Shawnee Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Herrin, Illinois.
- Location
- 1901 13th Street, Herrin, Illinois 62948
- CMS Provider Number
- 146036
- Inspections on file
- 43
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Shawnee Senior Living during CMS and state inspections, most recent first.
Surveyors found that the facility failed to recognize and address severe weight loss in three residents, despite clear weight trends, low meal intakes, and electronic alerts. One resident with multiple chronic conditions had documented severe weight loss over several months and frequent low intakes, yet no new nutritional interventions were implemented and the RD had not reassessed the resident for an extended period. A second resident, already underweight, experienced significant weight loss while the care plan lacked any nutrition or weight-loss focus, RD assessment was based on inaccurate high weights, and the resident reported poor intake due to disliking cold food and limited snacks. A third resident with dementia had documented severe weight loss and frequent low intakes, with RD notes acknowledging ongoing losses but no new interventions added beyond an earlier change to include ice cream at lunch. The DON reported that she alone reviews weights, there are no formal IDT weight-review meetings, the RD is not systematically notified of residents with weight loss, and CNAs described inconsistent snack availability, all contributing to the lack of timely nutritional interventions for these residents.
A resident with severe cognitive impairment, psychotic and eating disorders, and a known history of PICA was care planned for 1:1 supervision due to frequent ingestion of non‑food items, including cigarette butts and other materials, and unsafe smoking habits. Despite this, the resident was placed on 15‑minute safety checks for a period while behavior tracking repeatedly showed attempts to ingest non‑food items, without detailed notes describing the incidents. Progress notes documented episodes of the resident putting stool in her mouth and biting a cigarette found at the nurse’s station, while staff interviews revealed that CNAs regularly observed the resident putting various objects in her mouth and marked this in behavior tracking. The DON and administrator stated they believed the resident was not exhibiting PICA behaviors during the period without 1:1 supervision, and the NP reported she was not informed of these behaviors until later, contrary to the facility’s behavior management policy requiring increased observation and thorough behavior tracking.
A resident with severe cognitive impairment, psychotic and eating disorders, and known PICA behaviors was care planned for 1:1 supervision and close monitoring, yet behavior tracking over several months repeatedly showed attempts to ingest non-food items without corresponding detailed notes. Progress notes documented episodes of the resident putting stool in her mouth, inappropriately handling bowel movements, and biting into a cigarette found at the nurse’s station. While CNAs reported that the resident would put various items such as hair ties, cigarettes, and paper products in her mouth whenever behavior tracking was marked, facility leadership stated the resident was not exhibiting PICA behaviors and kept her only on 15-minute safety checks, and the NP reported not being informed of these behaviors until much later. This inconsistent documentation and communication resulted in a failure to deliver necessary, person-centered behavioral health services and appropriate supervision as required by the facility’s own behavior management policy.
A kitchenette sink used for resident dining was found with a significant amount of black substance, dead gnats, and a broken bottom shelf, with similar black substance noted around a nearby ceiling vent. The Maintenance Director was notified weeks earlier but did not address the issue due to other priorities, and the Administrator confirmed the expectation that such repairs should be handled promptly.
A resident with hemiplegia and total dependence for transfers was moved using a sit-to-stand lift by a CNA who did not verify the care plan or Kardex, despite orders for a sling lift with two-person assist. During the transfer, the resident experienced a syncopal episode and sustained an impacted right humeral neck fracture. Staff interviews confirmed that transfer requirements were documented and accessible, but not followed in this instance.
Two residents with histories of cognitive and behavioral issues engaged in escalating altercations, culminating in one stabbing the other multiple times with a pen. Previous incidents of aggression, including scratching and verbal disputes, were documented, but staff were unaware of all injuries as they occurred. Both individuals required ER evaluation after the stabbing, and staff only learned of a prior bruise during the investigation.
A resident with cognitive deficits and a history of aggression was found with a bruise above the left eye, which staff did not report or investigate as potential abuse due to its size and an assumption it was caused by a fall. Despite facility policy requiring immediate reporting of suspicious injuries, the incident was not escalated to the Abuse Coordinator, resulting in a missed opportunity to investigate possible resident-to-resident abuse.
Expired medications, including Ondansetron and stock Aspirin, were found in both the medication cart and storage room. A resident with multiple chronic conditions had expired Ondansetron available in their medication cart, and staff confirmed the presence of expired stock Aspirin. Nursing and pharmacy staff acknowledged that checks for expired medications were not consistently documented or performed as required by facility policy.
CNAs did not perform required hand hygiene when assisting multiple dependent residents with eating and serving drinks, alternating between residents and handling utensils and glasses without sanitizing their hands. The residents involved had significant cognitive and physical impairments and required staff assistance for eating, as documented in their care plans. Staff acknowledged not following hand hygiene protocols, and facility policy required hand hygiene before direct resident contact.
The facility failed to ensure safe transfers and adequate supervision, leading to multiple falls among residents. A resident fell twice from a mechanical lift due to untrained staff, while another resident's wheelchair lacked necessary anti-roll backs. Additional residents experienced falls without proper assessments or care plan updates, indicating significant deficiencies in resident safety and fall prevention.
Two residents at risk for elopement exited the facility without staff knowledge due to inadequate supervision and malfunctioning electronic monitoring devices. One resident exited through the front door and re-entered through the kitchen, while another exited through a window and was found 1.3 miles away. Staff lacked training on monitoring devices, contributing to the incidents.
A resident with moderate cognitive impairment reported being hit by a nurse, as witnessed by a visitor. Despite the visitor's consistent account, the facility's investigation did not substantiate the abuse due to conflicting reports and lack of physical evidence. The nurse was suspended, and the incident was reported to the Department of Professional Regulation.
A LTC facility failed to administer medications and treatments as ordered for three residents, leading to significant health issues. One resident missed Lasix for 30 days, resulting in hospitalization for COPD exacerbation. Another resident did not receive treatment for a skin tear and rash, and a third resident did not receive fluconazole for a UTI after hospital discharge. These failures were due to discrepancies in medication administration and lack of documentation.
Two residents experienced significant weight loss due to the facility's failure to provide prescribed nutritional supplements and monitor dietary intake. One resident, with severe dementia, did not receive health shakes or double eggs as ordered, while another resident, who is cognitively intact, was dissatisfied with the food and not offered alternatives. The facility's lack of effective communication and monitoring contributed to these deficiencies.
The facility failed to provide adequate staffing, affecting the care of 99 residents. A resident with dementia reported long waits for toileting assistance, leading to incontinence. Another resident at high risk for falls experienced multiple falls without new preventive measures. A cognitively intact resident reported infrequent showers due to staffing shortages, and a resident requiring oral care was observed with poor hygiene. Staff confirmed insufficient staffing to meet residents' needs, impacting essential care tasks.
The facility failed to promote dignity for residents during meals and care. CNAs were observed standing while feeding a resident with dementia, citing staffing issues. A cognitively intact resident received incontinence care without privacy, and a severely impaired resident was left unattended in a state of undress. Another resident struggled to eat independently, expressing distress over the lack of assistance.
The facility failed to provide adequate assistance for residents needing help with ADLs, including personal hygiene and eating, due to staffing shortages. Observations showed residents not receiving necessary oral care, showers, or eating assistance. Staff reported being unable to meet residents' needs timely, and documentation confirmed the lack of consistent care.
The facility failed to provide individualized, person-centered care for residents with dementia, relying on generic care plans and failing to update them despite residents' specific needs. Observations revealed that residents engaged in behaviors like wandering and inappropriate actions without staff intervention, due to staff shortages and inadequate training. The facility's policy emphasized individualized care, but this was not implemented, leading to deficiencies in dementia care.
The facility failed to provide menu items and ensure substitutions for residents, leading to dissatisfaction and unmet dietary needs. Residents reported inconsistencies between posted menus and actual meals, lack of choice, and unavailability of items like butter and sour cream. The administrator acknowledged issues with the corporate menu process and dietary management.
The facility failed to document and respect the advance directives of two residents. One resident, admitted with serious health conditions, lacked documentation of end-of-life wishes in their care plan, and their POLST form was completed only after a surveyor's inquiry. Another resident also lacked documentation of end-of-life wishes until prompted by the surveyor. The facility's policy requires advance directives to be documented upon admission, which was not followed in these cases.
A facility failed to notify a resident, their doctor, and a family member about a room change. The resident, who was alert and oriented, expressed confusion about the change. The facility administrator could not provide documentation or a reason for the change, and there was no policy for notifying residents of room changes.
A resident with severe cognitive impairment was found with a bruised eye of unknown origin, but the incident was not reported to the Administrator as required by the facility's abuse prevention policy. The Administrator was unaware of the bruise and did not conduct an investigation or report it to authorities, leading to a deficiency finding.
A resident with severe cognitive impairment and multiple health issues was found with a bruised eye of unknown origin. The facility failed to report, document, or investigate the bruise as required by their abuse prevention policy, resulting in a deficiency.
A resident with multiple health conditions was taken to the ER by a family member, despite a nurse's suggestion for in-house care. The facility failed to provide the required bed hold documentation for the resident's hospital stay, as per their policy.
The facility failed to conduct PASARR II screenings for two residents diagnosed with mental health conditions after admission. One resident with bipolar disorder and another with both bipolar and major depressive disorders did not have the required screenings documented. The administrator confirmed the absence of these screenings and noted the facility lacks a policy for PASARR screenings.
A resident at high risk for skin breakdown developed a pressure ulcer on the right hip, which was not properly assessed or documented by the facility. Despite the resident's family requesting an air mattress, it was not provided until after the ulcer was identified. The facility's protocol for assessing and documenting new pressure areas was not followed, leading to inadequate care.
A resident with multiple diagnoses, including gangrene and peripheral vascular disease, experienced a delay in receiving prescribed pain medication, Norco, at a facility. Despite orders for pain management, the medication was not administered until the day after it was ordered, leading to the resident refusing care due to severe pain. Facility staff were uncertain about the delay, and there was no documentation of the medication being administered from the emergency kit.
A facility failed to document a specific FDA-approved diagnosis for a resident's use of Quetiapine Fumarate, an antipsychotic medication. The resident was prescribed multiple psychotropic medications for conditions like dementia with agitation, depression, and anxiety, but the medical record lacked a specific diagnosis for Quetiapine Fumarate. The pharmacist noted the absence of an appropriate diagnosis, and the resident's son confirmed the resident's behaviors were due to dementia.
A resident with severe cognitive deficits and chronic respiratory failure was not provided with thickened liquids as ordered by the physician. Despite the facility's policy requiring thickened liquids for individuals with swallowing difficulties, the resident was served unthickened chocolate milk. Staff acknowledged the oversight, and there was confusion regarding the resident's dietary orders.
Two residents in a facility did not receive their prescribed therapeutic diets, which included double portions and double protein portions, as ordered by their physicians. Despite having care plans addressing potential nutritional problems, observations showed that the residents did not receive the required dietary portions. Interviews with the dietary manager and registered dietitian confirmed the expectation for residents to receive their prescribed diets, but the facility lacked a policy to ensure compliance.
A resident with pica and moderate cognitive impairment repeatedly ingested non-food items, including bleach wipes and plastic bags, due to the facility's failure to implement effective preventive measures. Despite having a care plan, staff were inconsistent in monitoring and preventing the behavior, leading to the resident's hospitalization after ingesting a plastic bag.
A resident with a history of confusion due to infections experienced neglect at a facility, leading to a significant decline in their condition. Despite being prescribed antibiotics for a urinary tract infection, the resident refused medications and care, resulting in the development of pressure ulcers. The facility failed to implement effective interventions, and the resident was eventually hospitalized for sepsis related to skin and soft tissue infection.
A resident with dementia and a history of elopement exited a facility unsupervised on multiple occasions due to inadequate interventions and supervision. Despite being assessed as an elopement risk, the resident was not provided with an elopement alert bracelet or specific interventions until weeks after the initial assessment. Staff interviews indicated a lack of awareness and implementation of necessary measures to prevent the resident from leaving the facility.
A resident with multiple medical conditions developed severe pressure ulcers due to the facility's failure to identify, treat, and prevent skin breakdown. The resident's refusal of care and medications, combined with inadequate communication and documentation by staff, led to prolonged periods of incontinence and lack of hygiene, resulting in hospitalization for sepsis and severe pressure injuries.
The facility failed to investigate and substantiate multiple incidents of peer-to-peer abuse involving residents with cognitive deficits. Despite witness accounts and resident complaints, the facility concluded there was insufficient evidence to substantiate abuse, attributing the behavior to dementia. Corporate directives influenced this approach, leading to a lack of specific interventions to prevent further incidents.
A resident with a history of falls and multiple medical conditions fell from a wheelchair and sustained a forehead laceration due to the absence of footrests during transport by a CNA. The resident unexpectedly placed her feet on the ground, causing the fall. The facility's fall policy requires documentation and discussion of fall risks, but the lack of footrests contributed to the incident.
A resident with severe cognitive impairment and physical limitations did not receive adequate mouth care as required by their care plan. Observations revealed poor oral hygiene, and staff interviews indicated inconsistencies in care provision. The facility's mouth care policy was not followed, and there was no documentation of daily mouth care for the resident.
The facility failed to ensure thorough assessments and proper documentation for two residents, leading to significant discomfort and delayed treatment. One resident experienced prolonged respiratory distress and died due to a lack of timely assessments, while another resident was hospitalized with altered mental status and other conditions. Additionally, the facility failed to identify and treat wounds for the first resident.
The facility failed to protect residents from misappropriation of medications by an LPN, who diverted narcotic medications intended for residents. The LPN refused a drug test, admitted to using the medications without a prescription, and resigned immediately. The investigation found discrepancies in narcotic logs and missing count sheets, but residents reported no issues with receiving their pain medications.
The facility failed to implement its abuse policy for three residents affected by misappropriation of property. An LPN refused a mandatory drug test and admitted to potentially testing positive for medications without a prescription. The facility did not report the incident to local law enforcement as required by their policy, and no new processes were implemented following the incident.
The facility failed to report a suspected drug diversion involving an LPN to local law enforcement, despite clear policies requiring such action. The LPN admitted to using medications without a prescription and refused a drug test, but the incident was not reported to the police.
The facility failed to maintain accurate records of narcotics and administer medications to meet the needs of three residents. The investigation revealed missing narcotic count sheets and discrepancies in the administration of controlled substances, leading to potential drug diversion by an LPN. The facility reported the incident to relevant authorities and replaced the missing medications.
Failure to Identify and Intervene for Severe Weight Loss in Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to identify and respond to severe weight loss in three residents and to implement needed nutritional interventions despite clear evidence of declining weights and poor intake. For one resident with multiple chronic conditions including CHF, dysphagia, COPD, diabetes, dementia, and depression, daily weights showed a progressive and severe weight loss over 1, 3, and 6 months, with electronic alerts indicating significant losses. January intake records documented multiple meals with only 0–25% or 26–50% consumed and several meals with no documentation. The care plan identified risk for nutrition and hydration issues and directed staff to monitor, record, and report significant weight loss, but no new interventions were implemented in response to the documented severe weight loss, and there was no evidence of RD follow-up after an RD note from several months earlier that had been based on prior weight gain and higher intake levels. A second resident, admitted with diagnoses including diabetes, fracture, muscle wasting, and dysphagia, experienced a documented 6.9% weight loss in 30 days and a 10.2% loss since admission, with a BMI of 17.1 indicating underweight. The weight record contained clearly inaccurate high weights that were not rechecked, and the DON later confirmed these entries were wrong and should have prompted reweighs. The RD’s December assessment for this resident relied on one of these inaccurate weights and concluded the resident was consuming 51–100% of meals and should continue the current diet, with no additional interventions for weight loss. The resident’s care plan addressed only ADL performance and supervision with eating and did not include any focus area or interventions related to nutrition or weight loss, despite the documented severe weight loss and the resident’s report of poor intake due to disliking the food and receiving cold meals. A third resident with Alzheimer’s disease, dementia, muscle wasting, and other chronic conditions had documented significant weight loss over 30 days and 6 months, meeting the facility’s own definition of severe weight loss. The care plan identified risk for nutrition and hydration issues and included monitoring and reporting of significant weight loss, as well as provision of a regular diet with supplements such as super cereal, whole milk, health shakes three times daily, and ice cream at lunch. Weight records showed a drop from the 130-pound range to just over 106 pounds, and intake sheets for January documented frequent 0–25% and 26–50% meal intakes, with multiple days lacking documentation. RD notes over several months acknowledged 7.5% and then 10.5% weight loss and recommended continuing the regular diet with house supplements, encouraging intake, and monitoring weights and intakes, but the last new intervention (ice cream at lunch) had been implemented months earlier, and no new interventions were put in place in response to the most recent severe weight loss. Across these three residents, the DON stated that she alone reviews monthly weights, that there are no formal IDT meetings to review weights, and that the RD selects which residents to see based on monthly weights without being provided a list of new admissions, residents with weight loss, or residents with wounds. The DON acknowledged that no interventions were implemented for one resident’s severe weight loss and that the RD had not seen that resident since mid-year despite ongoing weight decline. The NP reported she had not received recent notifications about residents’ weight losses and that prior notifications had related to weight gain, and she found no RD or nursing notifications or recommendations in the chart regarding the recent weight losses. CNAs reported that they perform weights and record meal intakes, that snacks are generally not offered between meals and are inconsistently available at bedtime, and that residents sometimes do not receive snacks because the kitchen runs out. The facility’s written policy on weight assessment and intervention requires nursing and the RD to cooperate to prevent, monitor, and intervene for significant weight changes and to focus interventions on food and snacks first, but the documented practices and lack of timely interventions for these three residents’ severe weight loss did not follow those policy expectations.
Failure to Provide Required Supervision for Resident With PICA Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevention of accident hazards related to a resident with known PICA behaviors. The resident was admitted with diagnoses including brief psychotic disorder, other specified eating disorder, delusional disorders, depression, malnutrition, and a psychotic disorder, and had a BIMS score of 3 indicating severe cognitive impairment. The care plan identified the resident as requiring 1:1 supervision due to PICA, with documented behaviors of eating cigarette butts, plastic, Styrofoam, and pages from books, and noted that the resident was a current smoker needing supervision due to unsafe smoking habits. Despite this, the resident was placed on 15‑minute safety checks instead of 1:1 supervision for a period, based on management’s belief that she was not exhibiting PICA behaviors during that time. Behavior tracking documentation from September through December showed repeated entries indicating the resident attempted to ingest non‑food items on numerous dates, but there were no corresponding narrative notes specifying what items were involved or describing the behaviors. Staff interviews revealed that when CNAs marked “yes” for putting non‑food items in the mouth, it meant the behavior was occurring and that the resident would put anything she could get her hands on into her mouth, including hair, hair ties, cigarettes, paper towels, and toilet paper. A CNA stated that when behavior tracking is triggered, a box appears to type in what the behavior is, and that she tries to enter a note, but also reported that no one asks follow‑up questions about the behavior tracking. The DON stated she reviews behavior tracking and progress notes every 72 hours and that the resident was not on 1:1 supervision during the identified period because she believed the resident was not having PICA behaviors. Progress notes documented specific incidents during the same timeframe that demonstrated ongoing PICA‑related behaviors. On one date, the resident had three loose stools and was reported to have put the stool in her mouth each time. On another date, the resident was found rummaging through a desk drawer behind the nurse’s station, where she found a package of cigarettes and took a bite out of one before staff intervened. A later note recorded that the resident was inappropriately handling her own bowel movement during a bed check. The NP stated she had not been informed of the resident’s PICA behaviors or feces ingestion until December and that she would have initiated 1:1 supervision as a first intervention if she had been notified. The facility’s Behavior Management Policy required increased observation per the plan of care and the use of behavior tracking forms on all shifts so occurrences could be tabulated and analyzed, but the documented behaviors and staff statements showed that the resident’s ongoing PICA behaviors were not effectively communicated or acted upon to maintain the prescribed level of supervision.
Failure to Provide Adequate Behavioral Health Services and Supervision for Resident With PICA
Penalty
Summary
The deficiency involves the facility’s failure to provide person-centered, interdisciplinary behavioral health services and appropriate supervision to a resident with significant psychiatric and cognitive impairments and known PICA behaviors. The resident was admitted with diagnoses including brief psychotic disorder, other specified eating disorder, delusional disorders, depression, malnutrition, and a psychotic disorder, and had a BIMS score of 3 indicating severe cognitive impairment. The care plan identified risks for psychosocial issues, physical and verbal aggression, wandering, PICA behavior (including eating cigarette butts, plastic, Styrofoam, and pages from books), chronic pain, and the need for psychotropic medications, as well as the need for 1:1 supervision and supervised smoking due to unsafe habits. Despite these identified risks, behavior tracking records from September through December documented repeated episodes where the resident attempted to ingest non-food items on numerous dates, yet there were no corresponding detailed notes describing the specific behaviors or circumstances. Progress notes show that on one occasion the resident had three loose stools and was reported to be putting the stool in her mouth, and on another occasion the resident was found rummaging through a desk drawer behind the nurse’s station, where she located a package of cigarettes and bit into one before staff intervened. Another progress note documents that the resident was inappropriately handling her own bowel movement during a night shift bed check, and this was reported to nursing and the NP. Interviews revealed discrepancies between staff perceptions and the documented behavior tracking. The administrator and DON stated the resident was not on 1:1 supervision from mid-September to early December because they believed she was not exhibiting PICA behaviors and was instead on 15-minute safety checks. However, the CNA reported that when she marked “yes” for putting non-food items in the resident’s mouth, the behavior was occurring and that the resident would put anything she could get her hands on into her mouth, including hair, hair ties, cigarettes, paper towels, and toilet paper. The NP stated she was not informed of the PICA behaviors or feces ingestion until December and that she had not received earlier reports. The DON stated she reviewed behavior tracking and progress notes every 72 hours and discussed results in IDT, but also stated the resident was not having PICA behaviors during the period when behavior tracking showed repeated entries for putting non-food items in the resident’s mouth. The facility’s Behavior Management Policy requires monitoring for behavioral changes and appropriate interventions, but the lack of detailed documentation and communication about the resident’s ongoing PICA behaviors and ingestion of feces led to a failure to provide necessary behavioral health services and appropriate supervision.
Failure to Maintain Kitchenette Sink in Good Repair
Penalty
Summary
A sink located in the kitchenette of the resident dining room was found to be in disrepair and not properly maintained. During observation, a significant amount of black substance was noted on the bottom shelf and both sides of the sink cabinet wall, along with multiple dead gnats on the bottom drawer face. The bottom shelf of the cabinet was also broken, and black substance was observed sporadically around the ceiling vent above the refrigerator in the same area. These conditions were directly observed by surveyors and confirmed through interviews with facility staff. The Maintenance Director reported being notified by kitchen staff about the issue with the sink area approximately 2-3 weeks prior to the survey, noting the presence of the same black substance at that time. However, the Maintenance Director had not addressed the problem due to being occupied with facility remodeling and had not removed or replaced the sink. The Administrator stated that her expectation was for the Maintenance Director to communicate any needs for repairs, including those related to the kitchenette sink, and that the issue should have been addressed when first reported by staff. The facility's census documented 98 residents in-house at the time of the deficiency.
Failure to Use Correct Mechanical Lift Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living due to significant right-sided weakness and hemiplegia, was transferred using an incorrect mechanical lifting device. The resident's care plan and physician orders specified the use of a sling lift with the assistance of two staff members for all transfers. However, a CNA transferred the resident using a sit-to-stand lift, contrary to the documented requirements. The CNA was unsure of the correct transfer method and relied on the resident's verbal input rather than consulting the Kardex or care plan, which clearly indicated the need for a sling lift. During the transfer back to the wheelchair, the resident experienced a syncopal episode and was lowered into the chair. Immediately following the incident, the resident complained of right shoulder pain. Subsequent assessment and imaging revealed an impacted fracture of the right humeral neck. The incident was not witnessed by the nurse on duty, but the nurse responded promptly to the resident's complaints and initiated appropriate medical evaluation and notification procedures. Interviews with facility staff revealed that the expectation was for all staff to reference the Kardex or consult nursing staff if unsure about a resident's transfer needs. The facility's policy required mechanical lifts for residents needing two-person assistance and prohibited manual lifting except in emergencies. The CNA involved had not verified the transfer requirements in the resident's records, leading to the use of an inappropriate lift and resulting in injury.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in one resident stabbing another multiple times in the back with an ink pen. Both residents involved had documented histories of cognitive or behavioral issues, including dementia, major depressive disorder, anxiety disorder, epilepsy, and cerebral palsy. Prior to the incident, there were documented altercations between the two, including an argument over a jacket that led to scratching and verbal aggression. The care plans for both residents noted a history of being both recipients and aggressors of verbal and physical aggression. On the day of the incident, one resident reported being stabbed in the back with a pen by the other after a confrontation in another resident's room. The resident who was stabbed was found to have ten superficial puncture wounds on her upper back and shoulder. The resident who did the stabbing claimed it was in self-defense after being punched in the forehead by the other resident, an injury that was later observed as a large healing bruise. Both residents were sent to the emergency room for evaluation following the incident. Interviews and record reviews revealed that staff were not aware of the forehead injury until after the stabbing incident was reported. The resident with the bruise did not report the injury to staff at the time it occurred. There was no documentation in the emergency room records regarding the alleged punch or a psychiatric evaluation for the resident who was stabbed. Both residents were subsequently placed under one-to-one supervision, and their rooms were separated to prevent further interactions.
Failure to Investigate Bruise of Unknown Origin as Potential Abuse
Penalty
Summary
The facility failed to investigate a bruise of unknown origin as potential physical abuse for one resident with moderate cognitive deficits and a history of both receiving and exhibiting aggression. The resident was observed by the Assistant Director of Nurses to have a bruise above the left eye, which appeared to be in different stages of healing. When questioned, the resident was unable to recall the cause of the bruise, initially suggesting a possible fall but providing no details. The bruise was measured at 4 centimeters, and the nurse notified the resident's current nurse, who continued to monitor the situation. Despite the facility's policy requiring immediate reporting and investigation of suspicious bruises or injuries of unknown origin, the Director of Nurses advised that the bruise did not need to be reported to the Abuse Coordinator because it was under 7 centimeters in diameter. As a result, the incident was not reported or investigated as potential abuse at that time. The resident later reported that another resident had punched her on the forehead, which led to a retaliatory incident involving a pen, but this information was not initially known to the staff responsible for reporting. Interviews with staff confirmed that the decision not to report the bruise was based on its size and an assumption that it was caused by a fall, despite the resident's inability to recall the incident and the presence of a suspicious injury. The facility's failure to follow its own abuse prevention policy resulted in a lack of timely investigation into a possible case of resident-to-resident physical abuse.
Expired Medications Not Removed from Medication Cart and Storage Room
Penalty
Summary
The facility failed to properly dispose of expired medications, as evidenced by the presence of expired drugs in both the medication cart and storage room. During an inspection, an expired card of Ondansetron 4 mg was found in the medication cart for a resident with diagnoses including type 1 diabetes, heart failure, and chronic pain syndrome. The medication card, which contained 26 pills, had an expiration date of 12/27/24, yet was still available for administration months after expiration. Nursing staff confirmed the medication was expired and acknowledged that pharmacy staff are expected to check for expired medications, but the expired medication remained accessible. Additionally, two bottles of expired Aspirin 325 mg, with an expiration date of September 2024, were found in the medication storage room. These were identified as stock medications and not resident-specific. Nursing staff and the DON confirmed that pharmacy checks are supposed to occur monthly, but also revealed that the pharmacy only spot checks and does not provide documentation of these checks. The facility's policy requires monthly examination of medication storage areas and quarterly checks of medication carts for expired medications, but these procedures were not followed, resulting in expired medications being present and accessible.
Failure to Perform Hand Hygiene During Meal Assistance
Penalty
Summary
Certified Nurse Assistants (CNAs) failed to perform proper hand hygiene before and during the process of assisting dependent residents with eating and while serving drinks. Observations revealed that a CNA alternated between assisting two residents with eating, touching their faces, hands, and utensils without performing hand hygiene at any point. Another CNA was observed assisting two residents with eating and handling their glasses by the rim, as well as touching the table and residents, again without performing hand hygiene. These actions were directly observed during mealtimes, and the staff involved acknowledged not performing hand hygiene, citing forgetfulness and lack of hand sanitizer. The residents involved had significant medical and cognitive impairments, including critical illness myopathy, traumatic brain injury, dementia, Parkinson's disease, and dysphagia, requiring varying levels of assistance with eating. Care plans for these residents documented their dependence on staff for eating and supervision. Interviews with residents and staff confirmed that hand hygiene was not performed between assisting different residents, and the facility's policy required hand hygiene before direct contact with residents. The Dietary Manager also stated that staff should not grab cups by the top where residents drink from.
Deficiencies in Resident Safety and Fall Prevention
Penalty
Summary
The facility failed to ensure safe transfers and adequate supervision to prevent accidents for several residents. One resident, who was cognitively intact and dependent on staff for transferring, experienced two falls from a sit-to-stand mechanical lift. The first fall occurred when a CNA attempted to transport the resident to the shower room, despite the resident expressing concerns about their knees giving out. The second fall happened during a transfer from a bedside commode to a wheelchair. The CNA involved had not received training on the mechanical lift, and the facility did not document any post-fall assessments or updates to the resident's care plan following these incidents. Another resident, who was moderately cognitively impaired and at high risk for falls, fell when attempting to stand up, causing their wheelchair to roll out from under them. Although an intervention to add anti-roll backs to the wheelchair was documented, the resident was later observed without these safety features. The nursing supervisor was unaware of the need for anti-roll backs until checking the care plan, indicating a lack of communication and implementation of safety measures. Additional residents also experienced falls without proper follow-up. One resident with severe cognitive impairment had multiple falls, but the facility failed to complete fall risk assessments for each incident. Another resident, also with severe cognitive impairment, had several falls without corresponding interventions added to their care plan. The facility's failure to conduct thorough assessments and implement necessary interventions after falls highlights significant deficiencies in ensuring resident safety and preventing accidents.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and interventions for residents assessed as being at risk for elopement, leading to two separate incidents involving residents exiting the facility without staff knowledge. One resident, with a history of elopement and severe cognitive deficits, exited the facility when a visitor entered, walked half the length of the facility, and re-entered through the kitchen door. The electronic monitoring device was found to be malfunctioning due to placement issues and extra socks, and no alarm sounded during the incident. Staff interviews revealed a lack of awareness and understanding of how to properly check the functionality of the monitoring devices, contributing to the failure to prevent the elopement. Another resident, with moderate cognitive impairment and a history of wandering, exited the facility through a window, crossed a busy highway, and walked approximately 1.3 miles without staff knowledge. The resident had been calling 911 earlier in the day, indicating distress, and was later found at a local business by the police. The window screen had been kicked out, and the electronic monitoring device did not alarm because the resident exited through a window. Staff were unaware of the resident's whereabouts for a significant period, and the facility's elopement and search policy was not effectively implemented. Both incidents highlight deficiencies in the facility's supervision and monitoring systems for residents at risk of elopement. The staff's lack of knowledge and training on the use of electronic monitoring devices and the failure to conduct regular checks contributed to the residents' ability to leave the facility undetected. The facility's policies and procedures for preventing and responding to elopement were not adequately followed, resulting in immediate jeopardy for the residents involved.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that a resident, identified as R45, was free from verbal, mental, and physical abuse. R45, who has a moderate cognitive impairment and a history of psychiatric issues, was reportedly struck in the face by a nurse, V49, as witnessed by a visitor, V57. The visitor reported seeing the nurse hit R45 in the face and hearing R45 say, 'You hit me.' Despite this, R45 denied being hit in the face during interviews but mentioned being hit on the back of the head by an unknown staff member. The facility's investigation included interviews with staff, residents, and family members. While the visitor's account was consistent, staff members either denied witnessing any abuse or described the nurse as stern but not abusive. R45's family member, V56, confirmed that R45 had previously reported being hit on the head, but this was not substantiated by other staff or witnesses. The nurse, V49, denied all allegations of hitting or cursing at residents. The facility's administrator, V1, did not substantiate the abuse allegation due to conflicting reports and the lack of physical evidence. However, the nurse was suspended pending investigation, and the incident was reported to the Department of Professional Regulation. The facility's abuse policy emphasizes the residents' right to be free from abuse and outlines procedures to prevent such occurrences, but the investigation did not conclusively determine the abuse had occurred.
Medication and Treatment Failures in LTC Facility
Penalty
Summary
The facility failed to provide medications and treatments as ordered by a physician, resulting in significant health issues for three residents. One resident, with a history of chronic obstructive pulmonary disease (COPD) and other serious conditions, did not receive their prescribed Lasix medication for approximately 30 days. This oversight led to the resident experiencing shortness of breath and being admitted to the hospital with a COPD exacerbation and acute pulmonary edema. The facility's records showed discrepancies in medication administration, and there was a lack of documentation regarding the reassessment and evaluation of the resident's condition. Another resident, who was admitted with multiple diagnoses including osteoarthritis and morbid obesity, did not receive the prescribed treatment for a skin tear and a rash. The resident's medical records indicated that the treatment orders were not initiated or administered, and there was no follow-up on the wound care plan. The resident expressed concerns about the lack of treatment and care for the skin condition, which had persisted for several weeks without proper intervention. A third resident, who had been hospitalized for a urinary tract infection (UTI), did not receive the prescribed fluconazole medication upon returning to the facility. The resident's discharge summary from the hospital included orders to stop Jardiance and start fluconazole, but these orders were not followed. The facility's staff failed to transfer the necessary medication orders, leading to a delay in the resident receiving appropriate treatment for the UTI. The oversight in medication management and documentation contributed to the resident's ongoing health issues.
Failure to Provide Adequate Nutritional Support and Monitoring
Penalty
Summary
The facility failed to provide adequate nutritional support and monitoring for two residents, leading to significant weight loss and potential health risks. Resident R53, a female with severe dementia and multiple health issues, experienced a 23% weight loss over six months, dropping to 76 pounds. Despite having dietary orders for fortified foods, super cereal, double eggs, and thickened nutritional shakes three times a day, R53 did not receive these supplements consistently. Observations over several days showed that R53 was not given the prescribed health shakes or double portions of eggs, and staff members confirmed the absence of these items in her meals. Resident R100, who is cognitively intact, also experienced a significant weight loss of 20% in one month. R100 reported dissatisfaction with the facility's food and was not offered alternatives, contributing to his weight loss. Despite being on a mechanical soft diet with thickened liquids due to dysphagia, R100's dietary needs were not adequately addressed. The Registered Dietitian was not informed of R100's weight loss in a timely manner, delaying potential interventions that could have mitigated the weight loss. The facility's failure to monitor and document weight changes effectively, as well as to communicate these changes to the dietitian and other relevant staff, contributed to the deficiencies observed. The dietary manager and medical staff were unaware of the significant weight losses and the residents' nutritional needs, indicating a breakdown in communication and adherence to the facility's nutrition policy. This lack of coordination and oversight resulted in inadequate nutritional support for the residents, compromising their health and well-being.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its 99 residents, as evidenced by multiple observations and interviews. Resident R21, who has moderately impaired cognition and requires assistance with activities of daily living, reported long wait times for toileting assistance, leading to incontinence and prolonged periods in wet clothing. This issue was corroborated by a registered nurse who confirmed the facility's chronic staffing shortages, impacting the quality of care provided to residents. Resident R259, with severe cognitive impairment and a high risk for falls, experienced multiple falls without new interventions being implemented to prevent further incidents. The MDS/Care Plan Nurse acknowledged the lack of updated fall prevention strategies, attributing it to inadequate training and staffing shortages. The facility's policy on fall management was not adhered to, as no new interventions were put in place following R259's falls, highlighting a systemic issue in addressing resident safety concerns. Resident R68, who is cognitively intact but dependent on staff for personal care, reported infrequent showers due to staffing shortages, resulting in feelings of uncleanliness and previous skin issues. Additionally, R2, who requires assistance with oral hygiene, was observed with poor oral care on multiple occasions, which staff attributed to insufficient staffing. Interviews with CNAs revealed that the staffing levels were inadequate to meet the residents' needs, leading to delays in essential care tasks such as oral hygiene, turning, and incontinence care. The facility's administrator acknowledged the staffing challenges, noting reliance on administrative staff and agency workers to cover shifts, but this was not always sufficient to address the deficiencies.
Failure to Promote Resident Dignity During Care and Meals
Penalty
Summary
The facility failed to promote dignity for several residents during meal times and while receiving care. For instance, a resident with dementia and impaired mobility was observed being fed by CNAs who were standing, rather than sitting, which is not in line with best practices for promoting dignity during meals. The CNA acknowledged the issue but cited staffing constraints as a reason for not being able to sit while feeding residents. Another resident, who is cognitively intact, received incontinence care without the blinds being closed, despite expressing a preference for privacy, as the window faced a courtyard frequented by other residents. Additionally, a severely cognitively impaired resident was found in a state of undress and covered in feces, while staff walked past the room without providing immediate care. A CNA later attended to the resident but mentioned that staffing shortages made it difficult to meet all residents' needs adequately. Another resident with moderate cognitive impairment struggled to eat independently, resulting in food covering her face and hands. She expressed distress over the situation and the lack of assistance, indicating a need for more support during meals.
Deficiencies in ADL Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide adequate assistance for residents requiring help with Activities of Daily Living (ADLs), including personal hygiene and eating assistance. Observations revealed that several residents did not receive necessary oral care, showers, or assistance with eating. For instance, one resident was observed with debris on their teeth and a thick yellow film on their tongue, indicating a lack of oral hygiene care. Another resident, who required substantial assistance for bathing and dressing, did not receive showers on scheduled dates, with no documentation of refusals or completed showers. Staff interviews highlighted significant staffing shortages, which contributed to the inability to meet residents' needs. Certified Nurse Aides (CNAs) reported being unable to provide timely care, including oral hygiene, showers, and incontinence care, due to insufficient staffing levels. One resident expressed concerns about waiting long periods for assistance and not receiving showers due to the lack of available staff to operate a mechanical lift. Another resident was observed struggling to eat without assistance, resulting in food spillage and inadequate intake. The facility's documentation and staff statements confirmed that the expected care was not consistently provided. The Assistant Director of Nursing acknowledged the expectation for daily oral care, and the facility administrator noted that showers should be documented or refused on scheduled days. However, the lack of specific policies and adequate staffing levels hindered the facility's ability to meet these expectations, leading to deficiencies in resident care.
Lack of Individualized Dementia Care in LTC Facility
Penalty
Summary
The facility failed to develop and implement individualized, person-centered interventions for residents diagnosed with dementia, affecting their physical, mental, and psychosocial well-being. This deficiency was observed in five residents, who were part of a sample of 51. The care plans for these residents lacked specific, personalized interventions tailored to their unique needs and conditions, relying instead on generic, pre-written templates. This lack of person-centered care was evident in the absence of updates to the care plans, despite the residents exhibiting behaviors and conditions that warranted individualized attention. One resident, with severe cognitive impairment and a history of dementia-related behaviors, was observed engaging in activities like folding clothes and doing puzzles. However, the care plan did not reflect these activities as structured interventions. The resident's care plan was not updated to include person-centered strategies, despite the resident's increased behaviors and elopement attempts. Staff members acknowledged the use of generic interventions and the lack of time to update care plans, highlighting a systemic issue in the facility's approach to dementia care. Another resident, also severely cognitively impaired, was observed wandering and engaging in inappropriate behaviors without staff intervention. The care plan for this resident included interventions for wandering and behavior management, but these were not implemented during observations. Staff shortages and inadequate training were cited as reasons for the failure to provide timely and appropriate care. The facility's policy on dementia care emphasized the need for individualized plans, but this was not reflected in practice, leading to deficiencies in the care provided to residents with dementia.
Failure to Provide Menu Items and Substitutions
Penalty
Summary
The facility failed to provide all items noted on the daily menu and ensure the availability of substitutions for four residents. Resident R73, who is cognitively intact and has a physician's order for a regular diet with double protein portions, reported not receiving the alternative meal he often requests. On multiple occasions, the meals served did not match the posted menu, and necessary items like butter and sour cream were unavailable unless specifically requested. Additionally, when R73 requested a substitute meal that he could not eat due to stomach issues, he was only offered a bowl of soup without an alternative protein option, despite his dietary requirements. Resident R43, who is alert and oriented, stated that a new policy from corporate removed the option for residents to receive menus before meals, and the menu posted in the dining room was not always updated. R43 reported that residents are not asked for their meal preferences and must check the menu themselves to request alternatives, which are not guaranteed. R43 also noted that butter was not provided unless requested, and on one occasion, sour cream was unavailable. Residents R31 and R7 also expressed concerns about the lack of meal choices and the removal of printed menus. R31 mentioned that the posted menu was often not updated, and they were not offered choices or butter with their meals. R7 stated that the removal of meal choice papers took away their right to choose meals, and if not served first, they might not get an alternative option. The facility administrator acknowledged issues with the corporate menu process and the dietary manager's struggles with menu changes when items were unavailable.
Failure to Document and Respect Advance Directives
Penalty
Summary
The facility failed to ensure that the rights of residents to have their advance directives documented and respected were upheld. Specifically, two residents, identified as R157 and R161, did not have their advance directives properly documented in their medical records upon admission. R157 was admitted with several serious health conditions, including gangrene and diabetes, but their care plan lacked documentation of their end-of-life wishes. Although a physician order for comfort measures was present, the POLST form was not completed until after the surveyor's inquiry. Similarly, R161, who was admitted with conditions such as osteomyelitis and hypertension, also lacked documentation of their end-of-life wishes in their care plan and medical record until the surveyor's visit prompted the completion of a POLST form. The facility's policy on advance directives requires that information about a resident's right to make medical decisions, including the formulation of advance directives, be provided prior to or upon admission. Additionally, the policy mandates that any existing advance directives be documented in the resident's medical record. However, in the cases of R157 and R161, these procedures were not followed, resulting in a failure to document and respect the residents' advance directives as required by both state law and facility policy.
Failure to Notify Resident of Room Change
Penalty
Summary
The facility failed to notify a resident, their doctor, and a family member about a room change, which is a requirement for situations affecting the resident. The deficiency was identified for one resident, who was alert and oriented to person, place, and time, and expressed confusion about the reason for the room change. The room change occurred on August 12, 2024, and the facility administrator was unable to provide documentation or a reason for the change. Additionally, the facility did not have a policy in place for notifying residents of room changes.
Failure to Report Bruise of Unknown Origin
Penalty
Summary
The facility failed to report a bruise of unknown origin for a resident, identified as R49, to the Administrator, which is a violation of their abuse prevention policy. R49, who was admitted with multiple diagnoses including hemiplegia, severe protein calorie malnutrition, and dementia, was found to have a bruised eye of unknown origin. The resident's Minimum Data Sheet indicated severe cognitive impairment, with a BIMS score of 00. A nursing note by a registered nurse documented the bruise on 7/26/2024, but this information was not communicated to the Administrator. The Administrator confirmed during an interview that she was not informed about the bruise and did not conduct any investigation or report the incident to the appropriate authorities. The facility's policy requires nursing staff to report suspicious bruises or abnormalities of unknown origin immediately and document them on a facility incident report. This report should be provided to the nursing supervisor, administrator, or designated individual, and the resident's physician and representative should be notified if necessary. The failure to follow these procedures resulted in the deficiency noted in the report.
Failure to Investigate Bruise of Unknown Origin
Penalty
Summary
The facility failed to investigate a bruise of unknown origin and did not provide necessary assessments for a resident identified as R49. R49 was admitted with multiple diagnoses, including hemiplegia, severe protein calorie malnutrition, and dementia, and was documented as severely cognitively impaired. A nursing note by a registered nurse on 7/26/2024 indicated that R49 had a bruised eye of unknown origin, but this was not reported to the facility's administrator or infection preventionist, nor was it documented or investigated further. The facility's policy on abuse prevention requires nursing staff to report and document suspicious bruises or injuries of unknown origin and to conduct a full assessment of the resident. However, in this case, there was no documentation of an assessment or investigation into the bruise found on R49. The policy also outlines procedures for internal investigation, including appointing an investigator to gather facts and report findings, but these steps were not followed, leading to a deficiency in the facility's handling of the incident.
Failure to Provide Bed Hold Documentation
Penalty
Summary
The facility failed to provide bed hold documentation for a resident, identified as R63, who was transferred to a hospital. R63 had a medical history that included chronic obstructive pulmonary disease, non-ST elevation myocardial infarction, essential hypertension, dementia, anxiety disorder, atrial fibrillation, and type 2 diabetes mellitus. On July 5, 2024, R63 was taken to the emergency room by a family member, V24, despite the registered nurse, V39, suggesting that R63 could be seen by the nurse practitioner in-house. R63 was subsequently admitted to the local hospital. The facility's administrator, V1, and the Minimum Data Set Coordinator, V38, were unable to locate any bed hold documentation for R63's hospital visit from July 5 to July 8, 2024. The facility's policy, as outlined in an undated document, requires that a bed hold form be provided to residents or their representatives when they are transferred to a hospital or take therapeutic leave. This form is meant to inform them of the bed hold policy and to request notification of their intent to return or be discharged from the community. However, this procedure was not followed in R63's case, resulting in a deficiency.
Failure to Conduct PASARR II for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to conduct a PASARR II (Preadmission Screening and Resident Review) for two residents who were diagnosed with mental health conditions after their admission. Resident 15 was admitted with multiple diagnoses, including dementia and bipolar disorder, but the facility did not complete a PASARR II following the diagnosis of bipolar disorder. The administrator confirmed the absence of the required screening in the resident's medical records. Similarly, Resident 49 was admitted with several health conditions, including bipolar disorder and major depressive disorder, but the facility did not perform a PASARR II after these diagnoses were made. The administrator acknowledged that there was no documentation of the required screenings for this resident either. Additionally, it was noted that the facility lacks a policy for conducting PASARR screenings, which contributed to the oversight.
Failure to Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to properly assess and document newly identified pressure areas for a resident, referred to as R27, who was at very high risk for skin breakdown. R27 was admitted with multiple diagnoses, including diabetes, hypertension, and chronic kidney disease, and had a moderate cognitive deficit. Despite being at risk for pressure ulcers, the facility did not conduct an initial skin assessment upon admission. A new pressure area was identified on R27's right hip, but there was no documented assessment, measurements, or description of the area in the medical record. The care plan included interventions such as administering treatments and using a low air loss mattress, but these were not implemented in a timely manner. The resident's family member reported that R27 developed bed sores at the facility and had requested an air mattress, which was not provided until after the pressure area was identified. The facility's protocol required a full assessment of skin condition and documentation of any new pressure areas, which was not followed. The LPN who administered treatment noted the pressure area was scabbed and surrounded by red/purplish tissue, indicating a lack of timely intervention. The infection preventionist confirmed the absence of documented assessments and was unaware of the request for an air mattress, highlighting a breakdown in communication and protocol adherence.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to ensure that narcotics were available and administered as ordered to prevent pain for a resident, identified as R157, who was admitted with multiple diagnoses including gangrene, cellulitis, diabetes, peripheral vascular disease, atrial fibrillation, and edema. R157's care plan included interventions for pain management due to osteoarthritis, peripheral vascular disease, and wounds, with orders to administer analgesia as needed. Despite these orders, there was a delay in administering the prescribed Norco for pain relief, which was ordered on 7/27/24 but not administered until 7/28/24. R157's progress notes indicate that the resident frequently refused care due to severe pain, stating that he did not want to be touched because it hurt too much. The resident's refusal of care included wound care and repositioning, and he expressed understanding of the potential harmful outcomes of refusing treatment. The facility's staff, including a Licensed Practical Nurse (LPN), acknowledged the delay in administering the pain medication and suggested that the medication could have been pulled from the emergency kit if not delivered by the pharmacy, although there was no documentation to confirm this. Interviews with facility staff revealed uncertainty about why there was a delay in starting the pain medication. The facility's administrator noted that the pharmacy did not have a record of the narcotics being administered from the emergency kit. The facility's undated Pain Management Program policy emphasizes the importance of managing pain effectively to promote resident comfort and dignity, yet the delay in administering pain medication to R157 suggests a failure to adhere to this policy, resulting in unrelieved pain for the resident.
Lack of Specific Diagnosis for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the attending physician documented a specific diagnosis in the medical record for the use of a psychotropic medication for one resident. The resident, identified as R96, was prescribed multiple psychotropic medications, including Lorazepam, Celexa, Quetiapine Fumarate, Mirtazapine, and Buspirone, for conditions such as unspecified dementia with agitation, depression, and anxiety. However, the medical record did not contain a specific FDA-approved diagnosis for the use of Quetiapine Fumarate, an antipsychotic medication. The facility's policy requires that antipsychotic drugs should only be used for specific conditions, which were not documented in this case. The pharmacist, identified as V43, acknowledged that a recommendation was sent to clarify the appropriate FDA-approved diagnosis for the use of Quetiapine Fumarate, but the diagnosis provided, Major Depressive Disorder, single episode, was not FDA-approved for this medication. Additionally, the resident's son, identified as V42, stated that the resident had never had any mental health diagnosis other than dementia and some depression, and most of the resident's behaviors were attributed to dementia. This lack of proper documentation and diagnosis for the use of psychotropic medication led to the deficiency identified by the surveyors.
Failure to Provide Thickened Liquids as Ordered
Penalty
Summary
The facility failed to provide thickened liquids as ordered by the physician for a resident with severe cognitive deficits and chronic respiratory failure with hypoxia. The resident was admitted with a requirement for a mechanically altered diet, including pureed food and nectar-thick liquids. However, during observations, the resident was served chocolate milk that was not thickened, contrary to the physician's orders. The resident's care plan did not document specific diet orders, and there was confusion among staff regarding the resident's dietary needs, with some believing hospice had changed the order to thin liquids. The facility's policy on thickened liquids indicates that individuals with swallowing difficulties should have their liquid consistency evaluated and ordered by a Speech Language Pathologist. Despite this policy, the resident was repeatedly served unthickened chocolate milk, and staff, including a CNA and the Dietary Manager, acknowledged the oversight. The lack of adherence to the prescribed diet consistency and the absence of clear documentation and communication among staff contributed to the deficiency.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to provide therapeutic diets as ordered for two residents, R67 and R73, who were part of a sample of 51 residents reviewed. R67, who has diagnoses including essential hypertension, chronic pain, and type 2 diabetes mellitus, was ordered a regular diet with double portions for all meals. However, observations on multiple days revealed that R67 did not receive double portions as prescribed. R67's care plan highlighted a potential nutritional problem related to weight loss, with an intervention to provide and serve the diet as ordered. Similarly, R73, with diagnoses such as chronic systolic heart failure and type 2 diabetes mellitus with diabetic nephropathy, was ordered a regular diet with double protein portions for all meals. Observations showed that R73 did not receive the double protein portions as ordered on several occasions. R73's care plan noted a risk for nutritional problems related to psychotropic medication use and dysphagia, with interventions to provide and serve the diet as ordered. Interviews with the dietary manager and registered dietitian confirmed that residents who are supposed to receive double portions or proteins should indeed receive them. The registered dietitian stated that such dietary recommendations are made for reasons like weight loss, wound healing, or weight maintenance. The facility administrator acknowledged that there was no policy in place for following diet orders, which contributed to the failure in providing the prescribed diets.
Failure to Prevent Resident's Pica Behavior
Penalty
Summary
The facility failed to develop and implement effective interventions to prevent a resident with pica from ingesting non-food items. The resident, who has a history of moderate cognitive impairment and various medical conditions, including diabetes and depression, was observed attempting to eat non-food items such as cigarette butts, pages from books, and dirt. Despite having a care plan in place that included interventions like offering snacks and monitoring behavior, the facility did not consistently implement these measures, leading to multiple incidents where the resident ingested or attempted to ingest hazardous items. The documentation revealed numerous instances where the resident attempted to eat non-food items, including bleach wipes, plastic bags, and foam cups. Staff interviews indicated that while they were aware of the resident's behavior, there was a lack of consistent preventive measures. Staff members reported taking items away from the resident when observed but acknowledged that it was challenging to prevent the behavior entirely. The facility's administrator and other staff members admitted to being unaware of the full extent of the resident's behavior until the surveyor's investigation. The facility's failure to adequately address the resident's pica behavior resulted in the resident being hospitalized after ingesting a plastic bag. The hospital records confirmed the presence of a foreign body in the resident's gastrointestinal tract, which was eventually passed with medical intervention. Despite the known risks associated with the resident's behavior, the facility did not have a specific pica policy in place, and staff were not fully informed or equipped to manage the resident's condition effectively.
Neglect Leads to Resident's Decline and Hospitalization
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a significant decline in the resident's condition. The resident, who had a history of confusion with infections, was readmitted to the facility with a urinary tract infection and was prescribed antibiotics. However, the facility did not implement effective interventions to prevent the worsening of the infection. The resident refused medications and care, including incontinence care and repositioning, which led to the development of pressure ulcers. These pressure ulcers were not treated, resulting in the resident being hospitalized for sepsis related to skin and soft tissue infection. The resident's medical history included angina pectoris, heart failure, unspecified dementia, atrial fibrillation, type 2 diabetes mellitus, paranoid schizophrenia, chronic kidney disease, hypothyroidism, chronic peripheral disease, gout, and COPD. Despite being cognitively intact, the resident required substantial assistance with daily activities. The care plan documented the resident's risk for skin impairment and pressure injuries, with interventions to minimize moisture exposure and assist with repositioning. However, these interventions were not effectively implemented, as evidenced by the resident's refusal of care and the subsequent development of pressure ulcers. Staff interviews revealed that the resident's behavior changed significantly, with increased violence and refusal of care. The facility staff, including CNAs and LPNs, were aware of the resident's refusal of medications and care but did not effectively address the situation. The resident's refusal of care was documented, but there was a lack of timely intervention to prevent the decline in the resident's condition. The facility's failure to adequately assess and treat the resident's condition led to the development of severe pressure ulcers and subsequent hospitalization for sepsis.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and interventions for a resident assessed as being at risk for elopement, leading to multiple incidents where the resident exited the facility unsupervised. The resident, who had a history of elopement and was diagnosed with unspecified dementia and severe cognitive deficits, was identified as an elopement risk on 6/13/24. Despite this assessment, no interventions were implemented to prevent elopement until 7/1/24, allowing the resident to exit the facility on multiple occasions. On 6/16/24, the resident attempted to leave through a staff entrance and was later found outside the facility. Staff were unable to locate an elopement bracelet in time to prevent the resident from exiting. On 7/10/24, the resident again left the facility, walking down a busy road before being persuaded to return. During these incidents, staff were either unaware of the resident's whereabouts or unable to prevent the elopement due to a lack of specific interventions and inadequate staffing to monitor the resident effectively. Interviews with staff revealed a lack of awareness and implementation of interventions for the resident's elopement risk. Staff members reported that the resident frequently attempted to leave the facility and required constant redirection, yet there were no person-centered interventions in place prior to 7/1/24. The facility's policy required immediate response to door alarms and visual checks for exiting residents, but these procedures were not consistently followed, contributing to the resident's ability to elope.
Removal Plan
- R16 was safely brought back into building, elopement evaluation completed, medication review completed, medications adjusted. Initiated monitoring of change of behaviors after family visits, monitored behavior after family visits and identified increased exit seeking behavior, care planned for increased safety checks during the evening hours after family visits until behavior resolves. Also discussed with family potential activities for re-direction during increased anxiety periods.
- Residents who are wander risks are at potential risk to be affected by the same alleged deficit. An audit was completed by the administrator and MDS coordinator of all wandering residents and no issues were identified.
- The Administrator and Maintenance Director in-serviced staff on the facility Elopement and Search (Code Amber) policy. Inservice included the topics elopement assessment, placing wander guard alarm band immediately when identified at risk, physician orders and where to locate the wander guard bands. Inservice included location of wander guard exit doors, wander guard alarm panels. Inservice included topics who responds to alarms, search indoors and outdoor perimeter, announcing alarm and calling all clear when resident is returned safely to building. Inservice includes remaining with resident and completing safety checks until exit seeking behavior resolves.
- All staff have been in serviced on the Elopement and search code amber policy and will be in serviced prior to their next scheduled shift.
- In-services were initiated and will continue to be given by Administrator designee prior to the staff next scheduled shift until completed.
- The administrator has ensured all residents who are at risk for elopement have been assessed and appropriate interventions have been implemented.
- The Administrator has reviewed the policy and procedure Elopement and Search Code Policy and no updates at this time.
- Administrator and/or designee will complete one Elopement drill rotating shifts daily. Any areas for improvement will be immediately addressed.
- Director of Nursing/DON and or designee will audit all new admissions/re-admission for Elopement evaluation, wander guard placement if applicable and interventions initiated, interventions on care plan. Any issues will be addressed immediately.
- Administrator or designee will audit incidents of elopement to ensure they were thoroughly investigated.
- Results of all audits will be discussed at QAPI in meetings and any further recommendations of interdisciplinary team will be immediately implemented and audit until 100 percent compliance.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to identify, treat, and prevent the development of pressure ulcers for a resident, resulting in the resident developing a Stage 3 wound and an unstageable wound on the bilateral buttocks. The resident, who was cognitively intact, required substantial assistance with daily activities and had a history of multiple medical conditions, including heart failure, diabetes, and chronic kidney disease. Despite these risk factors, the facility's records did not document any unhealed pressure ulcers or skin problems prior to the resident's hospitalization. The resident exhibited behavioral changes, including refusing care and medications, which were noted by various staff members. The resident's refusal of care led to prolonged periods of incontinence and lack of hygiene, contributing to skin breakdown. Staff members, including CNAs and LPNs, reported the resident's refusal to allow skin checks and personal care, which were documented in the Treatment Administration Record and Medication Administration Record. Despite these refusals, there was a lack of communication and documentation regarding the resident's skin condition and the development of pressure ulcers. The facility's policy on pressure ulcer care required regular skin assessments and documentation of risk factors, but these were not adequately followed. The resident's condition deteriorated, leading to hospitalization for sepsis secondary to skin and soft tissue infection. Hospital records revealed the presence of deep tissue pressure injuries and a Stage 3 pressure injury, which were not previously identified or treated by the facility. The lack of timely intervention and communication among staff members contributed to the resident's decline and the development of severe pressure ulcers.
Failure to Investigate and Substantiate Peer-to-Peer Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of witnessed peer-to-peer abuse involving several residents. The facility's policy on abuse prevention mandates prompt and aggressive investigation of all reports and allegations of abuse, neglect, exploitation, and mistreatment. However, the facility did not substantiate abuse in multiple incidents involving residents with cognitive deficits, despite witness accounts and resident complaints. For instance, one resident reported being struck in the head by another resident, but the facility's investigation concluded there was insufficient evidence to substantiate abuse, citing a lack of physical or mental harm. In another case, a resident with severe cognitive impairment was reported to have hit another resident on the head. Witnesses, including staff members, confirmed the incidents, yet the facility's investigation again determined there was insufficient evidence to substantiate abuse. The facility's rationale was that the actions were not willful or intentional due to the residents' cognitive impairments. This approach was consistent across multiple incidents, where the facility attributed the behavior to dementia rather than abuse. The facility's failure to substantiate abuse in these cases was influenced by corporate directives, as noted by staff interviews. The Director of Nursing and other staff members indicated that corporate policy required them to conclude that there was insufficient evidence to substantiate abuse if there was no physical or mental harm. This approach led to a lack of specific interventions to prevent further incidents, as the facility did not recognize the behavior as abuse, despite repeated occurrences and staff witnessing the incidents.
Resident Falls from Wheelchair Due to Lack of Footrests
Penalty
Summary
The facility failed to prevent an accident involving a resident, identified as R2, who sustained a 2 cm laceration on the forehead and required emergency room treatment. R2, who has a history of falls and multiple medical conditions including vascular dementia and legal blindness, was being assisted by a CNA in a manual wheelchair without footrests. During the transport, R2 unexpectedly placed her feet on the ground, causing her to fall forward out of the wheelchair. R2's care plan noted a risk for falls due to various factors such as weakness, dementia, and a history of falls. Despite these documented risks, the CNA did not use footrests while transporting R2, which contributed to the fall. The CNA reported that R2 had previously been able to keep her feet elevated during transport, but on this occasion, she placed her feet down, leading to the accident. The facility's fall policy outlines the need for staff to document and discuss fall risk factors, which include cognitive impairment and musculoskeletal abnormalities. However, the incident suggests a lapse in implementing appropriate safety measures, such as using footrests, to mitigate these risks during wheelchair transport. This oversight resulted in R2's injury and subsequent medical treatment.
Failure to Provide Adequate Mouth Care for a Resident
Penalty
Summary
The facility failed to provide adequate mouth care for a resident (R9) who was dependent on staff for all activities of daily living due to severe cognitive impairment and physical limitations. R9 was readmitted to the facility with multiple diagnoses, including traumatic brain injury, pressure ulcers, and a gastrostomy tube. The resident's care plan specified the need for oral hygiene every morning, evening, and as needed. However, during an observation, R9 was found with grayish patches on the teeth and gums, and dry, yellowish skin on the lips, indicating a lack of proper mouth care. A CNA acknowledged that R9 needed mouth care and proceeded to provide it using foam applicators and a washcloth, but there were no mouth care supplies readily available in the resident's room. Interviews with staff revealed inconsistencies in the provision of mouth care, with one CNA stating that mouth care was provided a couple of times a day, while the Director of Nurses expected it to be done every shift. The facility's mouth care policy outlined specific procedures and documentation requirements, but there was no evidence of daily mouth care being documented for R9. This lack of documentation and the observed condition of R9's mouth suggest a failure to adhere to the facility's policy and ensure the resident's oral hygiene needs were met.
Failure to Assess and Document Changes in Condition
Penalty
Summary
The facility failed to ensure thorough assessments for changes in condition and proper documentation for two residents, resulting in significant discomfort and delayed treatment. One resident, with a history of chronic obstructive pulmonary disease, heart failure, and other serious conditions, experienced prolonged respiratory distress and was eventually transported to the hospital. The resident's condition deteriorated significantly due to a lack of timely assessments and documentation, leading to her death. The staff failed to document vital signs and assessments after administering medication for nausea and did not reassess the resident despite noticeable changes in her condition reported by the CNA and other staff members. Another resident, with diagnoses including dementia, Alzheimer's disease, and chronic kidney disease, exhibited symptoms such as drooling, dizziness, lethargy, and increased confusion. Despite these symptoms, there were no documented assessments or vital signs taken for several days. The resident was eventually sent to the hospital with a diagnosis of altered mental status, urinary tract infection with hematuria, and acute pulmonary edema. The staff's failure to promptly assess and document the resident's condition contributed to the delay in treatment. Additionally, the facility failed to identify, assess, and treat wounds for the first resident. Despite the resident's history of psoriasis and frequent incontinence, there were no documented skin assessments or interventions for potential skin issues. Upon the resident's admission to the hospital, multiple areas of bruising, erythema, and open wounds were noted, indicating a lack of proper wound care and monitoring at the facility. The facility's policies on notifying changes in condition and documenting assessments were not followed, leading to significant negative outcomes for the residents involved.
Misappropriation of Medications by LPN
Penalty
Summary
The facility failed to ensure residents were free from misappropriation of medications for three residents. The investigation revealed that a Licensed Practical Nurse (LPN) was involved in the diversion of narcotic medications, including oxycodone, hydrocodone, and tramadol, which were intended for the residents. The LPN in question refused to take a drug test and admitted to using the medications without a prescription, claiming they were provided by her mother. The LPN subsequently resigned from her position immediately after being confronted about the missing medications and narcotic count sheets. The investigation documented that the residents involved were receiving their pain medications as ordered, but discrepancies were found in the narcotic logs and medication counts. The facility's records showed that the LPN had signed out multiple cards of narcotic medications without proper documentation or destruction of the medications. The missing narcotic count sheets and the LPN's refusal to take a drug test raised concerns about the integrity of the medication administration process. Interviews with the residents indicated that they did not experience any issues with receiving their pain medications, although one resident had difficulty swallowing the medications. The facility's policies on controlled substance storage and abuse prevention were not adequately followed, as the incident was not reported to local law enforcement, and the facility had not implemented new processes to prevent future occurrences. The investigation concluded that the residents received their medications as directed, but the facility failed to protect the residents from the misappropriation of their medications by the LPN.
Failure to Implement Abuse Policy and Report Drug Diversion
Penalty
Summary
The facility failed to implement its abuse policy for three residents (R1, R2, and R3) who were affected by misappropriation of property. R1 had a prescription for oxycodone-Acetaminophen, R2 had a prescription for Hydrocodone-Acetaminophen, and R3 had a prescription for Tramadol. An incident involving a Licensed Practical Nurse (LPN) identified as V3 revealed that V3 refused a mandatory drug test and admitted to potentially testing positive for Tramadol, Norco, and Percocet, which she claimed to have received from her mother without a prescription. V3 also failed to provide evidence that medications were destroyed after removing them from the locked narcotic box and could not account for missing narcotic count sheets. The investigation, conducted by the Director of Nursing (DON) and the Human Resources Director, found that V3 was defensive and claimed she was being set up by coworkers. V3 eventually resigned without taking the drug test. The Assistant Director of Nursing (ADON) and the Human Resources Director confirmed that V3 could not produce the missing narcotic sign-out sheets and admitted she would test positive for the medications in question. Despite these findings, the facility did not report the incident to local law enforcement, as required by their abuse prevention policy. The facility's policy titled 'Abuse Prevention Program' mandates that local law enforcement be informed when there is a reasonable suspicion that a crime has been committed. However, the facility's Administrator and ADON were unaware of this requirement and did not notify the police. The facility also failed to implement any new processes following the drug diversion incident, although the Administrator did contact the pharmacy about an automated medication dispensing cabinet. This lack of action and failure to follow established policies contributed to the deficiency identified in the report.
Failure to Report Suspected Drug Diversion to Law Enforcement
Penalty
Summary
The facility failed to operationalize its Abuse Policy by not notifying local law enforcement when there was a reasonable suspicion of a crime involving drug diversion by a staff member. The incident involved three residents who had prescriptions for controlled substances, and the medications were suspected to have been diverted by an LPN. The LPN admitted to using similar medications without a prescription and refused to take a drug test, which raised further suspicion. Despite these red flags, the facility did not report the incident to local law enforcement as required by their policy. The investigation revealed that the LPN could not account for missing narcotic sign-out sheets and admitted to using medications that were not prescribed to her. The LPN resigned immediately after being confronted. The Director of Nursing and the Assistant Director of Nursing were aware of the situation but did not notify the police, citing a lack of awareness of the requirement to do so. The facility's policies clearly state that local law enforcement should be contacted when there is a reasonable suspicion of a crime, but this step was not taken. The facility's Controlled Substance Storage policy and Abuse Prevention Program both emphasize the importance of reporting discrepancies and potential criminal activities to the appropriate authorities. However, in this case, the facility failed to follow its own policies, resulting in a deficiency. The failure to report the suspected drug diversion to local law enforcement represents a significant lapse in the facility's adherence to its abuse prevention and controlled substance management protocols.
Failure to Maintain Accurate Narcotic Records and Administer Medications
Penalty
Summary
The facility failed to maintain accurate records of narcotics and administer medications to meet the needs of the residents. This deficiency was identified for three residents (R1, R2, and R3) who were reviewed for pharmacy services. The issues included missing narcotic count sheets and discrepancies in the administration and documentation of controlled substances such as oxycodone, hydrocodone, and tramadol. The facility's investigation revealed that the narcotic logs were not properly maintained, and there were instances where medications were unaccounted for, leading to potential drug diversion by a Licensed Practical Nurse (LPN), identified as V3. R1, who was admitted with diagnoses including Type 2 Diabetes Mellitus, Osteoarthritis, and Chronic Gout, had an order for oxycodone-Acetaminophen for pain management. The investigation found that the narcotic count sheets for R1 were missing, and there were discrepancies in the administration records. Similarly, R2, who had Chronic Pain and a Wedge Compression Fracture, had an order for Hydrocodone-Acetaminophen. The narcotic count sheets for R2 were also missing, and the medication administration records did not match the narcotic logs. R3, with diagnoses including Primary Osteoarthritis and Unspecified Dementia, had an order for Tramadol. The investigation found that the narcotic count sheets for R3 were missing, and there were discrepancies in the administration records. The facility's investigation concluded that the LPN in question, V3, could not provide evidence that the medications were destroyed after removing them from the locked narcotic box. V3 also admitted that she would test positive for three drugs, which she claimed to have obtained from her mother without a prescription. The facility reported the incident to the Illinois Department of Public Health, the Illinois State Police Medicaid Fraud Control Unit, and the Illinois Department of Financial Professional Regulation. The investigation determined that the residents received their pain medications as directed, but the facility had to replace the missing medications at its own cost.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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