's undated Abuse Policy emphasizes the residents' right to be free from abuse, including physical abuse, and outlines the facility's commitment to preventing such occurrences. However, during the incident, one resident admitted to smacking the other in response to being verbally provoked. The staff members present did not hear the initial verbal exchange and were unable to prevent the physical altercation. The incident report noted that no first aid was required for the scratch sustained by the resident.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to adequately respond to repeated concerns raised by the Resident Council, affecting all 96 residents. The Resident Council Meeting Minutes from January to August 2024 consistently documented requests for larger meal portions, which were relayed to the dietary supervisor. However, residents reported that the serving sizes remained small, and requests for second helpings were often denied. This issue was a constant complaint, yet the Dietary Manager did not respond to these grievances, as confirmed by the Activity Director. Additionally, the Resident Council Meeting Minutes from February to August 2024 documented requests for more frequent interaction with the administration. Residents expressed difficulty in accessing the Administrator and desired more availability and willingness from the administration to assist them. Despite these repeated requests, the Administrator and some department managers did not address the concerns, leading to dissatisfaction among the residents. The facility's policy encourages open communication and prompt resolution of grievances, but the lack of response to these issues indicates a failure to adhere to this policy.
Failure to Implement Enhanced Barrier Precautions for MDRO Prevention
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) to prevent the spread of multi-drug resistant organisms (MDROs) among its 96 residents. The facility's policy on EBP, which is undated, outlines the use of gowns and gloves during high-contact resident care activities for residents known to be colonized or infected with MDROs, as well as those at increased risk for MDRO acquisition. Despite this policy, observations on 9/17/24 revealed that no residents were in isolation, nor were there any signs indicating the implementation of EBPs on resident doors. On 9/19/24, the Director of Nursing/Infection Preventionist confirmed that the facility had not implemented EBP for any residents, despite having two residents with open wounds requiring dressing changes. The Director stated that the facility only used standard precautions and had recently received information about EBP from corporate but had not yet implemented it. This lack of implementation of EBP was confirmed despite the presence of residents with conditions that increase the risk of MDRO transmission, such as open wounds.
Failure to Prevent and Monitor Resident Abuse
Penalty
Summary
The facility failed to prevent and monitor residents for physical and verbal abuse, as evidenced by incidents involving four residents. The facility's abuse prevention policy, which aims to protect residents from abuse by anyone, was not effectively implemented. The policy outlines the need for a resident-sensitive environment and defines abuse as willful infliction of injury, including physical and verbal abuse. Despite these guidelines, incidents of abuse occurred, indicating a lapse in adherence to the policy. One significant incident involved a resident with a history of aggressive behavior and a criminal background, who was involved in physical altercations with another resident on two occasions. The first incident occurred on the smoking patio, where a verbal altercation escalated to physical violence, resulting in minor injuries to both residents. The second incident involved the same resident requesting a lighter from another resident, leading to a physical confrontation where the resident used a wheelchair to strike the other resident. Despite the facility's policy requiring supervision for this resident, the altercation occurred without staff intervention until after the incident had escalated. Another incident involved a verbal altercation between two residents in the dining room, which quickly escalated to a physical confrontation. Staff intervened immediately, but the incident highlights the facility's failure to monitor and prevent such altercations. The facility's initial report to the state agency documented the incident, but the investigation was still ongoing at the time of the report. These incidents demonstrate a failure to adequately supervise and protect residents from abuse, as required by the facility's policies.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as observed during an interaction between the resident and a staff member identified as V10 from Medical Records. The incident occurred when the resident, who had recently been hospitalized and had their diet order changed to a general diet, approached V10 to address the discrepancy in their meal. The resident calmly explained the situation, but V10 responded dismissively, instructing the resident to speak with their nurse and turning away to continue distributing trays to other residents. This interaction left the resident feeling upset and angry, as they felt they were being treated as problematic for simply wanting to ensure they received the correct meal. Further investigation revealed that V10 perceived the resident as aggressive and obsessive about their diet, although V10 could not specify any aggressive behavior during the interaction. V10 acknowledged that the resident's diet had indeed been changed to a general diet following their hospitalization. Despite being trained in de-escalation techniques, V10 admitted that the resident was not being aggressive at the time of the incident. This failure to treat the resident with dignity and respect, as outlined in the facility's Resident Dignity policy, contributed to the deficiency identified in the survey.
Failure to Assist Resident with Desired Transfer
Penalty
Summary
The facility failed to assist a resident, identified as R93, in finding an alternate nursing home placement, which was a deficiency noted during a survey. The facility's admission packet outlines that the Social Service Department is responsible for discharge planning and should be contacted when a resident considers leaving. Despite this, R93 expressed dissatisfaction with the current facility and a desire to return to a previous long-term care facility. The resident communicated this wish to various staff members, but no action was taken to facilitate the transfer. The administrator, identified as V1, acknowledged that R93 had expressed a desire to return to the previous facility but did not document any attempts to initiate the transfer process. The administrator of the previous facility confirmed that no requests for rescreening or reassessment of R93 had been received. This lack of action and documentation indicates a failure to support the resident's right to self-determination and choice in their living arrangements, as outlined in the facility's discharge planning policy.
Failure to Update PASARR for Residents with New Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) process was updated for two residents diagnosed with psychiatric conditions after their admission. Resident 8 was admitted without a documented psychiatric diagnosis, but later received a diagnosis of Schizoaffective Disorder, Bipolar Type. Despite this, the facility did not update the Level I PASARR to determine the need for a Level II PASARR. Similarly, Resident 67 was admitted without a psychiatric diagnosis, but was later diagnosed with Other Schizoaffective Disorders following a psychiatric visit. The facility again failed to update the PASARR screening to reflect this change. The Quality Assurance staff member, identified as V4, confirmed the lack of updated screenings for both residents.
Failure to Update Code Status Leads to Unwanted CPR
Penalty
Summary
The facility failed to update a resident's chart to reflect a change in code status from Full Code to Modified DNR, resulting in the resident receiving full CPR, including chest compressions, contrary to their wishes. The resident, identified as R99, had a POLST indicating a Modified DNAR, which specified non-invasive airway and breathing support, IV medications, and hospital transfer, but explicitly stated no chest compressions. However, the care plan still documented the resident as Full Code, and it was only updated to reflect the DNR status a day after the resident's death. The incident occurred when R99 was found unresponsive, and the LPN on duty used an ambu-bag until EMS arrived. The LPN was distracted and did not inform EMS of the DNR status, and the CNA who called 911 was unaware of the change in code status, leading to the dispatcher being informed that the resident was Full Code. Consequently, EMS performed chest compressions and other resuscitative measures. The resident's Health Care Power of Attorney confirmed that R99 had changed their code status while in the hospital, but this was not reflected in the facility's records at the time of the incident.
Failure to Provide Ordered Therapy Services
Penalty
Summary
The facility failed to provide therapy services as ordered for a resident with limited range of motion. The resident, who was observed with left upper extremity weakness and lack of coordination, had a physician's order for referrals to outpatient speech therapy, physical therapy, and occupational therapy. Despite being admitted to the facility for six weeks, the resident reported not receiving any therapy services and had to arrange for therapy with the help of his mother. The resident's Power of Attorney confirmed that no referral for therapy services had been received by the outside physical therapy department, and the lack of therapy was affecting the resident's ability to progress in his diet. The Restorative Nurse acknowledged the delay in treatment and confirmed that the resident was not on a formal restorative program to prevent further decline in range of motion while awaiting therapy evaluations.
Failure to Implement Dietician's Recommendations for Resident's Weight Loss
Penalty
Summary
The facility failed to follow the registered dietician's recommendations to prevent weight loss for a resident identified as R75. The facility's weight policy and procedure require that any dietary recommendations made by the dietician be referred to the physician for approval. However, despite significant weight loss documented over several months, there were no diet supplements or dietary recommendations included in R75's physician orders. The resident's weight declined from 190 lbs in November 2023 to 159.2 lbs by September 2024, indicating a significant weight loss of 10.3% over three months. The registered dietician had recommended changes to R75's diet, including substituting a sandwich and milk at bedtime with pudding and a thickened health shake, and providing a honey-thick health shake with breakfast and lunch, but these recommendations were not implemented. Observations and interviews revealed that R75 was not receiving the recommended dietary supplements. R75 expressed awareness of his weight loss and mentioned not receiving milkshakes, which he would drink if provided. Staff members, including an RN and an LPN, were unaware of any special supplements being provided to R75, despite the resident's significant weight loss and dietary needs. The facility's Director of Nursing stated that weight meetings were held weekly to discuss resident weight losses and interventions, but it appears that the necessary dietary interventions for R75 were not effectively implemented or communicated to the staff responsible for the resident's care.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the survey inspection book contained three years of previous survey results for both complaint and certification inspections. This deficiency was identified during a resident group meeting where several residents confirmed they were unaware of where to access the facility's previous annual and complaint investigation results. Additionally, they did not know that the State Agency survey results were available for their review. The facility had posted a notice on the main hall bulletin board indicating that survey results were available in the survey room, but access required assistance if the room was locked. Upon inspection, the survey results book was found behind the reception/security front desk and contained only the annual Licensure and Certification survey dated 6/2023. It lacked any complaint survey results or annual Certification surveys from the previous three years, except for the 2023 survey. The Quality Assurance representative confirmed the limited contents of the book and explained that it was kept in the family room or behind the security front desk, with access provided upon request. The family room was not always unlocked, as it was locked at night to prevent theft.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a vulnerable resident (R1) from resident-to-resident abuse on two separate occasions. R1, who has a history of Traumatic Brain Injury and is known to become agitated with loud noises and overstimulation, was involved in physical altercations with other residents on 4/7/2024 and 4/11/2024. On 4/7/2024, R1 argued with a female resident (R2) and punched her in the face, leading R2 to retaliate by hitting R1 with a chair, causing a laceration and nasal fracture. Despite being placed on 15-minute checks after this incident, R1 was involved in another altercation on 4/11/2024 with his roommate (R3), who attacked R1 for being in his bed, resulting in multiple injuries to R1's head and back. The facility's failure to maintain the 15-minute monitoring for R1 contributed to these incidents of abuse. R1's care plan, which included interventions such as removing R1 to a quiet area to de-escalate agitation and conducting 15-minute checks, was not effectively implemented. On 4/7/2024, there was no staff present in the dining room when R1 and R2 began fighting, and staff only intervened after the altercation had escalated. Similarly, on 4/11/2024, R1 was not on the required 15-minute checks when R3 attacked him in their shared room. The facility's Director of Nurses (DON) and other staff members acknowledged R1's impulsive behavior and susceptibility to overstimulation but failed to provide the necessary supervision and intervention to prevent these incidents. Interviews with staff members revealed that they were aware of R1's triggers and the need for close monitoring, yet the facility did not ensure that these measures were consistently followed. The lack of staff presence in the dining room and the failure to conduct 15-minute checks allowed the altercations to occur and escalate, resulting in injuries to R1. The facility's inability to protect R1 from abuse and maintain the prescribed interventions led to the determination of Immediate Jeopardy, which was later removed, but the facility remained out of compliance at a severity level two.
Removal Plan
- The facility has re-assessed R1 as being high risk for abuse and the assessment for R1 has been added to R1's Care plan.
- The facility has informed all staff that there is to be one staff member in the main dining room prior to serving meals when the residents are coming into the dining room. This will provide supervision to maintain a safe environment and prevent resident abuse for all residents.
- The facility did an all staff in-service to educate all staff on R1's high risk for abuse from other residents. They also educated all staff on the potential behaviors inducing triggers and provided education to protect all residents from resident abuse.
- The facility has started to develop a QA/QAA plan for increased monitoring of resident safety prior to the serving of resident meals.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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