Shelbyville Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Shelbyville, Illinois.
- Location
- 1111 West North 12th Street, Shelbyville, Illinois 62565
- CMS Provider Number
- 145441
- Inspections on file
- 30
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Shelbyville Manor during CMS and state inspections, most recent first.
A facility failed to conduct abuse risk assessments and to implement care-planned non-pharmacological interventions for several cognitively impaired residents with dementia and behavioral disturbances. One resident with severe cognitive impairment was struck on the face by another cognitively impaired resident, yet neither had documented abuse risk assessments. Another resident with Alzheimer’s disease and behavioral disturbance repeatedly engaged in sexually inappropriate and intrusive behaviors toward staff and female residents, including grabbing buttocks and breasts, exposing genitals, entering or attempting to enter female residents’ rooms, and touching or attempting to touch female residents while seated or asleep. Documentation showed that staff responses were often limited to verbal redirection, reminders that behavior was inappropriate, monitoring, and basic assistance with clothing or hygiene, with no consistent evidence that the broader, individualized non-pharmacological interventions listed in the care plan were implemented. A severely cognitively impaired resident was also identified as an alleged victim of breast touching by this behaviorally disturbed resident. Facility staff and leadership acknowledged that the social history assessment in use was for trauma-informed care and not an abuse risk assessment, and that no specific abuse risk assessment tool was used, despite an abuse prevention policy requiring identification of residents at risk of abusing others or being victims and inclusion of appropriate interventions on care plans.
A resident with CKD, diabetes, chronic pain, and morbid obesity, who was cognitively intact and dependent on staff for ADLs, was care planned to receive showers twice weekly with attention to drying skin folds. Shower records for a given month showed the resident received only four showers and missed two scheduled showers, with no documentation of refusals. The resident reported that staff frequently forgot to provide showers and that she often had to remind them, while the DON confirmed the resident was scheduled and care planned for two showers per week and had missed two showers during that month.
Two residents with dementia, neurological conditions, and multiple psychoactive and anti-seizure medications experienced repeated falls related to inadequate implementation of fall-prevention measures. For one resident, the care plan contained conflicting directions about wheelchair foot pedals, and an intervention to add non-slip material to the wheelchair seat was not documented or in place during observation. For another resident with a history of falls, documentation showed inconsistent or missing information about footwear, and the resident was later observed in a wheelchair wearing regular socks with a foot dangling between foot pedals, despite staff stating that non-slip socks were needed and that the resident attempted to stand without assistance.
A resident with dementia, multiple vitamin deficiencies, and documented dental issues had a physician order for a high‑protein supplement TID with meals and a recorded dislike of chicken. During a lunch meal, the resident was served chicken cordon bleu and did not receive the ordered high‑protein milkshake, even though both the supplement order and the chicken dislike were clearly printed on the diet ticket. The resident reported inconsistent receipt of the milkshakes and reiterated his dislike of chicken, while a CNA, the Dietary Manager, and the DON each confirmed that the meal and supplement provided did not match the documented physician orders and stated food preference.
Two residents with cognitive impairment and high fall risk experienced multiple falls due to the facility's failure to update care plans with appropriate interventions, lack of documentation of required 15-minute checks, and incomplete fall investigations. Staff did not consistently document or implement fall prevention measures, and leadership confirmed the absence of policies for tracking interventions or collecting witness statements.
Several hot water heaters located in resident closets were found with visible mold, rust, and lime build-up, with resident clothing hanging directly above or touching the units. Staff and family members had reported concerns about these unsanitary conditions, but the issues remained unaddressed, and there was no documentation of the concerns in the affected residents' records.
A resident with cognitive impairment and a history of falls was consistently placed in bed with full-length body pillows and a concave mattress to prevent bed exit, but the facility failed to assess or care plan these devices as restraints. Despite multiple falls and a resulting pelvic fracture, there was no documentation of restraint assessment or reassessment, and staff confirmed the interventions were used to restrict movement without proper evaluation.
A resident reported that a male CNA was rough during perineal care, resulting in a bleeding skin tear. Staff observed and documented the injury, and the CNA was identified as present on the unit. Despite the report and facility policy requiring suspension, the alleged staff member was not removed from duty and the incident was not reported to authorities.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Staff failed to prevent both staff-to-resident and resident-to-resident abuse, including a CNA using profanity and physically handling a resident with dementia, and another resident striking a peer with a plastic object, resulting in injury and pain. Prior disciplinary actions for the CNA and inadequate supervision contributed to these incidents.
A cognitively impaired resident with a high fall risk and multiple diagnoses required substantial staff assistance for transfers but was allowed to self-transfer and self-toilet without supervision. The resident fell while attempting to go to the bathroom alone, resulting in fractures that required emergency surgery. Staff were unaware of the resident's true assistance needs, and the care plan did not include targeted interventions to address self-toileting or increased supervision.
The facility did not transmit MDS assessments to CMS within the required time frames for five residents. Documentation and staff interviews confirmed that the assessments were submitted late or not at all, despite established procedures for timely completion and transmission.
Several residents who were diagnosed with severe mental illness after admission did not receive required Level 2 PASRR assessments. Staff misunderstood the requirements, believing Level 2 PASRRs were only needed for new admissions or significant changes, and failed to complete them when new mental illness diagnoses were made.
Staff failed to follow proper infection control procedures during catheter and incontinence care for multiple residents, including not changing gloves or performing hand hygiene between care tasks, improper cleaning techniques that led to cross-contamination, and not applying barrier cream as required by facility policy.
A resident with severe cognitive impairment and a history of modesty was transported by CNAs to the shower room while inadequately covered, resulting in exposure of multiple body areas in view of other residents and staff. Staff reported undressing the resident in his room for convenience, contrary to facility policy and the resident's known preferences.
A resident with a diagnosis of Major Depressive Disorder with recurrent psychotic symptoms and an Intellectual Disorder was admitted without the facility obtaining a required Level 2 PASRR, despite documentation indicating the need. The administrator reported that Level 2 PASRRs were only being completed after significant changes in status, contrary to facility policy.
A resident with pneumonia and emphysema received oxygen therapy without a complete physician order specifying the flow rate, and a CNA, rather than a licensed nurse, administered the oxygen by turning on the concentrator and setting the rate. The facility's policy requires licensed nurses to administer oxygen and for orders to include all necessary details.
A resident with a history of pain and mobility issues was unable to access her call light and bedside table during the night, resulting in a prolonged period of unmanaged pain. Staff confirmed the items were out of reach, and the nurse did not document the resident's pain level when administering PRN pain medication, contrary to facility policy.
A resident with severe cognitive impairment and multiple behavioral health diagnoses experienced repeated injuries during care due to combative behavior. Staff lacked behavioral health training, and psychiatric services were not in place at the time of the incidents. Injuries were not consistently reported or followed up according to policy, and care plan interventions were not always implemented.
The facility failed to ensure respect and dignity for two residents due to inappropriate communication by a CNA, V4. R2 reported feeling rushed and uncomfortable with V4's demeanor, while R1 felt disrespected and anxious due to V4's frequent room visits and rude manner. Despite the abuse being unsubstantiated, the facility acknowledged V4's inappropriate communication, leading to V4's termination.
A resident with Spastic Paraplegia and other mobility impairments fell from a shower chair when a wheel got caught on the shower curb, resulting in multiple back and neck fractures. The resident required emergency medical treatment and was diagnosed with six vertebral fractures, necessitating pain management and a cervical immobilizer upon return to the facility.
The facility has not employed a Certified Dietary Manager for almost a year, affecting all 80 residents. During a survey, it was confirmed that the position has been vacant for six months, with the Registered Dietician only visiting monthly and reviewing charts remotely weekly. The facility lacks a policy mandating a Certified Dietary Manager, although it is acknowledged that one should be employed.
A facility failed to maintain kitchen equipment in a sanitary condition, risking cross-contamination and food-borne illnesses for 80 residents. Observations included rust and grease buildup on equipment, standing water, and expired food items. Staff confirmed the lack of a cleaning schedule and maintenance issues, violating professional standards for food safety.
A facility failed to maintain resident dignity by not providing timely toileting assistance and allowing staff to engage in personal conversations during meal service. A resident reported waiting long periods for toileting help, leading to incontinence and humiliation. Staff were observed talking about non-work-related topics while assisting residents with severe cognitive impairments during meals, with minimal interaction directed towards the residents. The facility's Administrator acknowledged these as dignity issues.
The facility failed to maintain and store respiratory equipment properly, affecting four residents. Equipment was not dated when changed and was improperly stored, with tubing found on the floor and humidifier bottles on dirty surfaces. Staff confirmed the need for more hygienic practices.
The facility failed to prevent cross-contamination during meal service by not following hand hygiene protocols. A CNA used bare hands to move food on a resident's plate without gloves or hand hygiene, and an LPN assisted two residents without cleaning hands between them. Another CNA handled a resident's drinking cup without hand hygiene. These actions violated the facility's hand washing policy, risking infection spread.
A facility failed to report an allegation of verbal and physical abuse of a resident by a CNA to the Abuse Coordinator. The resident, with multiple medical conditions, was allegedly treated roughly, yelled at, and left in wet clothes. The Administrator was unaware of the incident until later, and the CNA was suspended during the investigation. The facility's policy mandates immediate reporting of such allegations, which was not adhered to.
A resident with Enterocolitis due to Clostridium Difficile did not receive prescribed doses of Fidaxomicin as per physician orders. The MAR showed missed doses on multiple occasions, which was confirmed by an RN. The facility's policy requires adherence to physician orders for medication administration.
A CNA failed to change gloves and perform hand hygiene after contamination with stool while providing catheter care to a resident with multiple medical conditions, including Parkinson's Disease and Bladder-Neck Obstruction. The CNA acknowledged the error, and the IP stressed the importance of proper infection control practices to reduce infection risks.
The facility failed to conduct necessary Psychotropic Medication Assessments for two residents, leading to a deficiency in managing unnecessary medications. One resident with Dementia and Depression had not been assessed in the past year despite being on Citalopram and Olanzapine. Another resident with Depression and Anxiety did not receive an Initial Assessment upon admission while on Buspar and Citalopram. These assessments are essential for the Care Plan and Gradual Dose Reduction Program.
Two residents received meals at a cold temperature due to staff delivering food without covering trays, leading to dissatisfaction and reduced meal consumption. The Nurse Manager acknowledged the lack of a formal policy on covering trays, which contributed to the issue.
A resident with severe cognitive impairment was not served a modified diet as ordered, leading to coughing after consuming un-thickened tomato soup. The CNA feeding the resident and a cook acknowledged the oversight in not thickening the soup, which was required per the resident's dietary order.
Failure to Implement Abuse Risk Assessments and Non-Pharmacological Interventions for Dementia-Related Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatments, services, non-pharmacological interventions, and abuse risk assessments for residents with dementia and severe cognitive impairment, particularly in relation to resident-to-resident and resident-to-staff incidents. Several residents were identified as having dementia or Alzheimer’s disease with behavioral disturbances, and Minimum Data Set (MDS) assessments documented severe or moderate cognitive impairment. Despite this, the medical records for some residents, including those involved in incidents, did not contain abuse risk assessments to determine whether they were at risk of being victims or perpetrators of abuse. One resident with dementia and severe cognitive impairment was involved in an incident where another cognitively impaired resident put a hand on her face; a CNA witness described the action as the second resident appearing to get mad and smacking the first resident, with apparent contact to the cheek under the eye. Neither resident’s record contained a documented risk assessment for abuse risk as victim or perpetrator. Another resident with Alzheimer’s disease and dementia with behavioral disturbance exhibited a pattern of sexually inappropriate and intrusive behaviors over an extended period, including grabbing the buttocks, breasts, and attempting to kiss CNAs, exposing genitals in public areas, walking naked in hallways, urinating and defecating outside the bathroom, following female residents to their rooms, entering or attempting to enter female residents’ rooms, and attempting or making physical contact with female residents while they were seated or asleep. Nursing progress notes repeatedly documented these behaviors and, in many instances, either documented no intervention or only minimal verbal redirection, reminders that the behavior was inappropriate, or simple monitoring. The same resident’s care plan identified behavioral problems directed at others and an inability to differentiate socially appropriate from inappropriate behaviors, and it listed multiple non-pharmacological interventions such as specific redirection strategies, engagement in activities of interest, and one-to-one supervision. However, there was no documented evidence that staff implemented these listed non-pharmacological interventions beyond repeated verbal redirection, monitoring, and occasional direction to watch a movie or have a snack. Another severely cognitively impaired resident was documented as the alleged victim of breast touching by the behaviorally disturbed resident, and was observed during the survey sitting in the dementia unit day room covered with a blanket, unlike other residents. Multiple staff, including CNAs, RNs, LPNs, and care plan staff, reported either not witnessing the inappropriate behaviors firsthand or only having hearsay knowledge, and facility leadership and care planning staff confirmed that the social history assessment in use was for trauma-informed care and not an abuse risk assessment, and that the electronic record system did not provide an actual abuse risk assessment. The facility’s own Abuse Prevention policy called for special attention to identifying behaviors that increase a resident’s potential for abusing others or being a victim, and for including appropriate interventions on care plans and communicating them to direct care staff, but the documentation showed that these expectations were not met for the residents involved. Throughout the documented period, the resident with Alzheimer’s disease and behavioral disturbance continued to display sexually inappropriate and intrusive behaviors toward staff and female residents, including repeated touching or attempts to touch staff and residents, making sexual comments, and exposing himself in public areas. Progress notes showed that staff responses were often limited to telling the resident the behavior was inappropriate, redirecting him, assisting with clothing or hygiene after episodes of disrobing or incontinence, or simply monitoring him, with no consistent documentation of the broader, individualized non-pharmacological interventions outlined in the care plan. Additionally, the facility did not document completion of the ordered referral to a geriatric psychiatric hospital for this resident. Social services and care plan staff acknowledged that they were not aware of specific abuse or neglect risk assessment tools being used, and that the existing social history assessment was not designed to evaluate resident-to-resident or staff-to-resident abuse risk, despite the facility’s written policy requiring identification of such risks and inclusion of appropriate interventions on care plans.
Failure to Provide Scheduled Twice-Weekly Showers to Dependent Resident
Penalty
Summary
The facility failed to provide scheduled showers twice weekly to a dependent resident, resulting in missed showers without documented refusals. The resident had chronic kidney disease, diabetes, chronic pain, and morbid obesity, and was cognitively intact with a Brief Interview of Mental Status score of 14 out of 15. The resident’s care plan, initiated on 03/14/2025, specified that the resident was to receive showers twice weekly and requested that staff ensure she was dry and that skin folds were patted dry. Shower documentation for February 2026 showed the resident received showers on 2/3/26, 2/10/26, 2/18/26, and 2/21/26, with no documentation that the resident declined showers between 2/3/26 and 2/10/26 or between 2/10/26 and 2/18/26, indicating two missed showers. The resident reported that staff almost weekly forgot to provide showers, that she often had to remind them, and that sometimes staff did not have time until later in the day, and the DON confirmed the resident was scheduled and care planned for two showers per week and had missed two showers in February 2026. These findings show that the facility did not follow the resident’s care plan and scheduled bathing routine, and did not document any refusals or other reasons for the missed showers, despite the resident’s dependence on staff for activities of daily living and her expectation of two routine showers per week on specific days.
Failure to Implement and Communicate Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and consistently follow fall-prevention interventions as outlined in residents’ care plans. One resident with dementia, multiple neurological conditions, and on numerous psychoactive and anticonvulsant medications had a history of falls from bed and from a wheelchair. After falls in which the resident became entangled with wheelchair foot pedals and struck her head, the interdisciplinary team determined that the wheelchair foot pedals should be removed and non-slip material placed on the wheelchair seat. However, the resident’s care plan contained conflicting information: the Resident Care Information section continued to require bilateral foot pedals on a high-back reclining wheelchair, while the Fall Risk section directed that the foot pedals be removed. The non-slip material intervention was not documented in the care plan. During observation, the resident was transferred into her wheelchair with no non-slip material present on the seat or under the padded cushion, despite the team’s prior decision to use it. A staff member later acknowledged carrying non-slip material intended for this resident’s wheelchair and stated she had revised the care plan to include it, but the care plan still listed foot pedals in one section and removal of foot pedals in another. The staff member also confirmed that the intervention to remove the foot pedals should have been revised in the Resident Care section of the care plan, and the administrator stated that care plan interventions recommended by the interdisciplinary team are expected to be implemented into the care plan. A second resident with encephalopathy, dementia with agitation and psychotic disturbance, Parkinsonism, seizures, osteoporosis, and other conditions, and who was receiving anti-Parkinson’s, antipsychotic, and multiple anti-seizure medications, experienced multiple falls in her room. Documentation showed one fall occurred when the resident was barefoot and looking for a bathroom, another when she was wearing non-skid slippers, and additional falls occurred with an orthopedic boot in place or with no documentation of footwear. Observation later found this resident seated in a high-back wheelchair with regular dress socks and her left foot dangling between the two foot pedals. A LPN stated the resident attempts to stand without assistance and should be wearing non-slip socks, and the DON indicated she would need to determine the status of non-slip socks for this resident, noting recent use and discontinuation of an orthopedic boot and initiation of hospice services.
Failure to Provide Ordered High-Protein Supplement and Honor Food Dislike
Penalty
Summary
The deficiency involves the facility’s failure to provide a physician‑ordered high‑protein supplement and to honor a documented food dislike for a resident with multiple nutritional deficiencies and moderate cognitive impairment. The resident’s diagnoses include unspecified dementia with moderate cognitive impairment, vitamin D, E, and ascorbic acid deficiencies, and a disorder of teeth and supporting structures. A dietary physician order dated February 4, 2026, specifies that the resident is to receive a regular high‑protein supplement three times daily with meals at 7:30 a.m., 12:00 p.m., and 5:30 p.m. The same physician order/meal ticket also documents that the resident dislikes chicken. On observation at a lunch meal, the resident was served chicken cordon bleu as the entrée and did not receive the ordered high‑protein milkshake supplement, despite both the supplement and the chicken dislike being clearly documented on the physician order/meal ticket. The resident later stated that he does not like chicken, but ate the entrée because the ham inside made it more tolerable, and reported that he enjoys the high‑protein milkshakes but does not receive them consistently at every meal as ordered. A CNA confirmed that the resident did not receive the high‑protein milkshake and was given chicken in error, acknowledging that both the supplement and the chicken dislike were on the ticket. The Dietary Manager confirmed that chicken was listed as a dislike and that the high‑protein supplement was ordered three times daily, and acknowledged that the kitchen staff missed adding the supplement. The DON also confirmed that the physician order/dietary ticket documented the chicken dislike and the high‑protein milkshake order.
Failure to Update Care Plans and Implement Fall Interventions
Penalty
Summary
The facility failed to update and implement fall interventions in the care plans for residents identified as high fall risks, and did not conduct thorough fall investigations. One resident with diagnoses including dementia, psychotic disturbance, and diabetes was documented as moderately cognitively impaired and required supervision for most activities of daily living. Despite being identified as a high fall risk, this resident experienced multiple falls, some unwitnessed, and the care plan was not consistently updated with new interventions following each incident. Staff involved in the falls were not asked to provide witness statements, and management did not systematically document or investigate the circumstances of each fall. Another resident, severely cognitively impaired with diagnoses such as encephalopathy, dementia, and repeated falls, also experienced an unwitnessed fall. The care plan for this resident included an 'alternate call light' intervention, which required staff to visualize the resident every 15 minutes. However, staff interviews revealed that these checks were not documented, and there was no way to verify that the intervention was consistently implemented. Staff could not confirm the last time the resident was visualized prior to the fall, and documentation in the medical record was found to be inaccurate regarding the timing of checks. Facility leadership confirmed that there was no policy or system in place to document 15-minute checks or to keep separate files for fall investigations. The only documentation available was in the electronic medical record, and there was no established process for collecting or reviewing witness statements from staff involved in falls. The lack of documentation and follow-through on care plan interventions and investigations contributed to the facility's failure to ensure a safe environment and adequate supervision to prevent accidents.
Unsanitary Hot Water Heaters in Resident Closets
Penalty
Summary
The facility failed to maintain sanitary conditions for hot water heaters located in resident closets, affecting six residents reviewed for physical environment. Observations revealed that several hot water heaters in resident closets had visible lime build-up, rust, and black mold on the units, surrounding floors, and walls. Residents reported that their clothes, which hung directly above or touched the water heaters, became very warm, and some expressed concerns about potential health risks due to the presence of mold and lime build-up. One resident's family member had previously reported concerns about mold and lime build-up to facility staff, but there was no documentation of this concern in the resident's electronic medical record, nor evidence that the issue was addressed. Interviews with staff, including the DON, Maintenance Director, and Custodian, confirmed awareness of the unsanitary conditions and the presence of water heaters in multiple resident closets. Staff acknowledged that some water heaters were in poor condition, with visible mold, rust, and lime build-up, and that resident clothing was in direct contact with the units. Despite these concerns being reported by residents and family members, and staff being aware of the issues, the unsanitary conditions persisted at the time of the survey.
Failure to Assess and Care Plan Use of Body Pillows and Concave Mattress as Restraints
Penalty
Summary
The facility failed to identify and assess the use of full body pillows and a concave mattress as physical restraints for a resident with cognitive impairment and a high risk for falls. Observations showed that the resident was consistently positioned in bed with full-length body pillows placed along both sides of the body, under a fitted sheet, on top of a concave mattress. Staff interviews confirmed that these interventions were used specifically to prevent the resident from getting out of bed, yet there was no documentation of a restraint assessment or inclusion of these interventions in the resident's care plan. The resident's medical record indicated a history of falls, cognitive impairment, and unsteady gait. Progress notes and post-fall documentation revealed multiple incidents where the resident exited the bed and ambulated unsupervised, despite the presence of body pillows and a concave mattress. On several occasions, the resident was found on the floor after attempting to self-transfer, and ultimately sustained a left pelvic fracture following a fall when the body pillows were in place. There was no evidence in the medical record of an assessment or reassessment for the use of these devices, even after falls occurred. Staff, including CNAs, an LPN, and the DON, acknowledged that the body pillows were intended to restrict the resident's ability to get out of bed and that no formal assessment or care plan intervention had been completed for their use. The facility's own restraint policy required an assessment prior to the use of any restraint and regular reassessment, but this was not followed. The hospice nurse practitioner also noted that the combination of body pillows and a concave mattress increased the resident's risk for injury by creating additional obstacles to safe bed exit.
Failure to Protect Residents Following Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to protect residents from further abuse by staff following an allegation of staff-to-resident abuse. Specifically, a resident reported to CNAs that a male CNA was rough while cleaning the perineal area during a shower, resulting in a 2 cm by 1 cm open area with bleeding on the scrotum. The incident was documented in nursing notes, and the resident's family and the administrator were notified. Multiple staff interviews confirmed that the resident reported the male CNA was rough, and that the injury was observed and reported to nursing staff. The CNA in question was identified as the only male CNA working on the resident's hallway during the relevant shift, and assignment records confirmed his presence on the unit with the resident and other residents. Despite the resident's report and staff observations, the administrator did not consider the incident to be an abuse allegation and did not report it to the state health department. The alleged perpetrator was not suspended pending investigation, contrary to the facility's own abuse prohibition and reporting policy, which requires immediate suspension of any employee alleged to have committed abuse. The CNA continued to work on the unit with other residents after the allegation was made, and no immediate protective measures were implemented.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Prevent Staff and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent incidents of both staff-to-resident and resident-to-resident abuse, affecting two residents. In one incident, a Certified Nursing Assistant (CNA) used profanity and physically handled a resident with severe cognitive impairment and dementia by placing hands on the resident's shoulders to restrict movement in a wheelchair. A family member witnessed the CNA aggressively jerking the wheelchair and using profane language toward the resident. The CNA had a documented history of prior disciplinary actions for similar behaviors, including previous use of profanity in the presence of residents and leaving residents unsupervised. In a separate incident, a resident with a history of verbal and physical aggression entered another resident's room despite being told not to by both a CNA and the resident. The aggressive resident picked up a plastic bubble wand and struck the other resident on the head and face, resulting in a significant bump, bruising, dizziness, and a high level of pain. The CNA present was unable to immediately intervene as he was providing care to another resident at the time. Both incidents demonstrate a lack of adequate supervision and failure to enforce abuse prevention policies. The facility's own documentation and staff interviews confirm that the abuse occurred and that the affected residents suffered physical and emotional harm as a result. The facility's policies prohibit such abuse, but repeated violations and insufficient supervision contributed to the deficiencies.
Failure to Provide Safe Transfer and Supervision for Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with a history of falls and multiple diagnoses, including dementia, muscle wasting, and difficulty walking, was admitted to the facility and assessed as high risk for falls. The resident required substantial to maximal staff assistance with transfers, as documented in both the physical therapy evaluation and the certified nursing assistant task sheet. Despite these documented needs, staff failed to provide the necessary assistance, and the resident was allowed to self-transfer and self-toilet without supervision. On the day of the incident, the resident was found on the floor in his room, having attempted to go to the bathroom independently. The environment was free of clutter, and the call light was not activated. The resident reported tripping over his heel while trying to reach the bathroom, which was approximately eight feet away from where he was found. He sustained severe injuries, including fractures to the left shoulder and left hip, requiring emergency medical attention and surgical intervention. Staff interviews revealed a lack of awareness regarding the resident's need for assistance and a misunderstanding of his level of independence, despite clear documentation of his high fall risk and need for staff support. Additionally, the facility failed to implement targeted post-fall interventions to address the root cause of the resident's self-toileting behavior. The care plan did not include increased toileting assistance or supervision prior to the incident, and staff did not recognize or act upon the resident's history of impulsivity and previous falls. The deficiency was identified through record review and staff interviews, which confirmed that the resident did not receive the level of supervision and assistance required to prevent accidents.
Failure to Timely Transmit MDS Assessments to CMS
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) Resident Assessment Instruments to the Centers for Medicare and Medicaid Services (CMS) within the required time frames for five residents. Specifically, the MDSs for these residents had Assessment Reference Dates (ARDs) in February, but the submissions were not completed until late April, well beyond the regulatory deadlines. In one case, an MDS was still not completed or transmitted as of the end of April. The facility's CMS Submission Reports confirmed the late submissions, and the MDS Coordinator acknowledged the delays during an interview. The MDS Coordinator explained the required timing process, which allows 14 days after the ARD to complete the assessment, 7 days to code the MDS, and an additional 7 days to transmit the data to CMS. Despite this process, the MDSs for the affected residents were not transmitted within the required time frames, as confirmed by both documentation and staff interview. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Complete Level 2 PASRR for Residents with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to obtain Level 2 Pre-admission Screening and Resident Review (PASRR) assessments for four residents who were diagnosed with severe mental illness after admission. In each case, the residents were initially admitted with no indication of mental illness or developmental disability, as documented by their original Level 1 PASRR screenings. However, subsequent diagnoses of severe mental illnesses such as Psychotic Disorder with Delusions, Bipolar Disorder, Psychosis, and Schizoaffective Disorder were made after admission. Despite these new diagnoses, there was no documentation of Level 2 PASRR assessments being completed for these residents in their comprehensive medical records. Interviews with facility staff revealed a misunderstanding of PASRR requirements, with staff believing that Level 2 PASRRs were only necessary for new admissions or in cases of significant change, rather than when a new mental illness diagnosis was made after admission. The facility's own policy required a Level 2 PASRR for residents with new mental illness diagnoses, but this was not followed. As a result, the facility did not coordinate appropriate assessments or referrals for services as required for residents with newly identified severe mental illnesses.
Failure to Prevent Cross-Contamination During Catheter and Incontinence Care
Penalty
Summary
Staff failed to provide appropriate catheter and incontinence care for multiple residents, resulting in cross-contamination and improper infection control practices. One resident with an indwelling urinary catheter for obstructive uropathy was observed with cloudy, sediment-laden urine and a soiled catheter insertion site. During catheter care, a CNA cleaned the resident's penis in the wrong direction, causing cross-contamination at the catheter insertion site, and failed to adequately clean the soiled catheter. The DON confirmed the improper technique and acknowledged the cross-contamination. Another resident, dependent on staff for all activities of daily living and with a diagnosis of neuromuscular dysfunction of the bladder, received perineal and catheter care from two CNAs. One CNA did not change gloves or perform hand hygiene after cleaning the front perineal area before moving to the rear, and a contaminated drainage bag cover was placed back over the urinary drainage bag after falling to the floor. Barrier cream was not applied after perineal care, contrary to facility policy. The DON confirmed that gloves should have been changed, hand hygiene performed, and a new drainage bag cover used. A third resident, severely cognitively impaired and dependent on staff, was provided incontinence care by two CNAs. After cleansing urine and feces from the resident's buttocks, a clean incontinence brief was applied without changing gloves or performing hand hygiene. The CNA later acknowledged the lapse, and the DON confirmed that hand hygiene should have been performed after incontinence care and before applying a new brief.
Resident Dignity Compromised During Shower Transfer
Penalty
Summary
A resident with diagnoses including Alzheimer's Disease, Anxiety, Schizoaffective Disorder Bipolar Type, and severe cognitive impairment was observed being transported by two CNAs from his room to the shower room while reclined in a mesh slatted shower chair. The resident was only covered by a thin bath blanket, leaving his left shoulder, trunk, buttock, and thigh visible. During this transfer, the resident was pushed past the nurse's station where other residents and staff were present, resulting in exposure. Interviews revealed that staff routinely undressed the resident in his room before transporting him to the shower room, citing the difficulty of transferring him once inside the shower room. The resident's Power of Attorney stated that the resident, a former minister with a history of modesty, would not have appreciated being unclothed in public. The facility's administrator confirmed that residents should be appropriately covered during transfers and that the shower room could accommodate necessary equipment for dressing or undressing. Facility policy requires residents to be treated with dignity and respect, which was not upheld in this instance.
Failure to Complete Required Level 2 PASRR for Resident with Intellectual Disability
Penalty
Summary
The facility failed to obtain a required Level 2 Pre-admission Screening and Resident Review (PASRR) for one resident who was diagnosed with Major Depressive Disorder with recurrent psychotic symptoms and documented as having an Intellectual Disorder. The resident's face sheet confirmed the diagnosis, and the Level 1 PASRR indicated the presence of an Intellectual Disorder. However, there was no documentation that a Level 2 PASRR had been completed for this resident. The administrator stated that the facility had only been completing Level 2 PASRRs when there was a significant change in status and was not aware that a Level 2 PASRR was required for all residents with an Intellectual Disability, as outlined in the facility's own policy.
Incomplete Oxygen Order and Unlicensed Administration
Penalty
Summary
A deficiency occurred when the facility failed to transcribe the complete physician order for oxygen administration for a resident with diagnoses including pneumonia, emphysema, and a stage II sacral pressure ulcer. The physician order sheet for the resident documented oxygen therapy but left the prescribed liter flow rate blank. During an observation, the resident was found in bed with a nasal cannula in place, but the oxygen concentrator was not turned on. The resident reported not receiving oxygen, prompting a certified nursing assistant (CNA) to turn on the concentrator and set the flow rate to two liters per minute. A registered nurse (RN) verbally confirmed the rate from across the bed after the CNA had already set it. The facility's policy requires that only licensed nurses administer oxygen and that physician orders specify details such as when to use, how often, the liter flow, and the delivery method. The administrator confirmed that the order should have included the oxygen rate and that only licensed nurses are permitted to administer oxygen, in accordance with facility policy and standard practice. The failure to transcribe the complete order and to ensure a licensed nurse administered the oxygen led to the deficiency.
Failure to Maintain Call Light Accessibility Resulting in Delayed Pain Management
Penalty
Summary
A deficiency occurred when a resident with a history of pain, osteoporosis, difficulty walking, and muscle atrophy was unable to access her call light and bedside table during the night. The resident, who was cognitively intact, reported that she experienced severe leg pain while in bed and was unable to summon assistance because the call light was out of reach. She attempted to call out for help, but her voice was too soft to be heard, and she did not have a roommate to assist her. As a result, she remained in pain for several hours until the morning, when she reported the incident to a nurse. Documentation showed that the resident had a PRN order for Tramadol for pain, but the nurse who administered the medication in the morning did not document the resident's pain level as required by facility policy. Interviews with staff confirmed that the call light and bedside table were out of reach during the night, and that this information was communicated among staff members. Facility policies required that call lights be accessible at all times and that pain assessments be documented every shift, but these procedures were not followed in this instance.
Failure to Provide Behavioral Health Services and Training Resulting in Resident Injuries
Penalty
Summary
The facility failed to provide necessary behavioral health care and services, as well as behavioral health services training, for a resident with significant behavioral health needs. The resident, who was diagnosed with Alzheimer's Disease, Anxiety, Schizoaffective Disorder Bipolar Type, and violent behavior, was severely cognitively impaired and dependent on staff for all activities of daily living. Despite documented care plan interventions instructing staff to ensure safety and re-approach the resident with different staff when physical behaviors occurred, the resident experienced multiple incidents of combative behavior during care, resulting in several skin tears and minor injuries. These injuries occurred during routine care activities such as bedtime care, transfers, and shower preparation, with staff sometimes failing to follow recommended interventions such as walking away or seeking assistance. Additionally, the facility did not have psychiatric services available until after several of these incidents had occurred, and the resident had not yet been seen by the psychiatric nurse practitioner. Staff had not received training on behavioral health or on providing care for residents with behavioral issues. Furthermore, required follow-up procedures were not consistently followed, as some injuries were not reported or investigated according to facility policy, resulting in missed opportunities for skin evaluations and appropriate notifications. The facility's policy on PASRR was not fully implemented, as recommendations from Level 2 screens and significant changes in status were not consistently incorporated into the care plan.
Failure to Ensure Respect and Dignity for Residents
Penalty
Summary
The facility failed to ensure the right of being treated with respect and dignity for two residents, R1 and R2, as part of an abuse investigation. For R2, the investigation revealed that a Certified Nurse's Assistant (CNA), V4, allegedly made inappropriate comments suggesting that no one liked R2 and that no one wanted to answer R2's call light. Although the abuse was deemed unsubstantiated due to R2's hearing difficulties, R2 reported feeling rushed and uncomfortable with V4's demeanor, describing V4 as unwilling to engage and perform care tasks willingly. The Director of Nursing (DON) acknowledged the issue and had previously educated V4 on communication and care delivery. In the case of R1, the investigation documented that V4 was reported to have entered R1's room frequently, causing discomfort and anxiety. R1 described V4 as having a rude and abrupt manner, making R1 feel disrespected and as if R1 was on V4's time. The Social Service Director and the DON were informed of these concerns, and it was noted that this was the second complaint regarding V4's verbal interactions with residents. Despite the abuse being unsubstantiated, the facility recognized V4's inappropriate communication style, leading to the decision to terminate V4's employment.
Resident Falls from Shower Chair, Sustains Multiple Fractures
Penalty
Summary
The facility failed to safely transport a resident after a shower, resulting in a traumatic fall. The resident, who has a medical history of Spastic Paraplegia, Abnormal Posture, Difficulty in Walking, and Muscle Wasting and Atrophy, is completely dependent on staff for all activities of daily living and uses a wheelchair for mobility. On the day of the incident, a Certified Nurse Aide was moving the resident on a shower chair when a wheel became caught on the shower curb, causing the resident to fall to the ground. This fall resulted in multiple back and neck fractures, requiring emergency medical evaluation and treatment at two hospitals. The resident was diagnosed with six fractures in the thoracic, lumbar, and cervical vertebrae and received intravenous morphine for severe pain at a regional trauma center. The resident remained an inpatient at the trauma center for several days before returning to the facility with orders for analgesic pain medication and a rigid cervical immobilizer. Prior to the fall, the resident had only taken a single dose of acetaminophen for pain in September, but after returning to the facility, the resident required pain medication nearly every day.
Absence of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a Certified Dietary Manager, which has the potential to affect all 80 residents residing in the facility. During the survey conducted from June 4 to June 7, 2024, no Certified Dietary Manager was observed in the dietary department. On June 4, 2024, a dietary aide mentioned that the facility had not had a dietary manager for almost a year. The facility administrator confirmed on June 5, 2024, that the position had been vacant for six months, although an offer had been made to a prospective candidate. The administrator also stated that the Registered Dietician is onsite monthly and reviews resident charts remotely every week, but is not present full-time. The facility does not have a policy mandating a Certified Dietary Manager, but it is acknowledged that one is supposed to be employed.
Unsanitary Kitchen Conditions and Expired Food in LTC Facility
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary condition, which could potentially lead to cross-contamination and food-borne illnesses affecting all 80 residents. During a kitchen tour, several deficiencies were observed, including a commercial ice machine with rust buildup, a rust-covered metal shelf under a leaking coffee maker, and standing water under a juice dispenser with rusted shelves. Additionally, expired food items were found in storage, such as lime juice and instant cheese mix, which were not disposed of in a timely manner. The facility also lacked a cleaning schedule for kitchen equipment, leading to significant grease and charcoal-like buildup on grills, stoves, and ovens. Further observations revealed a rusted and malfunctioning commercial can opener, and a dishwashing station with cracked and chipped caulking. These issues were confirmed by the facility's staff, who acknowledged the need for maintenance and cleaning. The facility's policy on cleaning and sanitizing work surfaces and equipment was not adequately followed, contributing to the unsanitary conditions. The report highlights the facility's failure to adhere to professional standards for food storage, preparation, and equipment maintenance, posing a risk to resident health and safety.
Failure to Maintain Resident Dignity in Toileting and Meal Assistance
Penalty
Summary
The facility failed to honor residents' right to dignity by not providing timely toileting assistance and engaging in inappropriate staff behavior during meal service. A resident, identified as R62, reported having to wait for long periods for staff assistance with toileting, resulting in episodes of incontinence and feelings of humiliation. Despite being continent of bowel and bladder, R62 required assistance from two staff members for transfers and ambulation due to decreased strength. The facility's policy on call light response was not adhered to, as the resident's call light was not answered promptly, leading to the resident being left in soiled conditions. Additionally, during meal service, staff members were observed engaging in personal conversations unrelated to resident care while providing feeding assistance to residents with severe cognitive impairments. Staff, including an MDS Coordinator and CNAs, were noted to be talking amongst themselves about off-work activities, rather than interacting with the residents they were assisting. This behavior was observed across multiple tables in the dining room, with minimal communication directed towards the residents, who were given only short instructions related to eating. The facility's failure to engage with residents during meal times and the delay in responding to toileting needs were acknowledged by the facility's Administrator/Registered Nurse as dignity issues. The facility's Residents' Rights Pamphlet emphasizes the importance of treating residents with dignity and respect, which was not upheld in these instances. The report highlights the need for staff to focus on resident interaction and timely response to care needs to maintain the dignity and quality of life of the residents.
Improper Storage and Maintenance of Respiratory Equipment
Penalty
Summary
The facility failed to maintain and store respiratory equipment in a clean and sanitary manner, affecting four residents who required respiratory or oxygen therapy. The facility's policy mandates that oxygen equipment, such as cannulas, masks, and tubing, should be exchanged every seven days and stored off the floor in a sanitary manner. However, observations revealed that the equipment was not dated when changed and was improperly stored. For instance, one resident's oxygen tubing was found laid over the bed and bed frame without a bag for sanitary storage, while another resident's tubing was on the floor and bed without proper storage. Additionally, a resident's oxygen humidifier bottle was found sitting on a dirty floor, and the nebulizer face mask of another resident was dated several months prior and placed on top of a dirty sock without being stored in a bag. These observations were confirmed by the facility's staff, including a nurse manager and an infection preventionist, who acknowledged that the equipment should be stored in a more hygienic manner and dated appropriately. The failure to adhere to these standards compromised the sanitary conditions required for respiratory care.
Failure to Maintain Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to prevent cross-contamination during meal service by not adhering to proper hand hygiene protocols. This deficiency was observed in multiple instances involving five residents. For instance, a Certified Nurse Aide (CNA) used her bare hands to move food on a resident's plate without using gloves or performing hand hygiene. This resident had a history of Methicillin-Resistant Staphylococcus Aureus (MRSA) and other medical conditions, making infection control crucial. Additionally, a Licensed Practical Nurse (LPN) assisted two residents with eating without using hand hygiene or alcohol-based hand rub (ABHR) between assisting each resident. This included an incident where a piece of food fell onto the LPN's wrist, and the LPN continued to assist another resident without cleaning her hands. Another CNA was observed assisting two residents with their meals, using her hands to reposition herself and then handling a resident's drinking cup without performing hand hygiene. The facility's policy on hand washing, which emphasizes the importance of hand hygiene in preventing the spread of infections, was not followed. These actions demonstrate a failure to adhere to infection prevention protocols, potentially exposing residents to cross-contamination and infection risks.
Failure to Report Alleged Abuse of a Resident
Penalty
Summary
The facility failed to report an allegation of verbal and physical abuse of a resident by a staff member to the Abuse Coordinator. This deficiency involved a resident with medical diagnoses including Postural Kyphosis, Hypertension, Anxiety Disorder, Altered Mental Status, Dysuria, Overactive Bladder, Open Angle Glaucoma, Corneal Edema, and Macular Degeneration. The resident's Power of Attorney alleged that a Certified Nurse Aide was rough during care, yelled at the resident, and left them in wet clothes after a shower. The facility's Administrator was unaware of the incident until a later date, indicating a failure in the reporting process. The Director of Nurses confirmed that the aide received a written warning and was suspended during the investigation, which overlapped with the aide's vacation time. The facility's policy requires immediate reporting of alleged abuse or neglect to the Administrator or Director of Nurses, which was not followed in this case.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to adhere to physician orders for a resident diagnosed with Enterocolitis due to Clostridium Difficile. The resident's care plan required the administration of antibiotics as ordered, specifically Fidaxomicin 200 mg twice daily for ten days. However, the Medication Administration Record (MAR) revealed that the antibiotic was not administered on several occasions, including the PM dose on the day of discharge, and doses on subsequent days. A registered nurse confirmed these omissions, acknowledging that the medication was not given as prescribed. The facility's Medication Administration Policy mandates that medications deemed necessary by the physician should be provided to stabilize the resident's condition.
Failure in Infection Control During Catheter Care
Penalty
Summary
The facility failed to prevent cross-contamination during urinary catheter care for a resident identified as R55. R55 has multiple medical diagnoses, including Parkinson's Disease, Malignant Neoplasm of Prostate, and Bladder-Neck Obstruction, and is dependent on staff for personal hygiene and toileting. On a specific date, a Certified Nurse Aide (CNA), identified as V11, provided urinary catheter care to R55 without changing gloves or performing hand hygiene after the gloves were contaminated with stool. The CNA continued to use the contaminated gloves to clean the urinary catheter tubing, which is a breach of proper infection control practices. The CNA acknowledged the mistake, stating that gloves should have been changed after providing bowel incontinence care and before performing catheter care. The Infection Preventionist (IP), identified as V9, emphasized the importance of hand hygiene in reducing infection risks and confirmed that staff should change gloves when they become contaminated. This incident highlights a failure in adhering to infection control protocols, potentially increasing the risk of infection for the resident.
Failure to Conduct Psychotropic Medication Assessments
Penalty
Summary
The facility failed to complete necessary Psychotropic Medication Assessments for two residents, leading to a deficiency in managing unnecessary medications. One resident, diagnosed with Dementia with Behavioral Disturbances and Depression, was prescribed Citalopram and Olanzapine but had not undergone a Psychopathological Observation in the past year. Another resident, diagnosed with Depression and Generalized Anxiety, was prescribed Buspar and Citalopram but did not receive an Initial Psychopathological Observation upon admission, despite being on these medications. These assessments are crucial for creating a data base for the Care Plan and Gradual Dose Reduction Program, as outlined in the facility's Psychopharmacological Drug Usage Procedure.
Failure to Serve Meals at Palatable Temperature
Penalty
Summary
The facility failed to provide meals at a palatable temperature for two residents, R51 and R52, as observed during a survey. Both residents were on a regular consistency diet as per their Physician Order Sheets. On the day of observation, R51 reported that her food was cold by the time it reached her room, and she only consumed about 10% of her lunch. Similarly, R52 also complained about the cold temperature of her meal, consuming only 25% of it. Both residents expressed dissatisfaction with the cold gravy on their beef cutlet. The deficiency was further highlighted by the actions of staff member V24, who delivered meals to both residents without covering the trays, which likely contributed to the meals being served cold. V24 acknowledged that covering trays could be beneficial, as there were frequent complaints about cold food. The Nurse Manager, V3, confirmed that meal trays should be covered during delivery to maintain temperature, although there was no formal policy in place. This lack of action in covering the food trays led to the residents receiving meals that were not at an appetizing temperature.
Failure to Provide Modified Diet as Ordered
Penalty
Summary
The facility failed to serve a modified diet as ordered for a resident with severe cognitive impairment. The resident's physician order specified a liquidized diet with nectar thick liquids. However, during a meal observation, a Certified Nursing Assistant (CNA) fed the resident pureed food thickened to a nectar consistency and a watered-down tomato soup that was not thickened as required. The resident began coughing immediately and repeatedly after consuming the un-thickened soup. A Licensed Practical Nurse (LPN) present at the scene instructed the CNA to pause feeding. The CNA acknowledged that the tomato soup was too thin and that the kitchen was responsible for thickening the resident's drinks. A cook later admitted to missing the step of thickening the soup while training another cook, despite knowing it was necessary.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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