South Shore Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 2425 East 71st Street, Chicago, Illinois 60649
- CMS Provider Number
- 145977
- Inspections on file
- 45
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 23 (1 serious)
Citation history
Health deficiencies cited at South Shore Rehabilitation during CMS and state inspections, most recent first.
Staff failed to perform hand hygiene between resident contacts during meal service, and the facility did not consistently display Enhanced Barrier Precaution (EBP) signage or provide PPE for residents with wounds, surgical incisions, or indwelling devices. Additionally, clean linens and personal laundry were found on the floor in the laundry area, contrary to infection control policy. These deficiencies affected multiple residents with complex medical needs.
Surveyors found that the facility did not follow its policy for cleaning lint traps in the laundry area, as a dryer was observed with a large amount of lint and the cleaning log was not completed for the day. This failure to adhere to scheduled lint removal and documentation requirements had the potential to affect all residents.
Multiple residents were found to be living in rooms with unrepaired damage, including holes in doors and walls, missing crown molding, and paint chipping. The Maintenance Director was aware of these issues but cited supply limitations, and the Administrator confirmed that maintenance is responsible for repairs and conducts daily rounds to identify such problems.
A resident with severe cognitive impairment and multiple comorbidities was repeatedly observed with their bed in a high position, contrary to the care plan requiring the bed to be in the lowest position, and did not receive quarterly fall risk assessments as required. Additionally, two oxygen tanks were found unsecured in another resident's room, not stored in holders as per facility policy, with staff confirming the correct procedures were not followed.
Surveyors found that several residents with respiratory conditions had their nebulizer masks left uncovered on surfaces instead of being stored in labeled bags as required by facility policy. Staff interviews confirmed awareness of the infection control policy, but the practice was not consistently followed, affecting residents with conditions such as COPD, heart failure, and pneumonia.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
The facility did not complete required PASARR screenings and referrals for two residents with mental health diagnoses, including one with a new diagnosis of schizophrenia and another with delusional disorders. Staff confirmed that necessary assessments were not performed or documented, and that some residents lacked proper PASARR Level 1 screenings due to inconsistent implementation of the electronic submission process.
A resident with a PICC line and cognitive intactness did not receive a scheduled IV Vancomycin dose, despite an LPN documenting its administration on the MAR. The LPN admitted to signing out the medication without giving it, contrary to facility policy, resulting in inaccurate medication records and a failure to meet professional standards.
A resident lost the ability to perform ADLs without a documented medical reason. The facility did not provide evidence that the decline was clinically unavoidable, as required.
Two residents with physical limitations, including one with severe cognitive impairment, were not provided necessary assistance with shaving facial hair. Despite facility policies and care plans requiring staff to help with personal hygiene, both residents were observed with noticeable facial hair and reported that staff had not offered or provided shaving assistance, even after requests. Staff interviews revealed inconsistent practices and a lack of adherence to established procedures, resulting in unmet ADL needs and compromised dignity.
A resident with significant mobility and cognitive impairments was found lying on a low air mattress set to a weight far exceeding their actual weight, contrary to manufacturer guidelines and facility policy. Nursing staff were unaware of the correct protocol, and there was no physician order for the mattress. The improper setting was verified by multiple staff, including a wound care technician and coordinator, who acknowledged that incorrect settings can contribute to pressure ulcer development.
A resident with multiple complex medical conditions became unresponsive and exhibited labored breathing, but staff failed to promptly assess, monitor, and notify the physician as required. Despite several staff observing the resident's deteriorating condition, appropriate interventions and timely physician notification did not occur, resulting in delayed care and the resident's subsequent death.
The facility did not update care plans to include isolation needs for four residents who had active physician orders for contact or contact and droplet isolation precautions. Despite these orders, the care plans lacked documentation or planning for isolation, as confirmed by the DON and in accordance with facility policy.
Staff were unable to access required PPE such as gloves and gowns for residents on enhanced barrier and contact precautions, with multiple instances of empty isolation bins and missing hand sanitizer. The DON confirmed PPE containers had been removed for refilling, leaving staff without necessary supplies. Additionally, a linen cart was found uncovered, contrary to facility policy, and was only covered after being pointed out by an LPN.
Several residents at risk for pressure ulcers were observed without pressure-relieving cushions in their wheelchairs, despite care plans indicating the necessity of such devices. Staff acknowledged the absence of these cushions, which are essential to prevent skin breakdown. Records confirmed the residents' risk for pressure ulcers, highlighting a lapse in adhering to preventative measures.
A resident with severe cognitive impairment and multiple medical conditions sustained a knee fracture due to improper transfer by a CNA who failed to use the required mechanical lift and two-person assistance. The CNA, aware of the policy, transferred the resident alone, leading to the injury. The facility's policy mandates mechanical lifting devices for residents needing two-person assistance to ensure safety.
A resident with dementia and hemiparesis, at moderate fall risk, was improperly placed in a shower chair instead of a shower bed, leading to a fall and fracture. Staff interviews confirmed the resident's inability to sit upright, yet the care plan lacked appropriate interventions until after the incident. The CNA left the resident unattended, resulting in the fall.
The facility did not have a policy for providing required beneficiary notifications, such as NOMNC and ABN, to its residents. Interviews and record reviews revealed that these notices were not given to Medicare residents, and the Social Service Director was unaware of the ABN requirements. The facility's administrator acknowledged the lack of a process for these notifications, affecting 182 residents under Medicare/Medicaid coverage.
The facility's kitchen failed to adhere to food safety and sanitation practices, including a dietary aide not wearing a beard protector, improper labeling and storage of food items, and inadequate refrigerator cleanliness. These deficiencies could impact all residents receiving food from the kitchen.
The facility failed to update its infection prevention and control policies annually, with some dating back to 2006, potentially affecting all residents. Additionally, an LPN did not sanitize a shared blood pressure device between uses on multiple residents, despite having the necessary wipes available. The DON confirmed that sanitization is required to prevent infection spread.
The facility failed to maintain effective pest control, with flying insects observed in resident rooms and common areas. Staff acknowledged the presence of gnats and flies, particularly in summer, and the Maintenance Director noted delays in pest control measures. Pest control reports indicated recurring issues with flies, gnats, and roaches over several months.
The facility failed to provide physician-ordered double portions to several residents, compromising their nutritional care. Observations and interviews revealed that residents prescribed double portions were often served single portions, despite their specific medical and nutritional needs. Staff acknowledged the inconsistency, attributing it to miscommunication, which could lead to inadequate nourishment and potential health issues.
The facility failed to follow medication management policies, including leaving medications at a resident's bedside without authorization, not locking medication carts, and not dating opened medications. Expired medications were also found in storage areas, indicating systemic issues with medication labeling and storage.
An LPN failed to lock the computer screen on the medication cart, leaving three residents' personal medication information visible to passersby in the hallway. The DON confirmed that this action violated the facility's policy on maintaining privacy and confidentiality of residents' medical records.
The facility failed to ensure call lights were within reach for two residents, leading to unmet needs and potential delays in care. One resident, unable to get out of bed without assistance, had their call light on the floor, while another resident with mobility issues had their call light placed out of reach. Staff acknowledged the oversight and repositioned the call lights as per facility policy.
A facility failed to obtain a physician order for a resident's code status, despite the resident being identified as DNR on the POLST form. The Social Service Director and Director of Nursing acknowledged the need for a physician's order, but the physician order sheet lacked this documentation. The resident's care plan indicated a DNR status, but the facility did not follow its policy to secure the necessary physician orders.
A facility failed to complete a Quarterly MDS assessment for a resident with multiple diagnoses, including diabetes and schizophrenia, within the required timeframe. The last assessment was completed in early February, and the next was due in early May but was not done on time. Staff acknowledged the delay, which could potentially affect care and reimbursement. The facility's policy requires assessments to be completed within specific timelines, which were not followed in this instance.
The facility failed to transmit MDS records to the CMS system within the required timeframes for three residents, affecting their care plans and reimbursement. Despite following RAI guidelines, the MDS assessments were submitted late, violating the facility's policy on timely completion and transmission.
A facility failed to conduct a PASRR for a resident diagnosed with bipolar disorder, as required by their Pre-Admission Assessment Policy. The resident's MDS assessment did not indicate a serious mental illness, despite the admission record showing a diagnosis of bipolar disorder. The facility provided an outdated PASRR from another facility and did not have a current PASRR for the resident's recent admission. The Admissions Director noted that the previous director should have completed the PASRR prior to the resident's transfer.
A resident with multiple chronic conditions, including paraplegia, was left in a soiled state for several hours despite requesting assistance. The CNA was unable to provide timely incontinence care due to other duties, resulting in the resident's brief being heavily soiled and leaking onto the bedsheet. The facility's policy requires incontinence care every two hours, which was not followed.
The facility failed to provide proper respiratory care by not storing oxygen and nebulizer masks in bags, not following oxygen flow rate orders, and not using humidifier bottles with oxygen concentrators. A resident's nasal cannula was found on the floor, and another resident's nebulizer tubing was overdue for replacement. The Director of Nursing confirmed the importance of following physician orders and infection control protocols.
A resident with a history of strokes did not receive a timely speech therapy evaluation despite a physician's order. The facility's Director of Rehabilitation Services initially claimed a screening was done, but later admitted evaluations are not conducted for residents on a regular diet. The resident's presentation indicated a need for evaluation, which was delayed until much later, contrary to facility policy.
The facility did not follow its policy for timely education and administration of the pneumococcal vaccine for two residents. The Infection Prevention Nurse failed to document education, consent, or declination for one resident, and another resident who consented did not receive the vaccine. The facility's process involves periodic vaccine clinics, but staff must administer vaccines for new admissions, leading to a lapse in vaccination.
The facility failed to ensure shower room safety by not maintaining non-skid tape on floor tiles, posing a risk to residents. Observations revealed missing or peeling non-skid tape in multiple shower rooms, with the Maintenance Director unaware of the issue due to a lack of supplies and incomplete reporting processes. The DON confirmed the necessity of non-skid surfaces to prevent slips, but no work orders for repairs were available.
The facility failed to maintain the privacy and dignity of two residents by not covering their urine collection bags, which were visible from the hallway. Observations revealed that the bags were not placed inside privacy bags as required by the facility's policy. Both the Case Manager and an LPN acknowledged the oversight, and the DON confirmed the necessity of covering the bags to promote dignity.
The facility failed to ensure proper labeling, physician ordering, and secure storage of inhaler medications for two residents. An LPN found an unlabeled inhaler and Latanoprost tubes on a resident's over-bed table without a physician's order. Similarly, another resident had an unlabeled inhaler with no order found. The facility's policy requires medications to be stored securely and labeled properly, accessible only to authorized personnel.
A resident reported sexual abuse by a CNA during incontinence care, but the facility failed to immediately report the allegation and remove the CNA, leading to further trauma for the resident. The resident had previously expressed discomfort with the CNA, but this was not escalated. The CNA continued to work until the police intervened, highlighting lapses in the facility's abuse reporting and prevention procedures.
Failure to Follow Infection Control Protocols and Maintain Precaution Signage
Penalty
Summary
The facility failed to follow established infection prevention and control protocols in several key areas, as observed through direct staff actions and environmental conditions. Staff did not consistently perform hand hygiene between resident contacts during meal service. For example, an activity aide and a CNA were observed setting up food trays and assisting residents without sanitizing their hands between tasks, despite facility policy and staff acknowledgment that hand hygiene is required after contact with residents or their wheelchairs. This lapse was noted during meal service for multiple residents with severe cognitive impairment and complex medical conditions, such as hemiplegia, epilepsy, and malnutrition. The facility also failed to properly implement and display Enhanced Barrier Precaution (EBP) signage and provide necessary personal protective equipment (PPE) for residents requiring these precautions. Several residents with wounds, surgical incisions, or indwelling medical devices did not have EBP signs posted on their doors, and PPE bins were not always available as required. In some cases, EBP orders were delayed or not in place upon admission, and signage was missing or removed without immediate replacement. Staff interviews confirmed that the expectation is for clear signage and PPE availability to inform staff of required precautions, but these measures were not consistently followed. Additionally, the facility did not maintain sanitary conditions in the laundry area. Clean linens and personal laundry were observed on the floor, and staff acknowledged that this practice is not permitted due to the risk of cross-contamination. Facility policies require that all linens and personal laundry be handled, stored, and transported in a manner that prevents the spread of infection, but these procedures were not adhered to during the survey. These failures affected multiple residents with complex medical needs and placed all residents at risk for the spread of infection.
Failure to Maintain Lint Trap Cleaning in Laundry Area
Penalty
Summary
Surveyors observed that the facility failed to empty the lint compartment and lint filter in one of the dryers in the laundry area. During a tour with the Housekeeping Director, a large amount of lint was found in dryer number 1's lint compartment, which had not been emptied as required. The Housekeeping Director confirmed that laundry staff are expected to check and empty lint traps every two hours, and that this process should be documented in a logbook. However, on the day of the survey, the lint trap cleaning logbook showed no staff signatures or completion for that date. Facility policy requires that lint removal and cleaning schedules for laundry equipment be documented, posted, and adhered to, with monthly quality assurance audits conducted by the Environmental Services Director. The job description for Laundry Aides also specifies strict adherence to health and safety rules. Despite these policies, the lack of documentation and observed accumulation of lint indicated that the required procedures were not followed, potentially affecting all 198 residents in the facility.
Failure to Maintain Safe and Homelike Environment Due to Unrepaired Physical Damage
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple instances of physical damage and disrepair in resident rooms. Specifically, one resident's bathroom door had a hole in the middle and another hole covered with a white substance, while two other residents' walls behind the head of their beds were missing crown molding and had paint chippings. Additionally, another resident's wall had a large hole. These deficiencies were directly observed by surveyors during their inspection. Interviews with facility staff revealed that the Maintenance Director was aware of the needed repairs but was limited by the availability of supplies, as the facility had discontinued its contract with a previous supplier and now relied on purchasing supplies from a retail store. The Administrator confirmed that staff are expected to submit work orders for repairs and that maintenance is responsible for addressing these issues, conducting daily rounds to identify problems. Facility policies and job descriptions reviewed by surveyors indicated that maintenance is responsible for timely repairs and coordination with outside vendors if necessary.
Failure to Implement Fall Precautions and Proper Oxygen Tank Storage
Penalty
Summary
The facility failed to implement a care planned fall precaution intervention for a resident with multiple comorbidities, including dementia, reduced mobility, and severe cognitive impairment. The resident was observed on multiple occasions lying in bed with the bed height visibly elevated, approximately 2.5 feet from the floor, despite the care plan specifying that the bed should be in the lowest position when the resident is lying in bed. The bed controller was consistently out of the resident's reach, and staff incorrectly stated that the resident was care planned for a high bed, which was not documented in the care plan. Additionally, the facility failed to perform the resident's fall risk assessment on a quarterly basis as required, with the most recent assessments not aligning with the expected schedule. The facility's own policy requires fall risk evaluations upon admission, quarterly, annually, and with significant changes in condition, and mandates individualized fall precautions for residents at risk. The policy also emphasizes the importance of maintaining an environment free from hazards and providing appropriate supervision. Interviews with staff confirmed that the bed should be kept in the lowest position to minimize injury in the event of a fall, and that regular fall risk assessments are necessary to identify changes in residents' needs. In a separate incident, the facility failed to secure a resident's oxygen tanks in a proper holder. Two oxygen cylinders were observed leaning against the wall in a resident's room, not placed in a holder as required by facility policy. Staff confirmed that oxygen tanks should not be free-standing and must be stored in a holder or on a designated rack to prevent accidents. The improper storage of oxygen tanks was acknowledged by multiple staff members, including the DON, who stated that the purpose of using a holder is to ensure resident safety.
Failure to Contain Nebulizer Masks per Infection Control Policy
Penalty
Summary
The facility failed to properly contain nebulizer masks for four residents who required respiratory care, as observed during a survey. The facility's policy requires that nebulizer masks be placed in a labeled bag when not in use to prevent contamination. However, surveyors observed that the nebulizer masks for several residents were left uncovered on nightstands or other surfaces, rather than being stored in bags as required by policy. Residents affected by this deficiency had significant medical histories, including chronic pulmonary embolism, asthma, chronic obstructive pulmonary disease (COPD), heart failure, and pneumonia. For example, one resident with asthma and pulmonary embolism had their nebulizer mask left on the nightstand without a bag. Another resident with COPD, pleural effusion, and heart failure also had their nebulizer mask left uncovered. Staff interviews confirmed that the masks should have been contained in bags for infection control, and staff acknowledged awareness of the policy but did not consistently follow it. Additional observations included a resident with pneumonia and moderate cognitive impairment whose nebulizer mask was left on a bedside table, and another resident with COPD and a heart assist device whose mask was placed on top of their LVAD, not in a bag. Staff, including nurses and the Director of Nursing, confirmed that the masks should be stored in plastic bags to prevent contamination, but this was not done for the residents observed.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals within the facility.
Failure to Complete Required PASARR Screenings and Referrals for Residents with Mental Disorders
Penalty
Summary
The facility failed to refer two residents for appropriate PASARR (Preadmission Screening and Annual Resident Review) evaluations and did not perform additional screening for one resident diagnosed with a new mental disorder. For one resident, the initial OBRA screening did not indicate any mental illness or developmental delay at admission, but subsequent medical records showed a diagnosis of schizophrenia and the use of antipsychotic medication. Despite this new diagnosis, the facility did not have a PASARR Level 2 evaluation in the resident's chart, and staff interviews confirmed that a referral for further assessment should have been made but was not completed. Another resident's admission record included multiple diagnoses, such as dementia and delusional disorders, but the only available documentation was an older interagency certification that did not specify the resident's physical or mental condition or required level of services. Staff confirmed that this document was not equivalent to a PASARR Level 1 screening and that no such screening had been completed for this resident. The facility's admissions and social services staff acknowledged that every resident should have a PASARR Level 1 screening and that the process for electronic submission had only recently been implemented, leaving some residents without proper screening. Facility policy required preadmission screening and resident review prior to admission and updates as needed, with responsibility assigned to the admissions director and administrator. However, interviews and documentation revealed that these procedures were not consistently followed, resulting in the lack of required PASARR screenings and referrals for residents with mental health diagnoses or changes in condition.
Failure to Accurately Document and Administer IV Medication
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) signed out an intravenous (IV) medication, Vancomycin HCL, as administered to a resident, but did not actually give the medication. The resident, who had a peripherally inserted central catheter (PICC) and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, reported not receiving the IV medication at the time it was documented as given. The Medication Administration Record (MAR) and Medication Administration Audit Record (MAAR) both indicated that the medication was administered at 10:01 am, but the resident stated at 1:00 pm that the medication had not been received. The LPN confirmed during an interview that the medication was signed out but not administered, and acknowledged that medications should only be signed out after they are given to prevent errors. The Director of Nursing (DON) also stated that facility policy requires medications to be signed out immediately after administration, and not before. The facility's policies and job descriptions for both LPNs and RNs specify that medications must be administered and recorded in accordance with physician orders and regulatory requirements. The failure to follow these procedures resulted in inaccurate documentation and a failure to meet professional standards of quality for medication administration.
Failure to Prevent Unnecessary Loss of ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their ADL abilities unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through observations and record reviews that did not show appropriate justification for the decline in residents' functional abilities.
Failure to Assist with Personal Hygiene and Shaving
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically personal hygiene related to shaving facial hair, for two residents. One resident with severe cognitive impairment and physical limitations was observed with medium-length chin hair and stated she was aware of the hair but could not remove it herself, and no staff had offered to assist her despite her desire to have it removed. Staff interviews indicated that shaving is supposed to be offered during showers or when facial hair is noticed, but this was not done in this case. Facility procedures and care plans documented the need for staff to provide total assistance with shaving for this resident. Another resident, who was cognitively intact but had physical limitations, was observed with a moderate amount of facial hair and reported repeatedly asking staff for assistance with shaving, but staff had not provided the service. Staff interviews revealed inconsistent practices, with some staff stating that shaving is done as needed or when time allows, and that a wound care technician sometimes performs shaving but is rarely available. Facility policies and job descriptions require staff to assist residents with personal hygiene, including shaving, but these were not followed, resulting in unmet care needs and a lack of dignity for the affected residents.
Failure to Maintain Correct Air Mattress Setting for Pressure Ulcer Prevention
Penalty
Summary
A deficiency was identified when a resident was observed lying on a low air mattress with the pump set to a weight setting significantly higher than the resident's actual weight. The air mattress pump was set past 360 pounds on the 'Firm' setting, while the resident's documented weight was 150.8 pounds. Nursing staff, including an RN, verified the incorrect setting and stated they were unaware of the facility's protocol for air mattress settings. The wound care technician confirmed that only specific staff members are authorized to change the air mattress settings and acknowledged that an incorrect setting could contribute to the development of pressure ulcers. The wound care coordinator further explained that low air mattresses are intended to promote wound healing and that improper settings can lead to wound decline. The resident in question had multiple diagnoses, including cerebral infarction, hemiplegia, mild neurocognitive disorder, and dysphagia, and was dependent on staff for all activities of daily living. The care plan identified a risk for skin integrity issues due to self-care deficits, impaired mobility, and comorbidities, and included interventions such as the use of a pressure redistribution mattress and frequent repositioning. Despite these interventions, there was no physician order for the low air mattress, and facility policy specified that such mattresses are to be used for residents with certain types of pressure ulcers. The manufacturer's manual indicated that the mattress should be set according to the resident's weight, which was not followed in this case.
Failure to Promptly Assess and Intervene for Resident's Change in Condition
Penalty
Summary
The facility failed to promptly assess, monitor, identify, and intervene for a resident who experienced a significant change in condition, transitioning from being responsive and communicative to unresponsive. The resident had multiple complex diagnoses, including heart failure, paroxysmal atrial fibrillation, hyperlipidemia, hemiplegia, shortness of breath, acute embolism and thrombosis of deep veins, type 2 diabetes, schizophrenia, and epilepsy. Despite these risk factors, staff did not take immediate and appropriate action when the resident became unresponsive and exhibited labored breathing. Multiple staff members observed and reported the resident's deteriorating condition throughout the day. A CNA was instructed by an LPN to sit with the resident and repeatedly call their name to keep them awake, despite the resident's labored breathing and unresponsiveness. The LPN noticed the resident was sweating and reported a change in condition to the wound care coordinator, who advised monitoring the resident but did not assess the resident in person or notify the physician. Another nurse observed the resident as lethargic and unresponsive, communicated this to the wound care coordinator, and was told to obtain vital signs and inform the physician, but there was no evidence that the physician was notified at that time. Documentation shows that the resident's physician was not notified of the change in condition until much later, and there was no record of timely assessment or intervention prior to the resident's transfer to the hospital. When paramedics arrived, the resident was in cardiac arrest and subsequently expired. The facility's own policies required prompt assessment and physician notification for acute changes in condition, but these protocols were not followed, resulting in a delay in care for the resident.
Failure to Update Care Plans for Residents on Isolation Precautions
Penalty
Summary
The facility failed to update and document care plans to accurately reflect the isolation needs of four residents who had active physician orders for contact or contact and droplet isolation precautions. Record reviews showed that, despite these orders, the care plans for each of these residents did not include information or planning related to their isolation requirements during their stay. The Director of Nursing confirmed that care plans should be updated to reflect isolation status when applicable. Facility policy also requires that care plans be revised as changes in a resident's condition dictate, including the need for isolation precautions.
Failure to Ensure PPE Availability and Proper Linen Handling
Penalty
Summary
The facility failed to ensure that personal protective equipment (PPE) was readily available for staff use when providing care to residents requiring enhanced barrier precautions and transmission-based precautions. Observations revealed that enhanced barrier precaution signs were posted on several residents' doors, but no PPE was accessible outside these rooms. Staff confirmed the absence of PPE, stating they would be unable to provide care without it. In multiple instances, isolation bins for residents on contact precautions were found to be missing gloves and hand sanitizer, with staff having to search for or relocate the last available box of gloves from other locations, leaving other areas without necessary supplies. The Director of Nursing acknowledged that PPE containers had been removed for refilling, resulting in their unavailability at the point of care. Additionally, the facility failed to maintain proper linen handling practices, as a linen cart was observed uncovered on the first floor. A nurse confirmed that the cart should always be covered to keep linens clean and reduce exposure to germs, and subsequently covered the cart upon observation. Review of facility policies confirmed requirements for PPE use and linen handling but did not specify procedures to ensure PPE availability at the point of care.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions as outlined in the care plans for residents at risk for pressure ulcers. During observations, several residents were found sitting in wheelchairs without the required pressure-relieving cushions, which are essential to prevent skin breakdown and pressure ulcers. Specifically, residents R2, R3, R4, R5, R6, and R7 were observed without these cushions, despite their care plans indicating the necessity of such devices due to their risk of developing pressure ulcers. Staff members, including a CNA, a Unit Manager, a Wound Care Technician, and a Wound Care Nurse, acknowledged the absence of the cushions and the need for them to prevent pressure ulcers. The records for each resident confirmed their risk for pressure ulcers, with assessments and care plans explicitly stating the need for pressure-reducing devices in their wheelchairs. The facility's policy on pressure ulcer prevention also mandates regular audits of care plans and the implementation of preventative measures based on residents' clinical conditions. However, the failure to provide the necessary cushions as per the care plans and policy indicates a lapse in adhering to these preventative measures, potentially affecting the residents' skin integrity and increasing their risk for pressure ulcers.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to adhere to its policy regarding the safe transfer of residents, resulting in a significant injury to a resident. The incident involved a resident who was severely cognitively impaired and dependent on assistance for activities of daily living, including transfers. The resident, who had multiple medical conditions including osteitis deformans and chronic kidney disease, required a mechanical lift device with two-person assistance for transfers. However, a newly hired CNA improperly transferred the resident alone, without using the mechanical lift device, leading to a fracture of the resident's right knee. The Director of Nursing (DON) was informed of the incident after the resident complained of knee pain, and an x-ray confirmed a fracture. The investigation revealed that the CNA, aware of the requirement for a mechanical lift and two-person assistance, chose to pivot the resident into a chair without assistance. This action was against the facility's policy, which mandates the use of mechanical lifting devices for residents needing two-person assistance to ensure safety and prevent injuries. The CNA involved in the incident did not return to the facility after being informed of the investigation and was unreachable for further statements. The facility's policy on safe lifting and movement of residents clearly states that mechanical lifting devices must be used for any resident needing a two-person assist, except in emergencies. The failure to follow this policy directly resulted in the resident's injury, highlighting a critical lapse in adherence to established safety protocols.
Inadequate Supervision and Equipment Use Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and use appropriate shower equipment for a resident, resulting in a fall and injury. The resident, who had medical diagnoses including dementia, seizures, cerebral infarction, hemiplegia, and hemiparesis affecting the right side, was at moderate risk for falls. Despite this, the resident was placed in a shower chair, which was inappropriate given their poor trunk control and inability to sit upright. This led to the resident falling out of the shower chair and sustaining a closed nondisplaced fracture of the greater trochanter of the right femur. Interviews with staff revealed that the resident's baseline status required the use of a shower bed rather than a shower chair due to their inability to sit up independently. On the day of the incident, a CNA left the resident unattended in the shower chair while retrieving linens, during which time the resident fell. The facility's care plan did not include the necessary intervention of using a shower bed until after the fall occurred. The facility's failure to adhere to appropriate care protocols and provide necessary supervision directly contributed to the resident's fall and subsequent injury.
Failure to Provide Required Beneficiary Notifications
Penalty
Summary
The facility failed to implement a policy and procedure for providing beneficiary notifications, specifically the Notice of Medicare Non-Coverage (NOMNC) and the Advanced Beneficiary Notice (ABN), to its residents. This deficiency was identified during interviews and record reviews, revealing that the facility did not provide these notices to Medicare residents, as required. The Social Service Director (SSD) admitted that NOMNCs were only given to managed care or insurance residents and was unaware of the ABN requirements. The Social Service Consultant confirmed that there was no established process for issuing these notifications. The review of records showed that no NOMNC or ABN had been provided to residents discharged from Medicare-covered Part A stays in the past six months. The facility's administrator acknowledged the absence of a process for beneficiary notifications and stated that the facility would adhere to CMS guidelines in the future. The facility's census indicated 182 residents under Medicare/Medicaid coverage, with 16 residents discharged without receiving the necessary notifications. The facility was unable to provide a policy or procedure for these notifications, highlighting a significant oversight in compliance with Medicare requirements.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in its kitchen, as observed during a survey. A dietary aide was seen in the kitchen without a beard protector, despite having facial hair, which is against the facility's policy requiring all kitchen staff with facial hair to wear beard coverings to prevent food contamination. The dietary manager confirmed the availability of beard guards and acknowledged the requirement for their use. Additionally, the facility did not adhere to proper labeling and storage protocols for food items. Several opened food items, including balsamic vinaigrette dressing and barbeque sauce, were found without opened or use-by dates, making it difficult to track their freshness and safety. Spices in the kitchen were also improperly labeled, with some containers missing use-by dates and others showing signs of age and wear, indicating they were past their recommended usage period. The facility's kitchen was also found to be inadequately maintained, with cleanliness issues noted in the refrigerator. A thermometer inside the refrigerator was covered in black spotted material, and the fan cover had visible black spots, suggesting a lack of regular cleaning. An opened bag of pureed bread mix was improperly stored, and a container of lemon juice was left unrefrigerated despite manufacturer instructions to refrigerate after opening. These lapses in food safety and sanitation practices have the potential to affect all residents receiving food from the facility's kitchen.
Infection Control Policy and Equipment Sanitization Deficiencies
Penalty
Summary
The facility failed to update its infection prevention and control policies annually, with some policies dating back to as far as 2006. This oversight was identified during a review of the facility's infection control policies, which included outdated protocols for various procedures such as blood and body fluid exposure, cleaning spills, and standard precautions. The Infection Prevention Nurse acknowledged that the policies were sent by a corporate consultant, and the Director of Nursing confirmed that policy reviews are conducted at the corporate level. This failure to update policies has the potential to affect all residents at the facility. Additionally, the facility did not ensure that shared medical equipment was sanitized between uses during medication administration. An LPN was observed using a manual blood pressure device on multiple residents without sanitizing it between uses. The LPN admitted to forgetting to sanitize the device, despite having the necessary wipes available. The Director of Nursing stated that nurses are required to sanitize all shared medical equipment before and after each use to prevent the spread of infections. This lapse in protocol was observed with three residents during the survey.
Pest Control Deficiency Due to Inadequate Measures
Penalty
Summary
The facility failed to maintain effective pest control, as evidenced by the presence of flying insects in resident rooms and common areas. Observations were made of flying insects in various locations, including a conference room, a ground floor hallway, and on a resident's bed linen. Staff interviews revealed that the presence of gnats and flies was a known issue, particularly during the summer months. A Licensed Practical Nurse mentioned efforts to quickly remove food trays to prevent fruit flies, while a Certified Nurses Aide and a Housekeeping staff member acknowledged seeing flies and gnats. The Maintenance Director confirmed that an outside pest control vendor visits every two weeks, but noted delays in addressing the issue. The pest control reports from the outside agency indicated recurring issues with flies, gnats, and occasionally roaches in different areas of the facility. These reports documented sightings of fruit flies and gnats in resident rooms, dining rooms, and the kitchen over several months. Despite the facility's pest control guidelines, the ongoing presence of pests suggests that the measures in place were insufficient to effectively manage the problem. The Director of Housekeeping acknowledged the issue and mentioned recent discussions to address it, but no immediate corrective actions were noted in the report.
Failure to Provide Physician-Ordered Double Portions
Penalty
Summary
The facility failed to provide physician-generated diet orders for several residents, leading to deficiencies in nutritional care. Observations revealed that residents who were prescribed double portions as part of their diet orders were not consistently receiving them. For instance, Resident 110, who was observed eating lunch, received only single portions despite a meal ticket indicating double portions. Similar discrepancies were noted for Residents 75, 15, 7, and 152, all of whom were supposed to receive double portions but did not. Interviews with staff, including a Dietary Aide and the Dietary Manager, confirmed the inconsistency in serving double portions. The Dietary Aide acknowledged that trays meant for double portions contained only single portions. The Dietary Manager stated that a double portion diet should include double servings of meat, vegetables, and starch, but this was not being followed due to miscommunication. The Registered Dietitian emphasized the importance of adhering to diet orders, noting that failure to provide double portions could lead to inadequate nourishment and potential health issues for the residents. The report highlights specific medical conditions and nutritional needs of the affected residents, such as Resident 110's vascular wound requiring increased calorie and protein intake for healing, and Resident 15's need for weight gain due to a low BMI and history of weight loss. Despite these documented needs and physician orders, the facility's failure to provide the prescribed double portions compromised the residents' nutritional care.
Medication Management Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards and facility policies regarding medication management. During an inspection, it was observed that medications were left at the bedside of a resident without a care plan or provider order for self-administration. Additionally, a Licensed Practical Nurse (LPN) left a medication cart unlocked multiple times while administering medications, which was against the facility's policy that requires medication carts to be locked when not attended. The inspection also revealed that several opened multi-dose medications, including insulin vials and eye drops, were not properly dated, which is necessary to ensure they are discarded after the recommended period. This was observed across multiple medication carts and storage rooms, indicating a systemic issue with labeling and dating medications upon opening. Furthermore, expired medications were found in the medication storage areas, which should have been removed and destroyed according to the facility's policy. The Director of Nursing acknowledged the importance of dating medications once opened to prevent the use of expired medications, which could lead to adverse reactions in residents. The facility's policies clearly state that medications should be stored securely and administered only by authorized personnel, and that opened medications should be labeled with a new expiration date. However, these policies were not followed, leading to the deficiencies noted during the survey.
Failure to Protect Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure privacy and confidentiality of residents' personal medication administration records for three residents. During a medication administration observation, a Licensed Practical Nurse (LPN) left the computer screen on the medication cart unlocked and displaying personal medication information for three residents at different times. The screen was visible to anyone passing by in the hallway. The LPN acknowledged forgetting to lock the computer screen, which is necessary to protect residents' personal information. The Director of Nursing confirmed that the computer screen should always be locked to maintain resident privacy and confidentiality, as per the facility's policy on dignity and resident rights.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that residents' call lights were within reach, affecting two residents out of a sample of 36. One resident, identified as R171, was observed lying in bed with the call light on the floor, making it inaccessible. R171, who is cognitively intact with a BIMS score of 13, expressed that they cannot get out of bed without assistance and sometimes have to scream for help when the call light is unreachable. A Certified Nursing Assistant (CNA) confirmed the call light should not be on the floor and acknowledged the potential problem of unmet needs. The Director of Nursing (DON) also stated that it is expected for staff to ensure the call light is within reach to prevent delays in care. Another resident, R43, who has a medical history of difficulty walking, repeated falls, and reduced mobility, was found sitting in a wheelchair with the call light out of reach. The call light cord was placed on a chair on the opposite side of the bed, making it inaccessible. R43, who has a care plan focusing on fall prevention and assistance with ambulation, was unable to call for help and requested the surveyor to refill their water pitcher. A CNA acknowledged the call light should be within reach and repositioned it accordingly. The facility's policy, last revised in 2008, states that call lights should be within easy reach when residents are in bed or confined to a chair.
Failure to Obtain Physician Order for Resident's Code Status
Penalty
Summary
The facility failed to obtain a physician order for the code status of a resident, identified as R109, who was reviewed for advance directives. The resident was admitted with multiple diagnoses, including spinal stenosis, chronic obstructive pulmonary disease, and paraplegia, among others. During an interview, the Social Service Director (V3) acknowledged that they were assisting the resident and family with advance directives, including code status, which requires a physician's order. However, upon reviewing the physician order sheet with V3, it was found that there was no code status order for R109, despite the resident being identified as DNR (Do Not Resuscitate) on the POLST form. The Director of Nursing (V2) confirmed that a resident's code status, whether full code or DNR, should have a physician's order and be maintained in the resident's health record. The care plan dated shortly after admission documented that R109 had a DNR advance directive. However, the physician order sheet reviewed on a later date still showed no order for code status. The facility's policy on advance directives indicated that any changes or revisions should involve contacting the resident's attending physician to secure appropriate orders, which was not done in this case.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (MDS) assessment for a resident, identified as R124, within the regulatory timeframe. R124 was admitted with multiple diagnoses, including Type 2 diabetes mellitus, major depressive disorder, anemia, schizophrenia, bipolar disorder, and dysphagia. The last quarterly assessment for R124 was completed on February 4, 2024, and the next assessment was due approximately 92 days later, around the first week of May 2024. However, the assessment was not completed on time, and the facility acknowledged that the quarterly assessment was late. Interviews with the MDS Director and the Reimbursement Specialist revealed that the MDS assessments are crucial for developing care plans and for reimbursement purposes. They follow the Resident Assessment Instrument (RAI) guidelines, which require the assessment to be completed within 14 days from the Assessment Reference Date (ARD) and transmitted within another 14 days. The failure to complete the assessment on time could potentially delay care and payment, as noted by the staff. The facility's policy, dated October 2023, outlines the required timeline for completing the quarterly assessments, which was not adhered to in this case.
Failure to Timely Transmit MDS Records
Penalty
Summary
The facility failed to electronically transmit Minimum Data Set (MDS) records to the CMS system within the required timeframes for three residents. The residents involved were admitted with various medical conditions, including diabetes, dementia, and heart failure. The MDS assessments, which are crucial for developing care plans and ensuring proper reimbursement, were not transmitted within the 14-day period following their completion. This delay in transmission was identified for a quarterly assessment, an annual assessment, and an admission assessment for the respective residents. The MDS Director and Reimbursement Specialist acknowledged the importance of timely MDS assessments and transmissions, as they are essential for care planning and payment purposes. Despite following the Resident Assessment Instrument (RAI) guidelines, the facility did not meet the regulatory timeframes, resulting in late submissions. The facility's policy outlined specific deadlines for MDS completion and transmission, which were not adhered to in these cases, leading to the identified deficiency.
Failure to Conduct PASRR for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to conduct a Preadmission Screening and Resident Review (PASRR) for a resident, identified as R101, who was part of a sample of 36 residents reviewed for PASRR compliance. The deficiency was identified through interviews and record reviews. R101's Admission Minimum Data Set (MDS) assessment, dated August 10, 2023, indicated that the resident was not considered to have a serious mental illness. However, the resident's Admission Record documented a medical diagnosis of bipolar disorder with an onset date of July 28, 2023. Despite multiple requests from the surveyor on July 23 and 24, 2024, the facility failed to provide a PASRR related to R101's admission on July 28, 2023. Instead, the facility provided an outdated pre-admission screening from January 10, 2021, which was directed to another facility. The Admissions Director, who started at the facility in October 2023, stated that R101 was a transfer from another long-term care facility and that the previous Admission Director should have completed the PASRR prior to the transfer or admission. The facility's Pre-Admission Assessment Policy from March 2016 requires a PASRR to be conducted prior to admission to determine the appropriate level of service.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as R109, who required assistance with toileting. R109, who was admitted with multiple diagnoses including paraplegia and chronic conditions, was observed to be alert and oriented but expressed dissatisfaction with the care received. On the morning of the observation, R109 reported being left in a soiled state since 3 AM and had requested assistance after breakfast around 8 AM. Despite activating the call light, the resident remained unchanged for approximately two hours until a Certified Nursing Assistant (CNA) and a Medical Records staff member attended to him. Upon observation, the resident's incontinence brief was heavily soiled, and the soiling had leaked onto the bedsheet. The CNA, identified as V14, acknowledged that incontinence care should be performed at least every two hours and as needed to prevent skin breakdown. However, she was unable to attend to R109 promptly due to other duties, such as picking up breakfast trays and assisting another resident. This was the first incontinence care provided to R109 during V14's shift, which began at 6 AM. The Director of Nursing confirmed that staff are expected to conduct regular rounds and provide incontinence care at least every two hours. The facility's policy on perineal care emphasizes the importance of cleanliness, comfort, and skin condition observation, which was not adhered to in this instance.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to ensure proper respiratory care for residents, as evidenced by several observations and interviews. One resident was observed with an oxygen mask on the bedside table, not stored in a plastic bag as required by facility policy. A Certified Nurses Aide confirmed that unused oxygen masks and cannulas should be wrapped in a plastic bag. Additionally, the same resident's nasal cannula was found on the floor with the oxygen machine running, and a Licensed Practical Nurse noted the need to replace the cannula and check the resident's oxygen saturation, which was at ninety-one percent. Another resident's nebulizer mask was found uncovered on a side table after a treatment, contrary to the facility's policy that requires such equipment to be stored in a bag to prevent contamination. An Agency LPN admitted to not placing the mask in a bag after use. The Director of Nursing confirmed that it is the nurse's responsibility to ensure the mask and tubing are bagged for infection control. Furthermore, the nebulizer tubing was overdue for replacement, having been dated nine days prior, while the policy mandates weekly changes. A third resident was observed receiving oxygen at a higher flow rate than ordered, without a humidifier bottle attached to the concentrator. The LPN was unaware of the correct order and confirmed the discrepancy upon checking. The Director of Nursing emphasized the importance of following physician orders and using a humidifier bottle to prevent dry air. The resident's care plan specified oxygen therapy related to congestive heart failure, with orders to maintain oxygen saturation at ninety-two percent or greater.
Failure to Provide Timely Speech Therapy Evaluation
Penalty
Summary
The facility failed to provide a speech therapy evaluation for a resident, identified as R176, despite having a physician's order for such services. The order for speech therapy to evaluate and treat was written on May 22, 2024, and signed by the physician on June 19, 2024. However, by July 23, 2024, the resident had not received the speech therapy evaluation. The Director of Rehabilitation Services initially stated that a speech therapy screening was performed and an evaluation was not indicated, but later admitted that the facility does not conduct evaluations for residents on a regular diet, which was the case for R176. The resident, R176, who had a history of multiple strokes, expressed uncertainty about receiving speech therapy, although they had attended physical therapy sessions. The Director of Rehabilitation Services mentioned that speech therapy screenings are not documented in the electronic health record but are kept in paper format. Upon further review, it was revealed that the speech therapy screening tool recommended an evaluation based on the resident's presentation, which included deficits in attention, speech, and language. Despite this, the evaluation was delayed until July 25, 2024. The facility's policy on rehabilitation screens indicates that screenings should be performed at admission based on clinical need. However, the facility's approach to speech therapy evaluations was inconsistent with this policy, as the decision not to evaluate R176 was based on their regular diet status rather than their clinical presentation. This inconsistency and failure to follow through with the physician's order led to a significant delay in providing necessary speech therapy services to the resident.
Failure to Administer and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to adhere to its policy and professional standards regarding the timely education and administration of the pneumococcal vaccine for two residents. The Infection Prevention Nurse (V4) acknowledged that the documentation of resident education, consent, or declination for the pneumococcal vaccine was missing for one resident, and although another resident had consented, the vaccine was not administered. The facility's policy requires that each resident be educated about the benefits and potential side effects of the vaccines, and their decision to accept or refuse must be documented in their clinical record. During the survey, it was found that the electronic health records of the residents did not contain the necessary documentation for the pneumococcal vaccine. The Infection Prevention Nurse admitted to not being aware of the need for vaccination for one resident due to a lack of consent documentation. Additionally, the facility's process involves a clinic that administers vaccines periodically, but for residents admitted after the last clinic visit, the facility staff is responsible for administering the vaccines. This lapse in the process led to the failure in providing the pneumococcal vaccine to the residents in question.
Deficiency in Shower Room Safety Measures
Penalty
Summary
The facility failed to maintain a safe and functional environment by not ensuring that the shower room floor tiles had non-skid tape attached, which is essential to prevent accidental hazards. This deficiency was observed in multiple areas, including the 3rd floor shower room where six floor tiles were missing non-skid grip tapes, and some were rolled up. The Maintenance Director, who was present during the observation, acknowledged the absence of non-skid tape and admitted to running out of supplies. Additionally, the 2nd floor shower room had a water puddle under the wash sink, and two shower stalls were missing non-skid tapes. On the 1st floor, the shower stall was observed to have peeling non-skid tape, and the Maintenance Director was unaware of these issues until they were pointed out by the surveyor. The Director of Nursing confirmed that the shower room floors should have non-skid surfaces to prevent slipping. Despite the facility's policy requiring staff to report maintenance issues via a log at the nurse's station, there was no work order available for the repair of the non-skid tapes as of the survey date. The Maintenance Director mentioned a transition from a maintenance book log to a computer form for tracking repairs, but this change had not yet been fully implemented. The facility's job description for the Director of Maintenance emphasizes the responsibility to maintain a safe and comfortable environment, including ensuring the availability of necessary supplies.
Failure to Ensure Privacy of Urine Collection Bags
Penalty
Summary
The facility failed to ensure the privacy and dignity of two residents by not covering their urine collection bags, which were visible from the hallway. On the specified date, one resident was observed in bed with a urine bag collection visibly noted from the hallway. When this was pointed out to the Case Manager, it was confirmed that the facility's policy required urine bags to be inside a privacy bag. Similarly, another resident was observed with a urine collection bag visible from the hallway, and the LPN acknowledged that it should have been covered with a dignity bag. The Director of Nursing also confirmed that urine collection bags should be covered to promote dignity. The facility's policy on dignity emphasizes treating residents with respect and ensuring their quality of life, which includes keeping urinary catheter bags covered.
Improper Medication Storage and Labeling for Two Residents
Penalty
Summary
The facility failed to ensure proper labeling, physician ordering, and secure storage of inhaler medications for two residents, R4 and R5. During an observation, R5 was found with an inhaler and Latanoprost tubes on the over-bed table, neither labeled nor ordered by a physician. The LPN acknowledged that medications should not be left at the bedside unless ordered and labeled with the patient's name and administration directions. Upon checking R5's physician order and MAR, there was no order for the inhaler or permission to leave it at the bedside. Similarly, R4 was observed with an unlabeled Symbicort inhaler on the over-bed table, with no physician order found in the electronic medical record. The RN case manager suggested that the family might have brought the medication, indicating a lack of awareness of residents' belongings. The facility's policy mandates that medications be stored securely and labeled properly, accessible only to authorized personnel. The DON confirmed that medications should be stored properly and locked away, aligning with the facility's policy on medication storage.
Failure to Report and Act on Allegation of Sexual Abuse
Penalty
Summary
The facility failed to follow their abuse policy by not ensuring the immediate reporting of an allegation of sexual abuse made by a resident regarding a certified nursing assistant (CNA). The resident, who has a history of major depressive disorder, PTSD, and heart failure, reported that the CNA penetrated her vagina with his fingers during incontinence care. Despite the resident's immediate distress and reporting of the incident to another CNA, the allegation was not promptly reported to the administrator or the nurse on duty, leaving the resident vulnerable to further trauma as the alleged perpetrator remained in the facility and re-entered her room shortly after the incident. The resident had previously expressed discomfort with the same CNA, reporting that he had rubbed her face and called her beautiful, but this concern was not escalated to the administration. On the night of the incident, the resident's husband called the facility to report the abuse, prompting the nurse manager to assess the resident and notify the police. The resident was sent to the emergency room for evaluation, where hospital records indicated mild bleeding and a urinary tract infection. The facility's investigation concluded that the allegation was unfounded, attributing the resident's perception to the CNA's cleaning process. Interviews with staff revealed that the CNA continued to work in the facility after the initial report, contrary to the facility's abuse prevention policy, which mandates the immediate removal of the alleged perpetrator. The night supervisor and other staff members failed to follow protocol, resulting in the CNA's arrest by the police only after the resident's husband intervened. The facility's failure to act promptly and protect the resident from further harm highlights significant lapses in their abuse reporting and prevention procedures.
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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