Southgate Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Metropolis, Illinois.
- Location
- 900 East Ninth Street, Metropolis, Illinois 62960
- CMS Provider Number
- 145386
- Inspections on file
- 35
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Southgate Health Care Center during CMS and state inspections, most recent first.
The facility failed to ensure continuous and effective pain management for three hospice residents with significant pain needs. One resident at end of life with multiple comorbidities had an order for scheduled oral Dilaudid every two hours, but staff allowed the supply to run out and did not secure replacement for approximately six hours, during which family and staff described severe, uncontrolled pain, thrashing, and agitation. Hospice had warned in advance that the Dilaudid would not last and instructed staff to call if it was not delivered, but hospice and the physician were not timely notified when the medication was depleted. Two other residents on scheduled opioid regimens with PRN opioids had MARs showing pain scores of 0 and no PRN use over multiple days, despite one resident reporting constant pain and another being observed grimacing and flinching, and a hospice CNA stating she frequently had to alert nurses about their pain. These actions and inactions demonstrate a pattern of inadequate pain assessment, failure to recognize and document non-verbal pain behaviors, and failure to ensure availability and administration of ordered pain medications.
The facility failed to provide adequate incontinence and oral care to multiple dependent hospice residents. One resident with multiple serious conditions and total ADL dependence was repeatedly found with dried feces on the buttocks and reported infrequent checks and rare oral care, despite being unable to perform self-care. Another resident with advanced cancer and incontinence was observed by a family member with bowel movement pasted to the bottom, and a CNA reported that dried stool on this resident was a common occurrence. A third resident with Parkinson’s disease, severe dementia, and total ADL dependence was observed with poor oral hygiene and was reported by staff to often have dried stool and be soaked in urine. Several CNAs acknowledged that residents are sometimes found with dried bowel movements and that oral care should be part of AM care, while facility policy on perineal care emphasizes cleanliness, comfort, and prevention of infection and skin irritation.
A non‑licensed CNA independently accessed the medication cart and medication room, prepared medications, and delivered them to cognitively intact residents without an LPN or RN present, while documentation in the EMR and MARs showed an LPN as the person who administered those medications. Video surveillance captured the CNA using medication keys, entering the medication room, preparing medication cups, taking them to resident rooms, and documenting on a facility laptop. Several residents reported that this CNA, whom they believed to be a nurse, brought their evening medications without another nurse present. The CNA acknowledged holding the medication keys and taking medications to residents, and the LPN later admitted giving the CNA her EMR login and not being present during administration, contrary to facility policies that only licensed personnel may administer and document medications and that the administering individual must document under their own credentials.
A CNA was observed on video independently accessing the medication cart and medication room, handling keys, opening the Schedule II controlled drug box, preparing medications, and delivering them to residents without an LPN or RN present. Several cognitively intact residents reported that this CNA, whom they believed to be a new nurse, brought their evening medications without another nurse present. Medication administration records and controlled drug logs showed that the CNA co-signed removals of controlled substances with an LPN, while the LPN later stated she was not present during administration and only signed the count at shift end. The DON confirmed that only licensed nurses are authorized to access medications and controlled substances, and that the CNA was not licensed, contrary to facility policy.
A CNA who had completed an LPN program but had not yet passed boards or obtained an LPN license was assigned a group of residents and independently performed licensed nurse duties, including accessing the med cart and med room, handling Schedule II controlled substances, and administering medications to several cognitively intact residents without an overseeing nurse. Video footage, resident interviews, and staff statements confirmed that this staff member was functioning as an LPN under a "license pending" designation that did not meet Illinois Nurse Practice Act requirements, and the facility’s own job description required current LPN or RN licensure for charge nurse duties.
The facility failed to maintain safe hot water temperatures in multiple shower rooms and a shared resident bathroom, where surveyors measured hot water at over 120°F using a calibrated thermometer despite mixing valves being set to lower temperatures or lacking functional controls. A plumber later determined that recirculation pumps on two halls were incorrectly plumbed so that they bypassed the mixing valves, and one hall’s mixing valve was nonfunctional. Facility logs showed prior weekly checks with no temperatures above 110°F, and the Administrator identified numerous confused and ambulatory residents, including those sharing the affected bathroom, while also acknowledging the absence of a hot water temperature policy.
A resident with ALS and a documented full code status was found unresponsive and without vital signs by an LPN, who, assuming the resident was DNR due to hospice care, did not initiate CPR. Despite clear documentation and physician orders for CPR, staff failed to provide basic life support, contrary to facility policy and the resident's wishes.
Staff failed to follow infection control protocols for two residents on contact precautions, including not wearing required gowns during linen changes for a resident with an MDRO infection and placing incontinence care supplies directly on a bedside rail without a barrier for a resident with severe cognitive impairment. These actions did not comply with the facility's infection prevention policies.
The facility failed to provide sufficient staffing, resulting in delayed care for residents. Several residents, including those with cognitive impairments and physical limitations, did not receive timely assistance with bathing and toileting. Staff reported being unable to meet residents' needs due to inadequate staffing, with some residents waiting hours for help. Despite these issues, the facility administrator believed staffing was adequate, although documentation did not support this claim.
A facility failed to provide timely showers and toileting assistance to residents due to staffing shortages. Four residents experienced significant delays in receiving showers, with gaps ranging from six to sixteen days. Staff confirmed prioritizing fall risks over other care needs, leading to extended wait times. Despite the facility's policy for twice-weekly showers, staffing issues resulted in delays, and the administration was unaware of complaints related to showers.
The facility failed to timely report and investigate abuse allegations involving two residents. One resident, cognitively intact, reported mistreatment by an LPN during medication administration, which was not investigated or reported promptly. Another resident with severe cognitive deficits was verbally abused by a CNA, but the incident was not reported to the Administrator until days later. Both cases violated the facility's abuse policy requiring immediate reporting and investigation.
The facility failed to investigate abuse allegations involving two residents. One resident, who is cognitively intact, reported mistreatment by an LPN during routine care, while another resident with severe cognitive deficits was reportedly verbally abused by a CNA. The facility did not conduct thorough investigations or ensure resident protection, as required by their abuse policy.
A facility failed to safely transfer four residents, leading to significant harm to one resident who sustained a large hematoma due to improper transfer techniques. Another resident fell in a transport van due to improper securing, and the incident was not reported promptly. Observations revealed that staff did not consistently use gait belts during transfers, contrary to facility policy.
Two residents with severe cognitive impairment experienced injuries that were not promptly reported to their families or physicians. One resident fell in a transport van, resulting in a shoulder bruise, while another was found with a large bruise during a shower. The facility's policy requires immediate notification of such incidents, but delays occurred, leading to a deficiency in communication and reporting procedures.
A resident with multiple health conditions, including malnutrition and Parkinson's Disease, experienced significant weight loss due to the facility's failure to monitor and implement interventions. The resident's weight loss was not addressed by the Registered Dietitian, who was unaware of the issue due to not being informed by the dietary manager. Observations showed inadequate food consumption and lack of dietary supplements, highlighting deficiencies in the facility's weight management practices.
A facility failed to ensure adequately trained CNA staff were present to meet residents' needs, particularly for a resident with multiple diagnoses and high fall risk. Unqualified Resident Assistants, who were CNA students, were observed assisting with ambulation, leading to a fall incident. Interviews confirmed that RAs were not qualified for such tasks, and the lack of a formal skills checklist contributed to the deficiency.
A resident with a history of falls and cognitive impairment was improperly positioned in a mechanical lift sling, leading to a fall during a transfer attempt. Two CNAs were involved, but the resident slid out of the chair before being lifted, resulting in a minor injury. The facility's policy on sling positioning was not followed.
The facility failed to accurately label and securely store medications for four residents. Insulin pens and eye drops were found without open dates, and one insulin vial was used beyond its expiration date. Additionally, an unlocked refrigerator contained an emergency medication box with controlled substances, contrary to facility policy.
The facility failed to conduct a proper skin assessment on a resident upon admission, resulting in undetected pressure ulcers under a walking boot. Nursing staff did not remove the boot during assessments, despite the resident being at high risk for pressure ulcers. The issue was only discovered when the resident was transferred to the hospital.
The facility failed to conduct smoking safety assessments for two residents, leading to inadequate supervision. Both residents, who were cognitively intact and allowed to smoke unsupervised, had no smoking assessments in their clinical records. The facility's smoking policy requires these assessments, but they were not performed.
A facility failed to provide proper urinary catheter care for a resident with multiple diagnoses. A CNA did not follow aseptic techniques or perform hand hygiene during and after catheter care, contrary to the facility's policy. The DON confirmed that staff are expected to follow these guidelines to prevent infections.
A resident with multiple diagnoses was given nifedipine ER in a crushed form by an LPN, contrary to pharmacy recommendations and facility policy. The DON confirmed that extended-release medications should not be crushed.
The facility failed to provide wound care per current standards of practice for three residents, leading to deficiencies in infection prevention and control. An LPN did not perform hand hygiene between glove changes and used the same bandage scissors without sanitizing them. The DON acknowledged that the staff is expected to follow clean aseptic techniques and good hand hygiene per facility policy to prevent infections.
The facility failed to offer pneumococcal vaccinations to two residents as per CDC recommendations and did not update its Pneumonia Vaccine policy to include the latest guidelines. Both residents had received a Prevnar 13 vaccination but did not receive any subsequent pneumococcal vaccinations or document any refusals. The facility's policy did not reflect the most recent CDC recommendations, and staff confirmed that the new vaccines had not been offered.
The facility failed to administer the updated (2023-2024 Formula) COVID-19 vaccine to three residents, despite their eligibility and medical conditions. The Infection Preventionist confirmed the absence of consent or refusal documentation, and the DON cited delays in vaccine scheduling and reliance on CDC recommendations.
Failure to Ensure Continuous and Effective Pain Management for Hospice Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide effective pain management for three residents receiving pain control, including one hospice resident at end of life. One resident with multiple myeloma, pulmonary embolism, chronic pain, spinal stenosis, osteoporosis with pathological fractures, fibromyalgia, and other comorbidities was on hospice care with orders for a Fentanyl patch, scheduled oral Dilaudid every two hours, and PRN Hydrocodone for breakthrough pain. Her care plan called for evaluation of pain, monitoring for non-verbal indicators, and assessing the effectiveness of pain interventions every shift. Despite this, the facility allowed her oral Dilaudid supply to be depleted and did not ensure timely replacement, resulting in a period of approximately six hours without the ordered narcotic while she was actively dying. Family members reported that on the day in question the resident was in severe, uncontrolled pain, thrashing and crawling in bed, attempting to get out of bed, and requiring family to hold her to prevent falls. Multiple family members stated that the facility could not get her Dilaudid all day, that they repeatedly called hospice and even a hospital seeking help, and that the resident suffered intensely until medication finally arrived later in the afternoon. The hospice RN had identified the day before that the Dilaudid supply would not last, sent refill orders to the facility’s pharmacy before noon, and instructed facility staff to notify hospice if the medication was not delivered so alternate arrangements could be made. The hospice RN reported she never received such a call and only learned the medication was depleted after the last partial dose was given around 10:00 a.m. Facility nurses confirmed that the last dose from the bottle was given that morning, that no additional Dilaudid was available in the building, and that they relied on hospice to locate an open pharmacy and bring replacement medication, which did not arrive until mid- to late afternoon. During the period without Dilaudid, staff documented that the resident’s scheduled doses at noon and 2:00 p.m. were not given and coded as “other/see progress notes,” while the resident exhibited restlessness, grimacing, and agitation as described by CNAs and family. An agency LPN caring for the resident stated she considered sending the resident to the emergency room for pain relief but did not do so, and another nurse reported that the facility’s pharmacy did not make Sunday deliveries. The primary physician/medical director stated he was not notified that the resident was out of Dilaudid or that her pain had increased. The facility’s own pain management policy required recognition of behavioral signs of pain and review of the MAR to determine the effectiveness and frequency of pain medication use, but the resident’s MDS documented no receipt of scheduled or PRN pain medications or non-medication interventions despite concurrent documentation that she was receiving an opioid. Two additional hospice residents with pain needs also did not receive adequate pain assessment and management. One resident with multiple sclerosis, contractures, and other serious conditions was on a scheduled Norco regimen three times daily and had PRN Dilaudid ordered for moderate to severe pain and dyspnea. He reported that he was always in pain, that staff did not routinely ask him about pain, and that he had to request medication himself, sometimes forgetting until his pain became severe. His MAR showed all scheduled Norco doses documented with a pain level of 0 over multiple days and no use of PRN Dilaudid during the review period, while a hospice CNA stated she always asked him about pain and that he consistently reported being in pain. Another hospice resident with Parkinson’s disease, severe dementia, heart failure, and other diagnoses had orders for scheduled Oxycodone four times daily and PRN Hydromorphone every four hours. His care plan required monitoring and recording pain characteristics every shift and observing for non-verbal signs of pain such as changes in breathing, facial expressions, and vocalizations. However, his MAR documented pain scores of 0 on all shifts over several weeks and no administration of PRN Hydromorphone. A hospice CNA reported that this resident complained of pain at times and that she had to notify the nurses. During observation, the resident was seen flinching in his legs, grimacing, gritting his teeth, and trying to adjust his feet, yet he was unable to answer questions, indicating reliance on staff to recognize and respond to non-verbal pain behaviors that were not reflected in the recorded pain assessments.
Removal Plan
- The DON, ADON, and floor nurses began assessing residents for pain using a standardized scale; residents with pain received immediate intervention; physicians were notified and new orders obtained as needed.
- The DON began re-educating licensed staff; education included medication inventory and physician notification.
- Licensed staff were educated to notify the physician if any medication is not available.
- Licensed staff were educated to notify the DON immediately if medication is not available or if there will be a delay in receiving ordered/reordered medications immediately upon discovery of a medication shortage.
- All notifications and order changes are to be documented in real time.
- The DON and ADON will complete medication audits to ensure residents always have an adequate amount of pain medications available.
- If less than four days of medications are noted, an order/reorder will be submitted to the physician; this audit will include hospice residents.
- Licensed staff unable to attend the education were educated via phone with the DON and ADON as a witness.
- A message was sent to all licensed staff via Mediprocity with the education.
- The DON/designee initiated real-time audits.
- The DON and ADON completed a 100% house-wide audit comparing pharmacy-dispensed medication orders for pain management to on-hand inventory; reorders were processed and delivered; orders were clarified/updated as needed; care plans were revised as needed.
- The DON/designee will complete biweekly audits for 4 weeks.
- The Administrator and DON will submit the plan to QA for monthly review.
- The QAPI committee will review and offer recommendations as needed until compliance is met.
Failure to Provide Adequate Incontinence and Oral Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate incontinence and oral care to dependent residents. One resident with multiple serious diagnoses, including Multiple Sclerosis, paralytic syndrome, and dysphagia, was documented as totally dependent for ADLs and always incontinent of bowel with an ileostomy. During a bed bath, a hospice CNA observed a medium-sized bowel movement and dried feces on this resident’s buttocks, stating it was “really dried on” and required effort to remove with warm soap and water. The resident reported not being checked during the night or early morning, stated that dried stool was left on him very often, and that he sometimes had to wait long enough for stool to dry. The observed personal care did not include oral care, and the resident stated he does not receive oral care very often and is unable to perform it independently. Another resident, admitted with multiple myeloma, pulmonary embolism, and other chronic conditions, was documented as always incontinent of bowel and occasionally incontinent of urine, requiring substantial assistance with mobility. A family member reported that during a visit, this resident had a bowel movement that was pasted to her bottom. A CNA who worked that day stated they believed the resident was dying and that when they went in to turn her, she was resting. The hospice CNA reported having seen dried bowel movements on this resident and described it as “sort of a normal thing,” noting that the resident frequently complained of pain during care, which the CNA reported to the charge nurse. A third resident with Parkinson’s disease, severe dementia, heart failure, and adult failure to thrive was documented as totally dependent on staff for ADLs, including oral care, and always incontinent of both bowel and bladder. This resident was not on a bowel program and was not toileted. Observation found the resident in a geri chair with poor oral hygiene, including teeth covered in a whitish-yellow, fuzzy substance, after receiving personal care that did not include oral care. The hospice CNA stated she had found dried feces on this resident several times and that the resident was usually soaked in urine. Additional CNAs acknowledged that they have found residents with dried bowel movements, with one CNA stating that oral care should be part of morning care and another attributing the issue to some staff lacking compassion. The facility’s perineal care policy states that the purpose of the procedure is to provide cleanliness and comfort, prevent infections and skin irritation, and observe the resident’s skin.
Unauthorized Medication Administration and Inaccurate EMR Documentation by Non‑Licensed Staff
Penalty
Summary
The deficiency involves the facility’s failure to ensure that only authorized, licensed personnel prepared, administered, and documented medications, and to ensure accurate documentation of who administered those medications. Video surveillance from the evening of 1/15/26 showed a certified nursing assistant (V5) removing medication cart and medication room keys from her pocket, opening the medication cart, popping medications into cups, entering the medication room without a nurse present, taking medication cups to resident rooms, and documenting on a facility laptop. The administrator (V1) stated that V5 did not have an EMR login and was unsure how V5 was documenting the medications. Additional surveillance footage showed V5 taking cups of medications to three residents’ rooms at specific times that evening, with no nurse visible accompanying her, despite V1’s statement that V5 was supposed to be working with another nurse and should not have been administering medications. Multiple cognitively intact residents reported that V5 personally brought and administered their medications that night without another nurse present. One resident (R1), admitted with anemia, atrial flutter, and hypertension and with a BIMS score of 15, stated that V5 brought his medications the evening of 1/15/26 and that he did not see another nurse with her; he believed V5 had finished her courses and was now a nurse working independently. However, R1’s MAR documented that an LPN (V7) administered his evening medications, including Atorvastatin, Melatonin, Tamsulosin, Iron Sulfate, Metformin, and Protonix. Another cognitively intact resident (R3), with COPD, type 2 diabetes, and fibromyalgia and a BIMS score of 15, reported that she believed V5 brought her medications and that V5 had not been working with another nurse recently; R3’s MAR documented that V7 administered multiple medications, including Hydrocodone/Acetaminophen, Olanzapine, Rosuvastatin, Docusate, Lactulose, Lamictal, Oxcarbazepine, Potassium, and Reglan. A third cognitively intact resident (R4), with type 2 diabetes, hyperlipidemia, and spinal stenosis and a BIMS score of 15, stated that the “new girl” (V5) gave him his medications and that he did not see her working with another nurse, while his MAR also showed V7 as the person who administered his evening medications. Staff interviews further demonstrated unauthorized medication administration and inaccurate documentation. V5 stated she did not work independently and that V7 was present while she was administering medications, but acknowledged she held the medication cart and medication room keys, helped set up medication cups with V7, and then took the medications to residents without V7 accompanying her; she also stated she did not chart in the EMR because she had no login. In contrast, V7 later stated she had given V5 her EMR login and that V5 had taken the computer, and confirmed she was not present while V5 was administering medications to residents. V7 said it was not typical to share her EMR login but she trusted V5. The DON (V2) confirmed that V5 was not a licensed nurse, stated she had told V5 she could not administer medications, and said she would not expect a nurse to give their EMR login to another employee or to allow someone else to document medication administration under their name. These practices conflicted with facility policies requiring that only persons licensed or permitted by the state prepare, administer, and document medications, and that the individual administering the medication initial the MAR, as well as job descriptions specifying that LPNs and RNs accurately administer and document medications in compliance with facility and regulatory standards.
Unauthorized CNA Access to Medications and Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to restrict access to medications, including Schedule II controlled substances, to authorized licensed personnel only. Surveillance footage from the evening of 1/15/26 showed a CNA (V5) removing keys to the medication cart and medication room from her pocket, opening the medication cart, popping medications into cups, taking those cups to resident rooms, opening the Schedule II controlled medication box, popping Schedule II medications into cups, signing out Schedule II medications in the controlled drug count binder, and opening the medication room door, all without a nurse present. The Administrator (V1) confirmed these observations while reviewing the surveillance footage. Multiple cognitively intact residents reported that V5 personally brought them their medications that evening and that no nurse was present with her. One resident (R1), admitted with anemia, atrial flutter, and hypertension and with a BIMS score of 15, stated that the “dark-haired girl” who had previously been a CNA and whom he believed was now a nurse brought his medications on the evening in question, and he did not see another nurse with her. Another resident (R3), with COPD, type 2 diabetes, and fibromyalgia and a BIMS score of 15, stated she believed V5 brought her medications and that V5 had previously worked with another nurse but had not been doing so recently; she saw only CNAs when V5 brought her medications. A third resident (R4), also cognitively intact with diagnoses including type 2 diabetes, hyperlipidemia, and spinal stenosis, reported that the “new girl” (V5) gave him his medications and that he did not see her working with another nurse. Medication records and controlled drug documentation further supported that V5 had access to and handled controlled substances. R3’s controlled drug record for hydrocodone/acetaminophen showed that two tablets were removed from the count on 1/15/26 with both V5 and an LPN (V7) signing the record. R2’s controlled drug record for pregabalin documented that one capsule was removed from the count with both V5 and V7’s signatures. V5 acknowledged holding the keys to the medication cart and medication room and stated that she and V7 both signed out Schedule II medications, claiming V7 had been present while she administered medications. However, V7 later stated she had not been present when V5 administered medications and that she signed the Schedule II count binder only at the end of the shift when they counted the medications together. The DON (V2) stated that only licensed nurses should have access to medication and controlled substance keys and confirmed that V5 was not a licensed nurse, which conflicted with the facility’s controlled substances policy and job description for charge nurses.
Unlicensed Staff Functioning as LPN and Independently Administering Medications
Penalty
Summary
The facility failed to ensure that staff functioning in licensed nursing roles held active licensure in accordance with state law. Video surveillance from the evening of 1/15/26 showed a CNA, identified as V5, removing keys to the medication cart and medication room from her pocket, opening the medication cart, popping medications into cups, taking the cups to resident rooms, opening the Schedule II controlled medication box, popping Schedule II medications into cups, signing out Schedule II medications in the count binder, and accessing the medication room without a nurse present. The licensed nurse schedule for that date documented that V5 was assigned a portion of the resident population, with no specific licensed nurse assigned to oversee her. Multiple cognitively intact residents confirmed that V5 independently administered their medications that evening. One resident (R1), with a BIMS score of 15 on the 1/9/26 MDS, stated that V5, whom he recognized as a former CNA who had “finished her courses” and was now “a nurse,” brought his medications on the evening of 1/15/26 and that he did not see another nurse with her. Another resident (R3), also with a BIMS score of 15 on the 12/13/25 MDS, reported that V5 brought her medications that night and that V5 had previously worked with another nurse but had not been doing so recently; she saw only CNAs when V5 brought her medications. A third resident (R4), with a BIMS score of 15 on the 11/25/25 MDS, similarly reported that the “new girl” (V5) gave him his medications and that he did not see her working with another nurse. Staff interviews and record review confirmed that V5 did not hold an active LPN license and did not meet Illinois requirements for “license-pending” practice. V5 stated she had completed an LPN program on 12/15/25 and was scheduled to sit for boards on 1/23/26, and that she was working as “LPN License Pending” and was supposed to be shadowing another nurse, not working independently. The DON (V2) stated that V5 was working as an LPN License Pending and that this status meant she did not yet have a license and should work under another nurse; V2 acknowledged V5 had not presented any documentation indicating she had passed the NCLEX. Another LPN (V7) reported that she had not been present when V5 administered medications on 1/15/26 and that V5 had been working independently as a licensed nurse for about a week, based on information that V5 was on a provisional license. The Illinois Nurse Practice Act excerpt in the report specifies that a license-pending LPN must have passed the licensure exam and presented official written notification of successful passage, among other criteria, and the facility’s job description for charge nurses requires maintaining current state nursing licensure, conditions that were not met in V5’s case.
Failure to Maintain Safe Hot Water Temperatures in Resident Areas
Penalty
Summary
A deficiency occurred when the facility failed to maintain safe hot water temperatures in multiple resident care areas, including shower rooms and a shared resident bathroom. Using a calibrated digital metal stemmed thermometer, surveyors measured hot water temperatures of 121.4°F at the A hall shower room hand sink, 128.0°F at the 200 hall shower room hand sink (which then slowly dropped below 110°F after about one minute), and 119.6°F at the B hall shower room hand sink. In the shared personal bathroom of three residents on the 200 hall, the hot water temperature was 120.7°F. At the time of these readings, the A hall mixing valve was set at 104°F, the 200 hall mixing valve was set at 126°F, and the B hall mixing valve lacked a functioning gauge or knob, making its setting indeterminable. The facility’s Maintenance Director reported that the B hall mixing valve was an older style with a knob that had broken off, so the temperature setting could not be known. The facility’s Weekly Water Temperature Log documented that hot water temperatures had been checked on all halls on three earlier dates in the same month, with no recorded temperatures higher than 110°F. However, during the survey, a plumber later identified that the B hall and 200 hall hot water heater recirculation pumps had been incorrectly plumbed, causing the recirculation pumps to bypass the mixing valves and rendering the mixing valve settings irrelevant to actual water temperatures. The plumber also stated that the B hall mixing valve was not working at all, as adjusting it did not change the water temperature. The Administrator provided a census list identifying 45 of 90 residents as confused and ambulatory, including two of the three residents whose shared bathroom had elevated hot water temperatures, and confirmed that these three residents lived in adjacent rooms sharing that bathroom. The Administrator also stated that the facility did not have a hot water temperature policy.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to initiate life-sustaining measures, specifically CPR, for one resident who was identified as a full code, despite clear documentation and orders indicating that CPR should be performed in the event of cardiac arrest. The resident had a complex medical history, including Amyotrophic Lateral Sclerosis (ALS), and was under hospice care. The resident's care plan and POLST form both indicated that CPR was to be performed if cardiac arrest occurred, and the chart was marked accordingly to reflect this status. On the evening in question, an LPN entered the resident's room to administer medications and found the resident pale, cold to the touch, and not breathing. The nurse checked for a pulse and, finding none, called another nurse to verify the absence of vital signs. Both nurses confirmed the resident had expired, but no attempt was made to initiate CPR. The LPN later stated she assumed the resident was a DNR due to hospice enrollment, despite the documentation indicating otherwise. The incident was later confirmed through interviews and record review, showing that staff did not follow the resident's documented wishes and physician orders regarding resuscitation. Interviews with the resident's power of attorney and physician confirmed that the resident's code status had been changed to full code, with explicit instructions for CPR but no intubation. The physician acknowledged awareness of the full code status and stated that, based on the reported condition of the resident when found, CPR would not have been effective. However, the facility's policy required staff to verify and adhere to each resident's code status, which was not done in this case, resulting in the failure to provide basic life support as ordered.
Failure to Follow Infection Control Practices During Incontinence Care and Linen Handling
Penalty
Summary
The facility failed to ensure proper infection control practices during incontinence care and the handling of contaminated linens for two residents on contact precautions. For one resident with a history of multidrug-resistant organism (MDRO) infection and an active urinary tract infection, a staff member changed bed linens while wearing gloves, mask, and shoe covers, but did not wear a gown as required by the facility's infection control policy. The staff member later acknowledged that gowns were not available in the PPE bin but admitted that a gown should have been worn during the procedure. The infection preventionist confirmed that contact precautions, including the use of gowns for handling bed linens, were in place for this resident. In another instance, a staff member providing incontinence care to a resident with severe cognitive impairment placed wet wipes directly on the resident's bedside rail without a barrier, contrary to facility policy. Both the infection preventionist and the staff member acknowledged that this practice did not follow the established procedures for infection prevention. The facility's perineal care policy specifies the use of barriers for supplies to prevent infection, which was not adhered to during the observed care.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its residents, affecting all 91 residents. On multiple occasions, residents did not receive timely assistance with activities of daily living, such as bathing and toileting. For instance, one resident, R2, who is cognitively intact and requires extensive assistance with bathing, did not receive a shower for six days. R2 reported that the facility was short-staffed, leading to missed showers and delayed assistance to the bathroom, with one incident involving a two-hour wait for help. Another resident, R3, also cognitively intact, experienced similar issues with delayed assistance. R3 requires partial to moderate assistance for toileting and bathing but did not receive a shower for six days. R3 confirmed the delay in response to her call light, which was not answered for a significant period, causing distress. The CNA responsible for the unit on the night of the incident reported being the only staff member available, with the nurse attending to another unit, leading to prioritization of fall risks over other care needs. Additional residents, such as R12 and R14, also experienced significant delays in receiving showers, with gaps of up to 16 days without bathing assistance. Staff interviews consistently highlighted the issue of insufficient staffing, with CNAs and nurses acknowledging the inability to meet residents' needs timely. The Director of Nurses admitted to staffing challenges and noted that while basic needs were met, tasks like showers were often delayed. Despite these issues, the facility administrator claimed there were no complaints about showers and believed staffing was adequate, although documentation did not support this claim.
Failure to Provide Timely Showers and Toileting Assistance
Penalty
Summary
The facility failed to provide adequate care and assistance for activities of daily living, specifically in ensuring that residents received showers and timely toileting assistance. Four residents, identified as R2, R3, R12, and R14, did not receive showers as per their care plans, with gaps ranging from six to sixteen days without a shower. R2 and R3, who are cognitively intact, reported delays in receiving assistance, with R2 stating that they had to wait two hours for toileting assistance due to staffing shortages. R12, who has severe cognitive impairment, and R14, who is legally blind, also experienced significant delays in receiving showers. The report highlights that the facility was experiencing staffing shortages, which contributed to the inability to meet the residents' needs timely. Interviews with staff members, including CNAs and the Director of Nurses, confirmed that the facility was short-staffed, leading to delays in providing showers and other care. The CNAs reported prioritizing fall risks over toileting and incontinence care, which resulted in extended wait times for residents needing assistance. Despite the facility's policy requiring showers twice a week, the administration acknowledged that showers were sometimes delayed due to staffing issues. The Director of Nurses mentioned hiring new staff, but they had not yet started working. The facility's administrator claimed there were no complaints related to showers, yet the documentation and interviews with residents and staff indicated otherwise. The facility's failure to adhere to its bathing policy and provide timely assistance reflects a deficiency in meeting the residents' basic care needs.
Failure to Timely Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of abuse allegations to the Administrator and the State Survey Agency for two residents. The first incident involved a resident who reported feeling mistreated by an LPN during a medication administration. The resident, who was cognitively intact, claimed the LPN was loud, refused to provide a medication list, and handled him roughly during a blood sugar check. The resident called the police to report the incident, but the facility did not initiate an investigation or report the allegation to the state agency until several days later. The second incident involved a resident with severe cognitive deficits. A Resident Assistant witnessed a CNA being verbally abusive to this resident, telling him to shut up and refusing to assist him out of bed. The Resident Assistant reported the incident to the Business Office Manager, who was the manager on duty at the time. However, the Administrator was not informed until days later, and no investigation was initiated until the surveyor brought it to the facility's attention. In both cases, the facility's failure to promptly report and investigate the allegations of abuse violated their own abuse policy, which requires immediate notification of the Administrator and the Director of Nurses, as well as reporting to the State Survey Agency within 24 hours. The delay in addressing these allegations highlights a significant deficiency in the facility's handling of abuse reports.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and ensure resident protection, as evidenced by incidents involving two residents. The first resident, R1, who is cognitively intact, reported an incident with an LPN, V13, where he felt mistreated during routine care. R1 alleged that V13 was loud, dismissive, and physically rough during a medication pass and blood sugar check. Despite R1's call to the police and his expressed desire to move to another facility, the facility did not conduct a comprehensive investigation or interview other staff or residents about the incident. The second incident involved R13, a resident with severe cognitive deficits, who was reportedly verbally abused by a CNA, V17. A Resident Assistant, V14, witnessed V17 being rude and dismissive to R13, telling him to shut up and refusing to assist him out of bed. This incident was reported to the Business Office Manager, V26, who noted it for discussion but did not follow up with an investigation or check on R13's well-being. The facility's administration, including the Administrator, V1, and the Director of Nurses, V2, did not initiate proper investigations into these allegations. They failed to interview involved parties or other potential witnesses and did not report the incidents as required by their abuse policy. The lack of action and failure to protect residents from potential further abuse highlight significant deficiencies in the facility's handling of abuse allegations.
Improper Transfer Techniques and Incident Reporting Deficiencies
Penalty
Summary
The facility failed to safely transfer four residents, resulting in significant harm to one resident. The first resident, who had severe cognitive impairment and was dependent on staff for mobility, sustained a large hematoma to the chest wall after being transferred using an improper technique. The resident was on Eliquis, a blood thinner, which exacerbated the bruising. The incident was not immediately reported, and the resident was eventually sent to the hospital for evaluation and pain management. The improper transfer method involved lifting the resident under the arms, which is not in accordance with the facility's policy to use a gait belt unless contraindicated. Another resident experienced a fall while being transported in a van, resulting in a bruise to the shoulder. The incident occurred when the wheelchair tipped over due to improper securing in the van. The transport driver failed to report the incident to the nursing staff upon returning to the facility, delaying the resident's assessment and care. The resident later reported shoulder pain, and an x-ray was conducted, revealing no fractures or dislocations. Two other residents were observed being transferred without the use of a gait belt, contrary to the facility's policy. One resident was transferred by two CNAs using a gait belt, while another was transferred by an LPN without a gait belt. The facility's policy mandates the use of a gait belt unless specific contraindications are present, none of which were documented for these residents. The lack of adherence to proper transfer techniques and failure to report incidents contributed to the deficiencies identified in the facility's care practices.
Failure to Notify Family and Physician of Resident Injuries
Penalty
Summary
The facility failed to notify a family member and physician of a change in condition due to injuries for two residents, R1 and R2. R2, who has severe cognitive impairment and is at risk for falls, experienced an incident on 10/3/2024 while being transported back to the facility in a van. The wheelchair tipped over, causing R2 to fall and sustain a bruise on the right shoulder. The transportation aide, V5, did not report the incident to the nursing staff, and the family member, V30, only learned of the incident from R2 during a visit on 10/4/2024. The facility was informed of the incident by V30, leading to an investigation and subsequent notification of the physician and family member on 10/4/2024. R1, who also has severe cognitive impairment and is dependent on staff for mobility, was found to have a large bruise on the left chest/breast area during a shower on 10/3/2024. The registered nurse, V26, assessed the bruise as superficial and attributed it to the resident's use of Eliquis, a blood thinner. V26 did not notify the physician or family until the early morning of 10/4/2024, after observing R1 throughout the night and finding no signs of pain or discomfort. The facility's policy requires immediate notification of the physician and family in the event of an accident, injury, or significant change in condition, which was not adhered to in these cases. The facility's failure to promptly notify the physician and family members of the incidents involving R1 and R2 represents a deficiency in adhering to their policy on accident, injury, and change in condition notifications. The delay in communication could have impacted the timely assessment and management of the residents' conditions. The incidents were only reported after family members became aware, highlighting a lapse in the facility's internal communication and reporting procedures.
Failure to Monitor and Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in a resident, identified as R3, who experienced a 9.5% weight loss in less than one month and a 14% weight loss in less than three months. R3 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, mild protein-calorie malnutrition, and Parkinson's Disease, and required assistance with eating. Despite these conditions, the facility did not implement effective interventions to prevent further weight loss, as evidenced by the lack of regular dietary supplements and the absence of R3 on the list of residents to be seen by the Registered Dietitian over the last three months. The facility's records showed discrepancies in R3's nutritional assessments and weight monitoring. R3's care plan indicated a history of weight loss and a goal to maintain a weight of 154 pounds or more, yet the facility's monitoring and intervention efforts were insufficient. The Registered Dietitian, V15, was unaware of R3's significant weight loss and had not seen R3 in the past three months due to not being included on the dietary manager's list. Additionally, the Director of Nursing acknowledged that the facility's weight management practices were inadequate, partly due to staffing changes, and confirmed that R3's weight loss was significant. Observations revealed that R3 consumed only 25% of the food on their tray, and no dietary supplements were present. The facility's policy on weight loss required notifying the resident's physician and dietitian if certain weight loss thresholds were met, but this protocol was not followed. The facility's failure to monitor and address R3's nutritional needs and weight loss resulted in a deficiency in providing adequate food and fluids to maintain the resident's health.
Inadequate Training and Qualification of Staff for Resident Care
Penalty
Summary
The facility failed to ensure that adequately trained and qualified Certified Nurse Aide (CNA) staff were present to provide routine care and meet the needs of residents, specifically in the case of a resident identified as R2. R2 was admitted with multiple diagnoses, including muscle weakness, lack of coordination, cerebral infarct, and Alzheimer's disease, which contributed to a high risk of falls. The resident's care plan required supervision and assistance with ambulation using a wheeled walker, yet the facility allowed Resident Assistants (RAs), who were not fully trained or qualified, to assist with these tasks. On several occasions, RAs, who were CNA students, were observed performing duties they were not qualified for, such as assisting with ambulation. The RAs had only been checked off on basic skills like hand washing and PPE donning and doffing, and were not trained in more complex tasks like transferring residents or assisting with ambulation. Despite this, RAs were involved in assisting R2, which led to an incident where R2's legs gave out during ambulation, resulting in a fall. The incident was witnessed by an RA who was not qualified to assist with ambulation, highlighting the facility's failure to ensure that only trained staff performed such duties. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed that RAs were not qualified to assist residents with ambulation. Despite this, RAs were observed performing tasks beyond their training, such as transferring residents and assisting with ambulation. The lack of a formal checklist of skills for CNA students further contributed to the deficiency, as it allowed unqualified staff to perform duties they were not trained for, compromising resident safety and care quality.
Failure to Ensure Safe Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide a safe mechanical lift transfer for a resident, leading to an accident. The resident, who had a history of repeated falls, cerebral infarction, and difficulty walking, was dependent on assistance for transfers. The care plan specified the use of a mechanical lift with the assistance of two staff members for transfers. During an attempted transfer from a chair to a bed, two CNAs were involved. They realized the resident was not properly positioned in the sling, with only two hooks attached to the lift. As a result, the resident slid out of the chair, landing on the footrests and legs of the wheelchair, causing a small scratch on the back of her right thigh. The incident occurred when the CNAs were preparing to use the mechanical lift but had not yet lifted the resident. One CNA, who was only a standby helper due to age restrictions, was unable to operate the lift. The LPN who assessed the resident after the incident noted that the nylon material of the sling might have contributed to the resident sliding out. The facility's policy and procedure for mechanical lifts indicated that the sling should be centered under the resident, with the lower edge behind the knees, which was not adhered to in this case.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to accurately label and maintain the security of medications for four residents. Specifically, insulin pens and eye drops for residents were found in the medication cart without open dates, and one insulin vial was used beyond its expiration date. Licensed Practical Nurse (LPN) verified the absence of open dates and stated that the undated medications would be disposed of and replaced per facility policy. The Director of Nursing (DON) confirmed the expectation that staff should date medications upon opening and dispose of any undated or expired medications. Additionally, during a tour of the medication storage room, an unlocked refrigerator was found containing an unlocked emergency medication box with controlled substances, including injectable Ativan and Ativan oral suspension. The LPN and DON were unaware of the presence of Ativan in the refrigerator and stated that all narcotic medications should be stored under a double locking system as per facility policy. The facility's policies on medication administration and storage were not adhered to, leading to the deficiencies observed. The facility's revised General Medication Administration policy and Medication Storage policy require that medications be dated upon opening and that controlled medications be stored securely under a double locking system. The failure to follow these policies resulted in undated and unsecured medications, compromising the safety and efficacy of the medications administered to the residents.
Failure to Conduct Proper Skin Assessment on Admission
Penalty
Summary
The facility failed to assess a resident's skin on admission, leading to the development of pressure ulcers. The resident, admitted with diagnoses including osteomyelitis, a sacral pressure ulcer, and a left lower extremity fracture, was noted to be at very high risk for pressure ulcers according to the Braden Scale. Despite this, the nursing staff did not remove the resident's walking boot during the initial skin assessment or subsequent evaluations, as they believed they were not allowed to do so. This oversight resulted in the discovery of pressure ulcers under the walking boot when the resident was transferred to the hospital a few days later. Interviews with the nursing staff revealed that they were unaware of any wounds on the resident's lower extremity and did not remove the walking boot during their assessments. The Director of Nursing stated that a full head-to-toe skin assessment is expected for every resident upon admission. The facility's Skin Care Management Policy also mandates thorough skin assessments and documentation of any pressure ulcers. However, these procedures were not followed, leading to the resident's pressure ulcers being undetected until the hospital transfer.
Failure to Conduct Smoking Safety Assessments
Penalty
Summary
The facility failed to assess residents for smoking safety, resulting in inadequate supervision to prevent accidents for two residents. Resident R44, diagnosed with Parkinson's disease, epilepsy, and bipolar disorder, was noted to be cognitively intact with a BIMS score of 14. Despite being allowed to smoke unsupervised, there were no smoking assessments in R44's clinical record. R44 confirmed that he does not wear an apron or have supervision while smoking. Similarly, Resident R27, diagnosed with chronic obstructive pulmonary disease, hepatitis C, and fibromyalgia, was also cognitively intact with a BIMS score of 15. R27's care plan allowed unsupervised smoking, but no smoking assessments were found in her clinical record. R27 also confirmed that she smokes without supervision and does not wear an apron. The Director of Nurses (DON) and Social Services staff confirmed the absence of smoking assessments for both residents upon admission and quarterly. The facility's smoking policy requires initial and quarterly smoking assessments to determine if a resident can smoke independently or requires supervision. However, these assessments were not conducted, leading to a failure in ensuring the safety of residents who smoke. The Social Services staff admitted to not performing the required assessments and stated an intention to start doing them quarterly in the future.
Failure to Provide Proper Urinary Catheter Care
Penalty
Summary
The facility failed to provide urinary catheter care per current standards of practice for a resident with multiple diagnoses, including hypothyroidism, aphasia, dementia, retention of urine, need for assistance with personal care, and dysphagia. The resident had an order for catheter care every shift and as needed. During an observation, a Certified Nursing Assistant (CNA) performed urinary catheter care for the resident but did not follow proper aseptic techniques. The CNA cleaned the resident's soiled areas without changing gloves or performing hand hygiene before proceeding to clean the urinary catheter. Additionally, the CNA did not perform hand hygiene after doffing gloves and exited the room without washing hands, which is against the facility's policy for preventing infections. The Director of Nursing (DON) confirmed that staff are expected to perform catheter care with aseptic techniques and practice good hand hygiene per the facility policy. The facility's catheter care policy, revised earlier in the year, emphasizes the importance of handwashing as the single most important step in preventing the spread of infection. The policy also outlines specific steps for cleaning the perineum and catheter area, including washing hands and obtaining clean equipment if the resident has had an involuntary bowel movement. The CNA's actions were inconsistent with these guidelines, leading to a failure in providing appropriate catheter care for the resident.
Improper Administration of Extended-Release Medication
Penalty
Summary
The facility failed to administer medication in the form recommended by the pharmacy for one resident (R20). R20, who has diagnoses including unspecified dementia, hypothyroidism, major depressive disorder, and essential hypertension, had a physician's order for nifedipine ER 30 mg to be taken once daily. On 5/28/24, an LPN crushed R20's nifedipine ER tablet and administered it in applesauce, contrary to the pharmacy's recommendation that extended-release tablets should not be crushed. The Director of Nursing confirmed that staff are expected not to crush extended-release medications. The facility's medication administration policy also specifies that extended-release tablets should never be crushed.
Failure to Follow Wound Care Protocols
Penalty
Summary
The facility failed to provide wound care per current standards of practice for three residents, leading to deficiencies in infection prevention and control. For Resident 4, the Licensed Practical Nurse (LPN) did not perform hand hygiene between glove changes while treating multiple pressure ulcers on the resident's left foot and ankle. Additionally, the LPN used the same bandage scissors without sanitizing them between uses, further compromising aseptic technique. The Director of Nursing (DON) acknowledged that the staff is expected to follow clean aseptic techniques and good hand hygiene per facility policy to prevent infections. For Resident 55, the LPN also failed to perform hand hygiene between glove changes during the dressing change of two wound sites. The resident was noted to be incontinent of bowel, and pericare was performed, but the LPN did not follow proper hand hygiene protocols before and after glove changes. This lapse in protocol was observed during the dressing change of the right hip and coccyx wounds. Resident 6's wound care was similarly compromised. The LPN did not use a barrier for the dressing supplies and failed to change gloves or perform hand hygiene between different wound sites. The LPN used the same scissors to cut gauze for multiple wounds without sanitizing them. The DON acknowledged that the LPN was nervous during the surveyor's observation but confirmed that the LPN knew the proper procedures. The facility's Skin Care Management Policy emphasizes the importance of clean techniques and good hand hygiene, which were not followed in these instances.
Failure to Offer Pneumococcal Vaccinations and Update Policy
Penalty
Summary
The facility failed to offer pneumococcal vaccinations to two residents, R18 and R12, as per the CDC's most recent recommendations. R18, who has multiple diagnoses including major depressive disorder, hypothyroidism, and dementia, received a Prevnar 13 vaccination in 2017 but did not receive any subsequent pneumococcal vaccinations or document any refusals. Similarly, R12, who has conditions such as hypothyroidism, major depressive disorder, and hemiplegia, received a Prevnar 13 vaccination in 2018 but did not receive any further pneumococcal vaccinations or document any refusals. The facility's Immunization Report for both residents did not document any administration or refusal of the Prevnar 20 vaccine, which is recommended by the CDC for adults aged 65 years or older who have previously received PCV13. Additionally, the facility's Pneumonia Vaccine policy, dated October 2021, did not include the most recent CDC recommendations for administering the series of pneumococcal vaccines. The Infection Preventionist and the Director of Nursing both confirmed that the facility had not offered the Prevnar 15 or Prevnar 20 vaccines to the residents. This oversight in updating the policy and offering the recommended vaccinations has the potential to affect any residents eligible to receive the pneumococcal vaccines.
Failure to Administer Updated COVID-19 Vaccine
Penalty
Summary
The facility failed to administer the updated (2023-2024 Formula) COVID-19 vaccine to three residents (R18, R67, and R36) out of a sample of 39 reviewed for immunizations. Resident R18, aged [AGE], with diagnoses including Major Depressive Disorder, Hypothyroidism, Essential Hypertension, Dementia, Pancytopenia, and Alcoholic Cirrhosis of the Liver, had no order or documentation for the updated COVID-19 vaccine in their medical record. Similarly, Resident R36, aged [AGE], with diagnoses including emphysema, atherosclerotic heart disease, chronic obstructive pulmonary disease, and essential hypertension, had no documentation for any COVID-19 vaccinations. Resident R67, aged [AGE], with diagnoses including major depressive disorder, atrial fibrillation, benign prostatic hyperplasia, atherosclerotic heart disease, hyperlipidemia, and dementia, also had no documentation for the updated COVID-19 vaccine in their medical record. The Infection Preventionist/Licensed Practical Nurse (V20) confirmed the absence of consent or refusal documentation for the updated COVID-19 vaccine for these residents. The Director of Nursing (V2) stated that there was a delay in scheduling the COVID-19 vaccinations due to waiting on the Health Department to provide the vaccines. V2 also mentioned that no COVID-19 vaccinations had been administered since the initiation of the use of COVID-19 vaccines and that the facility did not have a specific policy for COVID-19 vaccinations, relying instead on CDC recommendations.
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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