Southview Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 3311 S. Michigan Ave., Chicago, Illinois 60616
- CMS Provider Number
- 146161
- Inspections on file
- 36
- Latest survey
- March 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Southview Manor during CMS and state inspections, most recent first.
The facility did not protect multiple residents from physical abuse, resulting in altercations where one resident sustained a black eye and expressed fear, and another incident where two residents engaged in a physical fight after one kicked the other. Staff and police reports confirmed these events, and care plans had previously identified the residents as at risk for aggressive behaviors.
Surveyors identified extensive environmental hazards and poor housekeeping throughout the facility, including unclean resident rooms, missing closet doors, sharp metal guards, overflowing garbage cans, broken fixtures, and unaddressed maintenance issues. Common areas and the kitchen also showed significant cleanliness and safety deficiencies, with staff acknowledging the problems and lack of timely cleaning or repairs.
The facility did not maintain an effective pest control program, resulting in ongoing bed bug, rodent, and insect infestations throughout the building. Multiple residents and staff reported sightings of bed bugs in beds, walls, ceilings, and common areas, as well as mice and roaches. Pest control logs confirmed repeated pest activity in numerous rooms and areas, and staff acknowledged the problem was longstanding despite ongoing extermination efforts.
A resident with cognitive capacity reported that another resident entered his room, attempted to pull down his pants, and sexually assaulted him. Although the incident was reported and documented, and facility policy requires immediate hospital evaluation for a rape kit in such cases, the resident was not sent to the hospital. The administrator was unaware of this omission, and an LPN stated the resident did not report penetration at the time. Required investigative steps were not followed.
Multiple residents with histories of aggressive or inappropriate behaviors were involved in physical altercations, resulting in bruises, lacerations, and other injuries. Staff and witnesses confirmed that these incidents led to physical harm, and in some cases, residents required hospital evaluation. The facility did not prevent these abusive events, leading to substantiated findings of abuse.
A facility failed to protect residents from abuse, resulting in incidents of physical and sexual abuse. A resident was sexually assaulted by another resident while under medication, and the facility delayed reporting to law enforcement and providing medical care. The perpetrator, with a history of inappropriate behavior, was not adequately supervised, allowing access to other residents. Another resident was physically assaulted, causing severe back pain, with no updates to care plans to prevent future incidents.
The facility failed to implement its abuse prevention program, leading to multiple resident-to-resident abuse incidents, including sexual assault and physical altercations. The administration did not coordinate with the QA/QAPI committee to review these cases, resulting in inadequate responses and outdated policies. Affected residents experienced physical and psychosocial harm, with care plans not updated to prevent further incidents.
The facility's governing body failed to implement an effective abuse policy, resulting in multiple incidents of physical and sexual abuse among residents. The administrator, lacking an active LNHA license, did not report substantiated cases to the QAPI committee, and no root cause analysis or care plan updates were conducted. The regional team was unaware of updated regulations, and investigations were not completed within the required timeframe, putting all residents at risk.
Inaccurate resident assessments at a facility led to repeated incidents of physical and sexual abuse among residents. A resident with a history of inappropriate behavior was involved in a sexual assault, while another with a history of aggression was involved in a physical altercation. The facility's failure to update care plans and assessments left residents vulnerable, despite policies emphasizing comprehensive assessments.
A resident with severe cognitive impairment and a history of mental illness was involved in a physical altercation with another resident, resulting in facial swelling and psychosocial harm. Despite being identified as at risk for abuse, the resident's care plan was not updated to address these risks, leaving them vulnerable to further harm. Facility staff acknowledged the oversight and the importance of timely care plan updates to prevent such incidents.
A resident was sexually assaulted by another resident while under the influence of medication, leaving her unable to defend herself. The facility failed to promptly notify law enforcement and delayed administering a rape kit. The resident did not receive appropriate psychological support, and her care plan was inadequately updated. The facility's policies on trauma-informed care and abuse reporting were not followed, contributing to the resident's deteriorating mental health.
The facility failed to report and investigate abuse incidents timely, affecting multiple residents. One resident was sexually assaulted by another while sedated, and the incident was not reported to police until the next day. Another incident involved a physical altercation between two residents, resulting in injury, but was not reported or investigated promptly. The facility did not adhere to its abuse prevention policy, leading to inadequate protection for the residents.
The facility failed to complete investigations of abuse allegations involving four residents within the required timeframe. An incident between two residents was not thoroughly investigated due to conflicting evidence, and another altercation resulted in a resident's injury, which was not promptly reported. The facility's policy requires a final investigation report within five working days, but the investigations were incomplete, leading to deficiencies in handling abuse allegations.
A resident with severe cognitive impairment was involved in an altercation resulting in a swollen eye, which was not reported to the physician or family as required by facility policy. The incident was documented by an RN, but due to doubts about the residents' accounts and the perceived severity of the injury, no notification was made. Facility policies mandate reporting any resident injury to the attending physician and responsible party, which was not followed in this case.
A resident with multiple mental health diagnoses was prescribed psychotropic medications for 'prophylaxis,' an inappropriate indication. Facility staff, including the DON and pharmacist, acknowledged the error, and interviews revealed a lack of communication and clarity regarding medication management. The facility's policy requires proper justification for psychotropic drug use, which was not followed.
Two residents with mental health disorders engaged in a physical altercation, resulting in one resident's eye swelling. Both residents were cognitively intact and later expressed feeling safe. The facility's investigation confirmed that the altercation was initiated by one resident's inability to control his actions due to his diagnosis. The facility's policy prohibits physical abuse, and the administrator acknowledged that any physical altercation is considered abuse.
A facility failed to maintain a properly functioning walk-in freezer, affecting the nutritional needs of 139 residents. The freezer's temperature was above the required level, with unfrozen meat observed. Staff interviews revealed ongoing issues with the freezer, and facility documents indicated problems with over-temping and short cycling. The facility's policy requires freezer temperatures to be 0 degrees or below, which was not met.
The facility failed to maintain safe and functional shower rooms on the third to sixth floors, affecting 139 residents. Observations revealed a wet, black substance identified as mold, along with water damage and buckling ceiling tiles. The Maintenance and Housekeeping Directors acknowledged the need for repairs, emphasizing the importance of safety and infection control.
The facility failed to maintain an effective pest control program, resulting in ongoing bed bug activity affecting a resident and potentially all 139 residents. Despite weekly visits from a pest control company, the Maintenance Director and Housekeeping Director were unaware of current bed bug issues. The Administrator expressed dissatisfaction with the pest control company's effectiveness. A resident reported bed bugs in their room, but the nurse was unaware of any complaints. The Director of Nursing only addressed bed bugs if reported on a resident, involving skin assessments and room treatments.
A deficiency was identified in a facility where thirteen residents were observed without privacy curtains around their beds. The Housekeeping Director cited a lack of curtain hooks and broken tracks as reasons for the missing curtains, which are also removed for pest control treatments. The Maintenance Director noted ongoing remodeling plans to address the issue. Facility documents emphasize residents' rights to privacy, which were compromised in this situation.
A resident with a history of aggression physically attacked another resident, causing multiple injuries. The incident was triggered by a dispute over personal belongings and was not reported by the nursing staff on the shift it occurred. The facility failed to address the aggressor's known triggers in the care plan, and the investigation did not include all relevant staff, contrary to the facility's abuse policy.
A resident with a history of falls and requiring extensive assistance was found with fractures after falling from bed. The facility failed to update the care plan with fall prevention interventions, despite previous incidents. Staff had inconsistent views on the resident's abilities, and the facility's fall program policy was not followed.
A facility failed to thoroughly investigate a physical abuse allegation involving two residents. One resident, with a history of aggressive behavior, assaulted another over a personal belonging, resulting in injuries. The facility did not interview staff from the shift during which the incident occurred, nor did it address known triggers for aggression, contrary to its abuse policy.
A resident with a history of falls and high fall risk was not properly documented in the care plan after a fall incident. Despite being able to transfer independently, the care plan did not reflect the fall or address the risk factors. The DON failed to provide a care plan history with the created date for the incident, citing technical issues and the resident's discharge. Conflicting information about the resident's assistance needs was also noted.
The facility failed to maintain a homelike environment, with multiple residents experiencing issues such as bubbled paint with black substances, lack of privacy curtains, and various maintenance problems like protruding metal springs and loose ceiling tiles. Residents expressed dissatisfaction with the living conditions, citing ignored maintenance requests and discomfort due to the lack of privacy and disrepair.
The facility failed to properly date and label food items, discard expired foods, and maintain cleanliness in the kitchen, including the ice machine and walk-in freezer. These deficiencies were observed during a survey, with the dietary cook and manager acknowledging the lapses, which could lead to food spoilage and safety hazards.
The facility failed to ensure that dumpster lids were closed, potentially affecting all 144 residents. During an inspection, three dumpster lids were found open, and the Maintenance Director acknowledged the importance of keeping them closed to prevent pest issues. The facility lacked a policy for managing the dumpster, and job descriptions for key staff emphasize maintaining standards, indicating a lapse in oversight.
The facility failed to maintain a safe and clean environment, with issues such as uncleaned lint traps in laundry dryers, holes in walls, broken lights, and missing tiles in common areas. Staff acknowledged these problems but cited understaffing and delays in repairs, compromising resident safety and comfort.
During mealtime, a staff member served food trays in a manner that did not respect residents' dignity, affecting several individuals who were left waiting while others at their table were already eating. The facility's policy emphasizes serving all residents at a table before moving to the next to ensure dignity and minimize behavioral issues.
The facility failed to ensure call lights were within reach for five residents, impacting their ability to call for assistance. Observations showed one resident's call light cord was inaccessible, and four residents lacked bathroom call light cords. Staff confirmed the expectation for accessible call lights, but facility policies did not specify this requirement.
A facility failed to ensure accurate controlled substance counts and proper inventory procedures on the 4th floor. A resident's Phenobarbital count was incorrect due to undocumented administration and disposal by an RN. Additionally, the facility did not consistently have two licensed personnel conduct shift change inventories, affecting all 34 residents on the floor.
The facility failed to label opened multi-dose medications, affecting several residents. Observations revealed that inhalers and eye drops were opened without labels indicating the open date, which is necessary to determine expiration. The RNs acknowledged the importance of labeling, and the DON confirmed that facility policies require it, yet these procedures were not followed.
A facility failed to accurately assess a resident's functional limitation in range of motion, not identifying the impairment on both sides of the resident's upper extremity. The resident was observed with flaccidity in the right arm, confirmed by both the resident's actions and a nurse. Despite documentation of right-side paralysis, the MDS inaccurately stated no impairment, contrary to CMS's RAI Manual instructions.
The facility failed to complete preadmission screening assessments for two residents with mental illness diagnoses, as required. Despite having diagnoses of Schizoaffective Disorder, neither resident had a Level II PASARR completed. Interviews with staff revealed confusion and lack of responsibility for ensuring PASARR completion, contrary to facility policies.
A facility failed to provide range of motion restorative programming to a resident with flaccid hemiplegia on the right side. The resident was observed unable to move their right arm and indicated that staff had not been providing necessary exercises. The LPN confirmed the lack of documentation for these exercises and stated that the facility prioritized other restorative programs, despite the care plan requiring daily range of motion exercises.
A resident with dementia was prescribed RisperDAL for behavioral disturbances without a documented diagnosis justifying its use. The facility staff lacked awareness of the associated black box warning, and the facility's policy on psychotropic medication use was not followed.
The facility experienced a 25% medication error rate due to failures in administering medications per physician orders. A nurse nearly gave the wrong medications to a resident due to misidentification, another resident missed a dose of AmLODIPine due to an empty medication card, and a third resident received half the prescribed dose of Vitamin D3. The DON confirmed the need for adherence to the five rights of medication administration.
The facility failed to provide Enhanced Barrier Precautions (EBP) for two residents with wounds, as required. EBP signs were missing, and PPE bins lacked gowns outside the residents' rooms. The Director of Nursing acknowledged the absence of signs, and the Infection Preventionist highlighted the importance of EBP for infection control. Despite active orders and care plans for EBP, the facility did not comply with its infection prevention policies.
A resident reported a persistent issue with gnats in their bathroom, which was confirmed by a surveyor who observed a swarm of gnats and noted missing tiles and holes. The resident, who is cognitively intact and has a history of respiratory issues, expressed distress over the situation. Interviews with staff revealed confusion over pest control responsibilities, with the Director of Nursing indicating housekeeping was responsible, despite the facility's policy requiring an ongoing pest control program.
A resident suffered multiple bed bug bites and severe itching, resulting in open wounds and scarring, due to the facility's failure to address a bed bug infestation and timely prescribe medications. Despite the resident's ability to communicate the issue, staff did not take immediate action until prompted by a surveyor.
The facility failed to ensure a safe, clean, and homelike environment for its residents, as evidenced by the presence of bed bug eggs and excrement in a resident's room. Despite observations and reports from staff, the issue was not addressed due to insufficient housekeeping staff and unclear cleaning policies.
The facility failed to follow physician orders, provide timely podiatry services, document services rendered, obtain physician consult orders prior to services, implement a concern/resolution form, timely schedule a care plan meeting, and document specific health concerns for a resident with type II diabetes and circulatory problems. The resident's family member's concerns were also not properly addressed.
The facility failed to have a bed bug policy, ensure staff report bed bug observations, and clean bed bug excrement/eggs from a resident's room before placement. Despite previous treatments, bed bug excrement was found on the wall, and staff did not report or clean it. The DON cited short staffing as a reason for the uncleaned wall.
The facility failed to timely notify the physician of a resident's bed bug bites, resulting in untreated open bleeding and scabbed areas. The LPN acknowledged the bites and the need to call the doctor only after the surveyor's inquiry, which was not in accordance with the facility's policy for timely notification of a change in condition.
The facility failed to follow its policy for timely releasing trust funds to a resident upon discharge, resulting in a delayed disbursement and an incomplete amount. The resident was discharged on 2/29/24, but the trust fund check was not issued until 3/15/24 and cashed on 3/27/24, with $0.36 unaccounted for.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect four residents from physical abuse, resulting in multiple incidents of resident-to-resident altercations. Several residents with histories of aggressive behaviors and psychiatric diagnoses, including schizophrenia and schizoaffective disorder, were involved. One incident involved a resident physically assaulting another, resulting in a black eye and visible bruising, with the victim expressing fear of being around the perpetrator. Staff and police reports confirmed the altercation, and documentation showed ongoing monitoring of the injured resident's condition. Another incident involved a resident kicking another in anger, which escalated into a physical fight. Both residents involved had documented histories of aggressive behaviors and were identified as being at risk for abuse in their care plans. Staff interviews and facility incident reports corroborated the sequence of events, and police documentation identified one resident as the victim of simple battery. The facility's policy affirms residents' rights to be free from all forms of abuse, but these incidents demonstrate a failure to provide a safe environment and prevent physical abuse among residents.
Widespread Environmental Hazards and Poor Housekeeping
Penalty
Summary
The facility failed to maintain a clean, safe, and hazard-free environment for its residents, staff, and the public. During environmental rounds, multiple rooms were observed with significant cleanliness and maintenance issues, including caked blackish substances on floors, missing closet doors, sharp metal guards protruding, cracked and hole-ridden walls, overflowing garbage cans, and resident clothing stored on bare floors or in plastic bags. Several rooms lacked hangers and closet doors, leading to clothing being left unsecured, and some residents expressed concerns about theft due to the lack of secure storage. Maintenance and housekeeping staff acknowledged these issues, with the Maintenance Director confirming the presence of hazards and the assigned housekeeper admitting that cleaning had not yet been performed for the day. Additional observations included missing floor tiles, cobwebs, broken radiator covers with sharp edges, and water leaks from sinks, with residents sometimes attempting to manage these hazards themselves. Common areas such as hallways and shower rooms were also found to be unclean, with caked dry particles, stains, and the absence of non-skid mats, increasing the risk of falls. The elevator was noted to have a raised metal strip and missing tiles, which the Maintenance Director identified as a safety hazard. Similar issues were found on other floors, including holes in walls, leaking sinks, and cluttered rooms. In the kitchen and dining areas, debris, caked substances, and ice buildup in the freezer were observed, along with stained ceiling tiles and broken radiator covers. Food carts were found with caked blackish and whitish particles, and staff acknowledged that cleaning and maintenance were insufficient. Facility policies and operational manuals require regular maintenance and cleaning to ensure a safe and operable environment, but these standards were not met, as evidenced by the widespread and persistent deficiencies documented during the survey.
Failure to Implement Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program to eliminate bed bugs and rodents, as evidenced by multiple resident and staff interviews, direct observations, and pest control logs. Several residents reported ongoing issues with bed bugs in beds, walls, and bed sheets, as well as mice sightings under beds and in the walls. Staff, including the DON, ADON, Maintenance Director, RNs, LPNs, and CNAs, acknowledged persistent problems with bed bugs, roaches, and mice throughout the facility. One RN described bed bugs falling from the ceiling and being present in chairs at the nurse's station, while residents complained of itching and bug bites. Observations included rooms with clothing stored on the floor, overflowing garbage, and unclean conditions, further contributing to the pest problem. Pest control logs confirmed repeated bed bug activity in multiple rooms and areas such as baseboards, curtains, and bed frames over several weeks. Staff interviews indicated that although a new pest control company was engaged and extermination efforts were ongoing, pests continued to be seen throughout the facility. The DON stated that the bed bug issue was longstanding and attributed it in part to the age of the building. The facility's pest control book documented ongoing extermination efforts, but the presence of pests persisted, affecting the environment and potentially all residents.
Failure to Thoroughly Investigate Sexual Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of sexual abuse involving a cognitively intact resident with multiple diagnoses, including schizoaffective disorder and dementia. The resident reported that another resident entered his room, attempted to pull down his pants, and sexually assaulted him while he was sleeping. The incident was reported to the facility's administrator and documented in both the facility's incident report and a police report. Despite the facility's policy requiring immediate separation of residents, head-to-toe assessments, and sending the alleged victim to the hospital for a rape kit in cases of sexual abuse allegations, the resident was not sent to the hospital. Interviews with facility staff revealed that the administrator, who serves as the abuse coordinator, was unaware that the resident had not been sent to the hospital, and a LPN stated that the resident was not sent because he did not report penetration at the time. The LPN also mentioned the resident's history of making false allegations. The police were called, but the administrator acknowledged that law enforcement cannot rule out sexual assault. Documentation in the facility's incident report and statements from the resident indicated allegations of both sexual assault and theft, but the required investigative steps outlined in facility policy were not followed.
Failure to Protect Residents from Physical Abuse Resulting in Injuries
Penalty
Summary
The facility failed to ensure residents' right to be free from abuse, resulting in physical injuries to three residents. In one incident, a male resident with a history of aggressive and inappropriate behavior was involved in a physical altercation with another male resident, leading to a bruise and head injury. The injured resident initially gave conflicting accounts of the incident, but the facility's investigation substantiated that physical abuse had occurred. The resident was assessed and treated for his injuries, but was not sent to the hospital for further evaluation. Another incident involved two male residents, both with significant psychiatric and medical diagnoses, who engaged in a physical altercation in the dining room. One resident sustained a laceration above the eyebrow and was sent to the hospital for medical and psychological evaluation. The altercation was witnessed by a CNA, who intervened to separate the residents. The injured resident did not return to the facility after hospital evaluation. A third incident occurred during a holiday event, where a male resident with a history of inappropriate social boundaries initiated a physical altercation with a female resident, resulting in a bruise and skin tear above her eyebrow. The female resident was sent to the ER for evaluation and returned in stable condition. Witnesses confirmed that the altercation was unprovoked. The male resident was subsequently discharged from the facility due to repeated aggressive behaviors. In all cases, the facility's failure to prevent these incidents resulted in physical harm to the residents involved.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in multiple incidents of physical and sexual abuse. One resident was sexually assaulted by another resident while under the influence of antipsychotic medication, rendering her unable to defend herself. The assault was witnessed by another resident who intervened by physically assaulting the perpetrator. Despite the severity of the incident, the facility did not immediately report the abuse to law enforcement or provide the victim with timely medical care, including a rape kit, until the following day. Additionally, the facility did not implement adequate interventions to prevent further abuse by the perpetrator, who had a history of sexually inappropriate and aggressive behavior. The perpetrator was not placed under one-to-one supervision, allowing him continued access to other residents, including the victim. The facility's failure to update care plans and implement protective measures for both the victim and the perpetrator placed all residents at risk of further abuse. The facility also failed to address another incident where a resident was physically assaulted by a peer, resulting in severe back pain and fear for personal safety. The facility did not update the care plan for the aggressor or the victim to prevent future incidents. The lack of immediate and effective interventions following these incidents highlights significant deficiencies in the facility's abuse prevention and response protocols.
Removal Plan
- R1-background check completed, has no hits and is not an identified offender. Assessments and care plan have been reviewed and updated to include the following interventions: Provide supportive intervention and individual counseling minimum of 2x's weekly to resident to address appropriate social skills counseling, coping skills, etc. and provide counseling regarding inappropriate behaviors including inappropriate sexualized behaviors. Contact psychiatrist/medical doctor regarding resident behavioral status as needed. Will be encouraged to engage in supervised groups and activities consistently. Staff will provide redirection and counseling to R1 on respecting social boundaries with peers as needed. R1 placed on face checks hourly, documented in EHR. R1 will be supervised when off of his unit.
- R5- currently hospitalized, will be re-assessed for abuse risk, trauma risk upon readmission.
- R6- assessments and care plan have been reviewed and updated to include the following interventions: Staff to ensure safety while promoting emotional well-being. Provide supportive intervention, and counseling minimum 2x's weekly to provide counseling regarding coping skills, and anger management skills. Provide 1:1 counseling minimum 2x's weekly with R6 to address boundary issues relating to conflict. Redirect and counsel R6 when seen displaying inappropriate social boundaries. Use therapeutic communication to redirect R6 whenever she intends to assume staff role. Encourage R6 to participate in psychosocial programming to assist him/her in gaining insight into illness/behaviors/inappropriate social boundaries.
- Policies have been reviewed and updated for following: Abuse prevention Policy.
- All staff will be re-educated re: Abuse Prevention Policy, role of abuse coordinator and responsibilities regarding reporting. Education/ training beginning with completion. Employees on vacation/ leave, will be educated prior to returning to work.
- Residents who are identified as sex offenders through IOP will have high risk offender indicated on PCC special instructions.
- PRSD will review resident sex offenders care plans and update as needed. Review will be completed.
- Nursing and Psych social staff will be educated regarding need for behavior management and increased behavioral observation documented in EHR for minimum of 72 hours for residents involved in res-res abuse. Education/ training beginning with completion.
- Psych social staff will be educated regarding need to complete follow up assessments, including updating care plans as indicated by assessments for residents involved in res-res abuse. Education/ training beginning with completion.
Failure to Implement Abuse Prevention Program
Penalty
Summary
The facility failed to implement its abuse prevention program effectively, leading to multiple incidents of resident-to-resident abuse. The program was not developed in accordance with current regulatory guidelines, and there was a lack of coordination with the QA/QAPI committee to review substantiated cases of abuse. This resulted in several incidents, including a resident being sexually assaulted by another resident, and multiple physical altercations between residents, causing physical and psychosocial harm to those involved. The incidents involved residents with varying vulnerabilities, such as one resident who was unable to defend herself due to the effects of psychotropic medication, leading to a sexual assault. Another resident intervened by physically assaulting the perpetrator to stop the assault. The facility's response was inadequate, as the assaulted resident was not immediately sent for medical evaluation, and law enforcement was not promptly notified. Additionally, the facility failed to update care plans or provide necessary aftercare for the affected residents, further exacerbating their distress and fear. The facility's administration, including the abuse prevention coordinator, was unaware of the requirement to report substantiated abuse cases to the QAPI committee. This lack of awareness and action resulted in a failure to conduct root cause analyses or update care plans to prevent further incidents. The facility's policies were outdated, and there was no evidence of abuse data being reviewed in QAPI meetings, highlighting systemic deficiencies in the facility's practices and oversight.
Removal Plan
- The facility Abuse policy has been reviewed and revised.
- The facility QAPI plan has been reviewed and revised.
- All facility staff will be re-educated on the facility abuse policy. Staff not scheduled to work during this time or on leave will be re-educated prior to their next shift.
- All facility staff will be re-educated on the facility QAPI plan and policy. Staff not scheduled to work during this time or on leave will be re-educated prior to their next shift.
- A QAPI meeting will be held to review the last 30 days of abuse data and root cause analysis performed.
- QAPI meetings will be held monthly. Allegations of abuse to be reviewed during the meeting.
- The Administrator or designee(s) will monitor continued compliance via the following Quality Improvement programs: A root cause analysis will be conducted following any substantiated abuse allegation. An audit will be conducted weekly to ensure a root cause analysis is completed following any abuse allegation.
- The results of the audits completed under this plan will be submitted to the QA/QAPI Committee for review and follow-up and reviewed with Medical Director.
Failure to Implement Effective Abuse Policy Leads to Multiple Incidents
Penalty
Summary
The facility's governing body failed to develop and implement an effective abuse policy, leading to multiple incidents of abuse among residents. The report highlights several instances of physical and sexual abuse, including a resident being hit by another, a resident being sexually assaulted, and other altercations resulting in physical harm. The facility's administrator, who is also the abuse prevention coordinator, substantiated these cases but failed to report them to the Quality Assurance and Performance Improvement (QAPI) committee. Additionally, there was no root cause analysis or updates to the care plans of the affected residents, indicating a lack of follow-through in addressing the incidents. The administrator, who does not possess an active Licensed Nursing Home Administrator (LNHA) license, was unsure of the requirements for reporting substantiated abuse cases to the QAPI committee. The administrator's lack of licensure and experience, as well as the regional team's incompetence regarding abuse regulatory requirements, contributed to the facility's failure to meet regulatory standards. The regional director of operations and the regional director of behavioral health services were also unaware of the updated regulations and the necessity of timely investigations, further exacerbating the issue. The facility's abuse policy was outdated, referencing regulations from 2016, and the regional team was not aware of the updates made in 2022. The investigations into the abuse incidents were not completed within the required five working days, and the facility did not conduct a root cause analysis or review the incidents in QAPI meetings. This lack of compliance with regulatory requirements and failure to implement effective policies and procedures put all 142 residents at risk of harm.
Inaccurate Resident Assessments Lead to Abuse Incidents
Penalty
Summary
The facility failed to accurately complete resident assessments for three residents, which contributed to repeated incidents of physical and sexual abuse among residents. Resident 1 had a documented history of socially inappropriate behavior and aggression, yet their Aggression and Violence History Assessment did not reflect this history accurately. This oversight led to Resident 1 being involved in a sexual assault incident with another resident. Similarly, Resident 3, who had a history of arrests and aggressive behavior, was not accurately assessed, resulting in a physical altercation with another resident. Resident 6, who was involved in a physical altercation with a peer, also had an incomplete Aggression and Violence History Assessment. The assessment failed to document a history of abuse or socially inappropriate behavior, which contributed to the incident. The Psychiatric Rehabilitation Service Director acknowledged the inaccuracies in the assessments and the ongoing efforts to correct them. The facility's policies on behavior management and abuse prevention were not effectively implemented, as evidenced by the lack of accurate assessments and care plans. Interviews with facility staff, including the Administrator, Director of Nursing, and Medical Director, highlighted the importance of accurate assessments and care plans in preventing abuse and ensuring resident safety. However, the failure to update care plans and assessments in a timely manner left residents vulnerable to abuse and neglect. The facility's policies emphasized the need for comprehensive assessments and care plans, but these were not consistently followed, leading to the deficiencies observed.
Failure to Update Care Plan for Resident at Risk of Abuse
Penalty
Summary
The facility failed to identify and address the risk of abuse for a resident, R4, who was involved in a physical altercation with another resident, R3. R4, who has a history of mental illness and dementia, was hit in the face by R3, resulting in facial swelling and psychosocial harm. Despite R4's severe cognitive impairment and the documented risk for abuse, the facility did not update R4's care plan to reflect these risks and provide appropriate interventions. The incident occurred after R4's At Risk for Abuse Assessment indicated a need for a care plan due to R4's mental health diagnoses and need for extensive assistance with activities of daily living. However, the care plan was not updated following the assessment or after the altercation with R3. The facility's policy requires immediate updates to care plans when a resident is identified as at risk for abuse, but this was not done, leaving R4 vulnerable to further harm. Interviews with facility staff, including the Administrator, Psychiatric Rehabilitation Service Director, and MDS Coordinator, revealed a lack of timely action in updating R4's care plan. The staff acknowledged the importance of updating care plans to prevent harm and safeguard residents, but the necessary updates were not made. This oversight resulted in R4 experiencing fear and feeling unsafe in the facility, as well as physical harm from the altercation.
Failure to Provide Timely Aftercare and Psychological Support After Sexual Assault
Penalty
Summary
The facility failed to provide timely aftercare and psychological services to a resident, R5, who was sexually assaulted by another resident, R1. The incident occurred at night when R5 was under the influence of antipsychotic medication, which left R5 unable to defend herself. The assault was interrupted by another resident, R6, who intervened. Despite the severity of the incident, the facility did not promptly notify law enforcement, and a rape kit was not administered until the following evening. R5 expressed a desire to go to the hospital immediately after the assault, but this was not facilitated by the nursing staff. The facility's response to the incident was inadequate, as R5 did not receive appropriate psychological support following the assault. Although a well-being check was documented, it did not specifically address the trauma from the sexual assault. R5 continued to experience fear, depression, and flashbacks, exacerbated by R1's continued presence in the facility. The care plan for R5 was not updated to reflect the specific needs related to the sexual trauma until 13 days after the incident, and it failed to address R5's history of sexual trauma or provide a clear plan for counseling and support. The facility's policies on trauma-informed care and abuse reporting were not followed. The Director of Nursing and the Medical Director acknowledged the lack of timely action and documentation. The facility's failure to provide immediate and appropriate care and support for R5's trauma contributed to R5's deteriorating mental health, leading to a psychiatric hospitalization due to self-harm thoughts. The lack of documentation and follow-up care highlights significant deficiencies in the facility's handling of the incident.
Failure to Report and Investigate Abuse Timely
Penalty
Summary
The facility failed to notify law enforcement of a reasonable suspicion of a crime within the required reporting timeframe and did not submit initial and final physical and sexual abuse investigation reports to the state survey agency as mandated. This deficiency affected five residents who were sampled for abuse reporting. One resident reported being sexually assaulted by another resident while under the influence of psychotropic medication, and the incident was not reported to the police until the following day. The facility also delayed notifying the state survey agency about the incident, exceeding the 16-hour reporting requirement. In another incident, two residents were involved in a physical altercation, resulting in one resident sustaining a swollen eye. The facility did not report the incident to the appropriate authorities in a timely manner, and the residents were not separated immediately to prevent further altercations. The staff failed to report the injury to the medical director or the resident's family, and the incident was not documented or investigated promptly. The facility's policy on abuse prevention was not adhered to, as staff did not report or investigate allegations of abuse and neglect as required. The administrator and director of nursing acknowledged the failures in reporting and investigation, but could not provide reasons for the delays. The facility's failure to follow its abuse prevention policy and regulatory requirements resulted in a lack of protection for the residents involved.
Incomplete Investigations of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly complete investigations of abuse allegations involving four residents, resulting in deficiencies in the investigation process. The investigation into a physical abuse incident between two residents, R6 and R7, was not completed within the required five working days due to conflicting evidence. The Regional Director of Operations, V15, acknowledged the delay and uncertainty about extending the investigation period, while the Regional Director of Behavioral Health Services, V19, confirmed the abuse but noted the lack of a root cause analysis. Another incident involved a verbal and physical altercation between residents R3 and R4, where R3 punched R4, resulting in a swollen eye. Despite the incident being reported, the investigation was not conducted thoroughly, with only two interviews conducted. The Director of Nursing, V2, admitted that the incident was not reported promptly, and the nurse, V6, failed to report the injury, believing the residents' accounts were not credible. The facility's policy requires a final investigation report within five working days, including details of the incident, interviews, and conclusions. However, the investigations were incomplete and not conducted within the specified timeframe, leading to deficiencies in handling abuse allegations. The facility's staff, including the Administrator, V1, and other directors, acknowledged the shortcomings in the investigation process and the failure to separate the residents immediately after the altercation.
Failure to Notify Physician and Family of Resident Injury
Penalty
Summary
The facility failed to notify a physician and family regarding a resident who sustained an injury. This deficiency was identified during a review of a sample of eight residents, specifically affecting one resident. The incident involved a resident with a severely impaired cognitive status, as indicated by a Brief Interview for Mental Status (BIMS) score of 4, who had a history of schizoaffective disorder, dementia, major depressive disorder, anxiety disorder, and hemiplegia. The resident was involved in an altercation with a roommate, resulting in a swollen eye, which was not reported to the physician or family as required by the facility's policies. The incident was documented in the resident's progress notes by a registered nurse, who noted the swelling on the resident's eye and the resident's account of a fight with a roommate. However, the nurse did not report the injury to the physician or the resident's family, believing the injury was not severe and doubting the residents' accounts due to their confusion. The facility's policies require that any resident injury, regardless of severity, be reported to the attending physician and responsible party, which was not adhered to in this case. Interviews with facility staff revealed a lack of immediate action following the altercation. The Psychiatric Rehabilitation Service Director acknowledged the altercation but was unsure of the details and timing. The Director of Nursing confirmed that serious injuries or those potentially involving abuse should be reported immediately to a physician or nurse practitioner. The facility's policies on first aid treatment, change in condition, and abuse emphasize the importance of notifying the physician and responsible party of any changes in a resident's condition, particularly when the cause of an injury is unknown or suspicious.
Inappropriate Documentation of Psychotropic Medication Indications
Penalty
Summary
The facility failed to document appropriate indications and clinical needs for psychotropic medications for one resident, identified as R4. R4 has multiple diagnoses, including schizoaffective disorder, unspecified dementia with behavioral disturbance, major depressive disorder, and anxiety disorder. Despite these conditions, the facility's records indicated that psychotropic medications were prescribed for 'prophylaxis,' which is not an appropriate indication. The medications included Paroxetine, Aripiprazole, Trazodone, and Quetiapine, all administered daily or at bedtime. The facility's policy requires that psychotropic medications be used with appropriate indications and monitoring, which was not adhered to in this case. Interviews with facility staff revealed a lack of clarity and communication regarding the prescription and monitoring of psychotropic medications. The Administrator deferred questions to clinical staff, while the Medical Director and Psychiatric Medical Director were either unavailable or unwilling to discuss the issue. The Director of Nursing acknowledged that 'prophylaxis' is not an appropriate indication for psychotropic medications, and the Licensed Pharmacist confirmed that medication reviews are conducted monthly, but 'prophylaxis' is not a valid diagnosis. The facility's policy emphasizes avoiding unnecessary drugs and ensuring medications are used with proper justification, which was not followed in R4's case.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an altercation between two residents, R1 and R2. Both residents were diagnosed with mental health disorders, including Schizoaffective Disorder and Bipolar Disorder, and were cognitively intact with BIMS scores of 15 out of 15. The incident occurred when R1, who has a history of violent behavior, became agitated and struck R2 in the face. In response, R2 hit R1 back, resulting in R1's eye becoming swollen. Both residents later expressed that they felt safe and had no ongoing issues with each other. The facility's investigation confirmed that R1 initiated the physical aggression due to an inability to control his actions related to his diagnosis. The facility's abuse policy, dated March 2022, clearly prohibits any form of abuse, including physical abuse, which is defined as the infliction of injury that requires medical attention. The administrator acknowledged that any physical altercation between residents is considered abuse. Despite the residents' reconciliation, the incident highlights a failure to prevent resident-to-resident physical abuse, as required by the facility's policy.
Improper Freezer Functioning Affects Food Safety
Penalty
Summary
The facility failed to maintain a properly functioning walk-in freezer for storing residents' food, which has the potential to affect the nutritional needs of 139 residents. During an inspection, the surveyor observed that the freezer's temperature was above the required level, with the thermometer reading 6 degrees Fahrenheit on one occasion and 5 degrees Fahrenheit on another. Multiple boxes of meat were found unfrozen and soft to the touch, indicating that the freezer was not maintaining the necessary temperature to keep food safely stored. Condensation and water dripping from the ceiling of the freezer were also noted, suggesting issues with the freezer's operation. Interviews with facility staff revealed that the freezer had been experiencing problems, with the Dietary Manager stating that the freezer goes into defrost mode and that a repair company had been contacted to address the issue. The Administrator was unaware that the freezer was still malfunctioning, despite having spoken with a technician previously. Facility documents indicated that the freezer had been over-temping and short cycling, with the kitchen environment contributing to the freezer's struggles. The facility's policy requires freezer temperatures to be 0 degrees or below, which was not being met at the time of the survey.
Facility Fails to Maintain Safe and Functional Shower Rooms
Penalty
Summary
The facility failed to maintain a safe and functional environment in the shower rooms located on the third, fourth, fifth, and sixth floors, potentially affecting all 139 residents residing on these floors. During a tour conducted by the surveyor and the Maintenance Director, it was observed that the shower rooms on these floors had a wet, black substance on the stall areas and walls, which the Maintenance Director identified as rust and dirt. Additionally, there were brown stained buckling ceiling tiles and water damage to the ceilings, walls, and baseboards, attributed to a flood from toilets and sinks. The Maintenance Director acknowledged the need for repairs and stated that there were plans to address the damage with contractors. Further inspection with the Housekeeping Director revealed that the wet, black substance was identified as mold, which was beyond the cleaning capabilities of the housekeeping staff and required replacement and repair. The Housekeeping Director confirmed that the maintenance department was responsible for these repairs. Both directors emphasized the importance of maintaining the shower rooms for the safety and infection control of the residents. The job descriptions for both directors outlined their responsibilities to ensure cleanliness and maintenance, including making frequent rounds to monitor and address any issues immediately.
Ineffective Pest Control Program for Bed Bugs
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure it was free of bed bugs, affecting one resident and potentially all 139 residents. The Maintenance Director, V8, was unaware of any current bed bug issues, despite the pest control company visiting weekly. V8 did not receive pest control reports, relying on staff to inform them of pest control activities. The Housekeeping Director, V9, also denied knowledge of current bed bug treatments, although they participated in rounds with the pest control company. V9 stated that housekeeping staff prepared rooms for pest control by removing and cleaning privacy curtains. The pest control company representative, V15, confirmed ongoing bed bug activity and treatments, including recent treatments in R9's room. The Administrator, V1, acknowledged the pest control company's efforts since February 2024 but expressed dissatisfaction with their effectiveness, planning to hire a new company. R9, a resident with a BIMS score indicating cognitive intactness, reported seeing bed bugs in their room but had not observed any on their skin or clothing. R9 reported the sightings to a nurse, but the nurse, V16, was unaware of any current bed bug complaints or activity. The Director of Nursing, V2, stated that they only address bed bugs if reported on a resident, involving skin assessments and room treatments. V2 explained that residents are returned to their rooms after a 24-hour heat treatment unless bite marks are present, in which case a physician is notified. Pest control documents indicated multiple treatments for bed bugs in various rooms, with recommendations for laundering curtains. The facility's pest control guidelines emphasized maintaining a pest-free environment, but the lack of communication and coordination among staff and management contributed to the deficiency.
Deficiency in Resident Privacy Due to Missing Curtains
Penalty
Summary
The facility failed to ensure that residents had privacy curtains that extended around their beds, affecting thirteen residents out of a total sample of twenty-two. On two separate occasions, surveyors observed these residents without privacy curtains. The Housekeeping Director, identified as V9, explained that the absence of privacy curtains was due to a lack of curtain hooks and broken curtain tracks. Additionally, V9 mentioned that privacy curtains are removed for pest control treatments and are supposed to be washed and replaced afterward. The Maintenance Director, identified as V8, acknowledged the issue and stated that the facility is undergoing remodeling, during which contractors plan to repair all broken privacy curtains. Both V9 and V8 recognized the importance of privacy curtains for maintaining residents' privacy. The facility's documents on Residents Rights emphasize the residents' right to privacy and a dignified existence, which was not upheld in this instance due to the missing privacy curtains.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident, R2, from physical abuse by another resident, R3, resulting in multiple injuries to R2, including bruising to the eye, swelling and blood in the mouth, and a damaged fingernail. R2, who has a history of bipolar disorder, major depressive disorder, and mood disorder, was attacked by R3, who has schizoaffective disorder, major depressive disorder, and dementia. The incident occurred when R3 became agitated over a personal belonging, specifically a jacket, leading to an unprovoked physical attack on R2. The facility's investigation revealed that R3 had a history of aggressive behavior, which was not adequately addressed in his care plan, particularly concerning personal space and belongings. The incident was not reported by the nursing staff on the shift during which it occurred, and the injuries were only discovered by staff on the following shift. The facility's administrator acknowledged that the staff from the prior shift were not included in the investigation, contrary to the facility's abuse policy, which requires interviewing anyone likely to have direct knowledge of the incident. The facility's policy emphasizes the importance of preventing abuse and ensuring a secure environment, but the failure to address R3's known triggers and history of aggression contributed to the incident. Additionally, the lack of timely reporting and investigation of the incident highlights deficiencies in the facility's response to abuse allegations.
Failure to Implement Fall Prevention and Update Care Plan
Penalty
Summary
The facility failed to implement fall prevention interventions and include each fall in the resident's care plan, which affected one resident who was reviewed for falls. This resident, who had a history of schizoaffective disorder, muscle weakness, dependence on a wheelchair, and dementia, was found on the floor with significant injuries, including fractures to the right leg, hip, and pelvis. The incident occurred after the resident was left unattended in bed, and it was noted that the resident required extensive assistance with activities of daily living, including transfers, and could not ambulate independently. Despite previous falls, such as one documented in April, the resident's care plan did not include details of these incidents or appropriate interventions to prevent future falls. Staff interviews revealed inconsistencies in the understanding of the resident's abilities, with some staff stating the resident could not ambulate or transfer independently, while others believed the opposite. The facility's fall program policy mandates that care plans be updated after every fall, but this was not adhered to, as evidenced by the missing documentation of the resident's previous fall in the care plan.
Failure to Investigate Abuse Allegation Thoroughly
Penalty
Summary
The facility failed to conduct a thorough investigation of a physical abuse allegation involving two residents. Resident R2, who has a history of bipolar disorder, major depressive disorder, and mood disorder, was physically assaulted by Resident R3, who has schizoaffective disorder, major depressive disorder, and dementia. The incident occurred when R3 became agitated over a personal belonging, leading to R3 punching R2 in the face, resulting in a swollen jaw and a partially detached fingernail. Despite the severity of the incident, the facility did not include the nursing staff from the shift during which the incident occurred in the investigation, contrary to the facility's abuse policy. The facility's abuse policy mandates interviewing anyone likely to have direct knowledge of the incident, but this was not adhered to. The incident was reported by V5, a Registered Nurse, and V8, a Certified Nursing Assistant, who noticed R2's injuries at the start of their shift. However, the staff from the previous shift, who might have had direct knowledge of the incident, were not interviewed. Additionally, the facility did not address the issue of personal belongings that triggered R3's aggression, despite R3's documented history of aggressive behavior. This oversight in the investigation process and failure to address known triggers for aggression contributed to the deficiency in handling the abuse allegation properly.
Incomplete Documentation of Fall Incident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced falls. The resident, who had a history of schizoaffective disorder, muscle weakness, dependence on a wheelchair, and dementia, was involved in a fall incident on 4/12/2024, which was not documented in the care plan. Despite being identified as a high risk for falls, the care plan did not reflect the fall or address the potential risk factors, such as the resident's ability to get up and transfer independently. This oversight was noted during a review by a restorative nurse, who highlighted the necessity of including every fall in the care plan. The Director of Nursing (DON) was informed of the missing documentation and initially provided a care plan that included the fall, but later failed to produce a care plan history with the created date for the fall incident. The DON cited technical issues and the resident's discharge as reasons for the inability to access the care plan history. However, conflicting information was provided regarding the resident's assistance needs, with some staff documenting the resident as requiring extensive assistance, contrary to the DON's statement. The inconsistency in documentation and failure to update the care plan after the fall incident led to the deficiency identified by the surveyors.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to ensure a homelike environment for several residents, as evidenced by multiple observations of disrepair and lack of privacy. In one instance, the wall above the sink in a shared room was observed with bubbled paint and a black substance, attracting insects. Additionally, some rooms lacked privacy curtains, which the Maintenance Director acknowledged as important for residents' dignity. The Maintenance Director cited understaffing as a reason for the delay in addressing these issues, while the Housekeeping Director noted that the absence of curtain tracks prevented the installation of privacy curtains. Further observations revealed safety hazards and maintenance issues, such as a metal spring protruding from a resident's chair and loose ceiling tiles in a restroom, which posed a risk of falling. The Maintenance Director admitted to being aware of these issues but stated that providing a homelike environment is an ongoing process. Residents expressed dissatisfaction with the state of their living conditions, with some reporting that maintenance requests had been ignored for weeks. Additional deficiencies included holes in walls and ceilings, missing window curtains, and broken fixtures, which residents reported had been in disrepair for extended periods. The Maintenance Director acknowledged these issues, attributing some to past flooding, and stated that repairs were underway. Residents expressed discomfort and frustration with the lack of privacy and the unaddressed maintenance problems, which detracted from their quality of life in the facility.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to proper food storage and handling practices, as observed during a survey of the kitchen area. The surveyor noted that food items in the facility's kitchen were not dated when received or opened, and expired food items were not discarded. Specifically, a block and a half block of yellow cheese were found not in their original packaging, undated, and unlabeled. Additionally, sliced apples and applesauce were observed to be past their expiration dates, and resident lunch bags were either undated or improperly dated. These lapses in food labeling and storage practices were acknowledged by the dietary cook, who admitted that such practices could lead to food spoilage and potential contamination. The survey also revealed issues with the cleanliness and maintenance of kitchen equipment. The ice machine was found with a black substance on its front plate, which the dietary cook identified as dirt, indicating that it had not been cleaned recently despite claims of daily cleaning. Furthermore, there was no cleaning schedule or logs maintained for the ice machine. In the walk-in freezer, a door plate was observed to be frozen solid with ice, posing a safety hazard as acknowledged by the dietary manager, who noted that the ice buildup could cause someone to fall. The facility's documentation, including policies from 2014, outlined the requirements for food and supply storage, safe food preparation, and ice machine use, emphasizing the need for cleanliness, proper labeling, and adherence to safety standards. However, these guidelines were not followed, as evidenced by the survey findings. The dietary manager was unable to provide the manufacturer's guidelines for the walk-in freezer and ice machine, further highlighting the facility's failure to maintain compliance with established food safety and sanitation protocols.
Failure to Ensure Dumpster Lids Are Closed
Penalty
Summary
The facility failed to ensure that the dumpster lids were closed, which has the potential to affect all 144 residents residing at the facility. During an inspection of the facility's dumpster area, the surveyor and the Maintenance Director observed three dumpster lids open. The Maintenance Director acknowledged that everyone who uses the dumpster should ensure it is closed and mentioned that the garbage company, which collects trash every day except Sunday, often leaves the lids open. However, on the day of the inspection, the garbage company had not visited, and the Maintenance Director was unsure how long the lids had been open. The Director of Nursing confirmed that the facility did not have a policy regarding the management of the outside dumpster. The job descriptions for the Director of Maintenance and the Director of Housekeeping/Guest Services Director emphasize the importance of maintaining facility standards in accordance with federal, state, and local regulations. These roles include making frequent rounds to evaluate and correct any issues immediately, which suggests a lapse in oversight regarding the dumpster area. The open dumpster lids pose a risk of attracting pests, which could compromise the cleanliness and safety of the facility environment.
Facility Maintenance and Safety Deficiencies
Penalty
Summary
The facility failed to maintain a safe and clean environment for its residents, staff, and the public, as evidenced by several deficiencies observed during a survey. In the laundry room, a surveyor found that the lint trap of dryer #3 was not cleaned, with thick lint debris accumulated in the compartment and on the floor. The Laundry Aide, V29, admitted to not cleaning the lint trap during their shift, despite having dried seven loads of laundry. The facility's Lint Trap Cleaning & Disposal Log, which requires documentation of lint removal after each use, had no entries for the days of the survey, indicating a lapse in following safety protocols designed to prevent fire hazards. On the third floor, multiple resident rooms and bathrooms were found to have large holes in the walls and broken lights, including a room with a missing wall outlet cover. The Maintenance Director, V9, acknowledged these issues but cited understaffing as a reason for the delay in repairs. The facility's job descriptions for maintenance staff emphasize the importance of maintaining the building in good repair and ensuring safety, yet these responsibilities were not met, potentially compromising the safety and comfort of the residents. Additionally, the common restroom on the fifth floor had missing baseboard tiles, bulging ceiling tiles, and a vent without a cover. The Maintenance Director, V9, confirmed these observations and stated that these issues had been reported the previous week but had not yet been addressed. The facility's maintenance staff is responsible for performing general repairs and responding to safety concerns, but the observed deficiencies indicate a failure to uphold these duties, affecting the overall environment of the facility.
Failure to Serve Meals with Dignity
Penalty
Summary
The facility failed to treat residents with dignity during mealtime in the 6th floor common dining area. Observations revealed that the staff member, identified as V12, served food trays to residents in a manner that did not respect their dignity. Instead of serving all residents at a table before moving to the next, V12 served trays from the top shelf of the food cart down, resulting in some residents being served while others at the same table were left waiting. This practice was observed to affect multiple residents, including R7, R65, R82, R87, R94, R97, R131, R135, and R145, who were left without food trays while their tablemates were already eating. Interviews with staff, including V11, the Assistant Director of Nursing, and V2, the Director of Nursing, confirmed that the expectation was for staff to serve all residents at a table before moving to the next. V2 emphasized the importance of this practice to minimize behavioral issues and ensure residents do not feel unimportant. The report documented that residents expressed dissatisfaction with the serving method, with some stating that it was not a new issue and that they had experienced similar situations before. The report also included details about the residents' medical conditions and cognitive statuses. For instance, R7 was noted to have a moderately impaired mental status with diagnoses including schizoaffective disorder and schizophrenia. Other residents, such as R54 and R65, were documented as cognitively intact. The facility's policy on accommodating resident needs and preferences was also mentioned, highlighting the importance of creating a homelike environment that maintains residents' dignity and well-being.
Deficiency in Call Light Accessibility
Penalty
Summary
The facility failed to ensure that call lights were within reach for five residents, leading to a deficiency in accommodating the needs and preferences of these residents. Observations revealed that one resident's call light cord was found on the floor and not easily accessible, despite the resident having severe cognitive impairments and multiple medical conditions, including schizoaffective disorder and muscle weakness. Interviews with staff confirmed that the call light should be within reach for residents to call for assistance, but this was not consistently ensured. Additionally, the surveyor observed that there were no cords attached to the call lights in the bathrooms of four other residents, making it difficult for them to signal for help. These residents had varying degrees of cognitive impairment and physical limitations, such as limited mobility and risk for falls. Staff acknowledged the absence of strings on the bathroom call lights and recognized the difficulty this posed for residents needing assistance. The facility's policy on call lights did not specify the need for them to be reasonably accessible, only that they should be plugged into the wall. The Director of Nursing acknowledged the expectation for call lights to be within reach and the need for strings on bathroom call lights. The facility's policy on accommodating resident needs emphasized creating a homelike environment and maintaining resident independence, which was not upheld in these instances.
Controlled Substance Count and Inventory Deficiencies
Penalty
Summary
The facility failed to ensure the accuracy of the controlled substance count for a resident and did not conduct a proper physical inventory of controlled substances on the 4th floor at each change of shift. During an observation of the medication cart, it was found that the controlled drug count for a resident's Phenobarbital medication was incorrect. The Controlled Drug Receipt/Record/Disposition Form indicated a count of four tablets, but only two tablets were present in the blister packet. The registered nurse involved explained that one tablet was administered, and another was dropped and disposed of, but these actions were not immediately documented as required. The resident in question has a diagnosis of absence epileptic syndrome, not intractable, without status epilepticus, and has a physician's order for Phenobarbital to be administered four times a day. The failure to accurately document the administration and disposal of the medication could potentially affect the resident's treatment and safety. Additionally, the facility's policy requires that all controlled substances be documented immediately upon administration or disposal, which was not adhered to in this instance. Furthermore, the facility did not ensure that two licensed personnel conducted a physical inventory of controlled substances at each shift change on the 4th floor. The Shift Change Accountability Record for Controlled Substances showed numerous instances where only one or no licensed personnel's initials were recorded, indicating a lack of compliance with the facility's policy. This oversight has the potential to affect all 34 residents residing on the 4th floor, as it compromises the accountability and security of controlled substances.
Failure to Label Opened Multi-Dose Medications
Penalty
Summary
The facility failed to label opened multi-dose medication vials, which has the potential to affect five residents reviewed for medications. During an observation of the medication cart on the 5th floor, it was noted that several inhalers, including Fluticasone, Ventolin, and Symbicort, were opened without labels indicating when they were opened. The Registered Nurse (RN) acknowledged that the open date should be recorded to determine the medication's expiration, as some medications expire sooner after being opened. The residents involved had diagnoses including chronic obstructive pulmonary disease and allergic rhinitis, with specific physician orders for the use of these medications. Further observations on the 4th floor revealed that Azelastine eye drops for two residents were also opened without labels indicating the open date. The RN on duty was unaware of why the medications were not labeled, despite acknowledging the importance of labeling for expiration purposes. The Director of Nursing (DON) confirmed that while there is no specific policy on multi-dose medications, the Medication Administration policy requires labeling with an open date. The facility's policies and job descriptions emphasize the importance of labeling and monitoring medication administration, yet these procedures were not followed, leading to the deficiency.
Inaccurate Assessment of Resident's Functional Limitation
Penalty
Summary
The facility failed to accurately assess a resident's functional limitation in range of motion, specifically not identifying the impairment on both sides of the resident's upper extremity as required. The resident, identified as R35, was observed to have flaccidity in the right arm and was unable to move it independently, as confirmed by the resident's own actions and the surveyor's observations. The resident's admission record and restorative observation documented a diagnosis of flaccid hemiplegia and right-side paralysis, respectively. However, the Minimum Data Set (MDS) assessment inaccurately stated that there was no impairment in the resident's upper extremity. This discrepancy was confirmed by a Licensed Practical Nurse, who acknowledged that the MDS should have reflected the impairment. The CMS's RAI Manual provides specific coding instructions for such impairments, which were not followed in this case.
Failure to Complete PASARR for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that preadmission screening assessments were completed for residents identified with a mental illness diagnosis, affecting two residents in the sample. Resident R21, diagnosed with Schizoaffective Disorder, had a documented history indicating a reasonable basis for suspecting a severe mental illness. Despite this, there was no record of a Level II Pre-Admission Screening and Resident Review (PASARR) being completed for R21. Similarly, Resident R53, also diagnosed with Schizoaffective Disorder, did not have a Level II PASARR completed, even though their records indicated a need for such an assessment. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of PASARRs. The Director of Nursing indicated that the Admissions Director was responsible for PASARRs, while the Admissions Director stated that PASARRs are done prior to residents arriving at the facility and that no one at the facility ensures their completion. The Social Services Director also expressed a lack of involvement and knowledge about the PASARR process. Facility policies outlined procedures for ensuring OBRA screens are completed, but these were not followed, leading to the deficiency.
Failure to Provide Range of Motion Restorative Programming
Penalty
Summary
The facility failed to provide range of motion restorative programming to a resident with a diagnosis of flaccid hemiplegia on the right side. During an observation, the resident was seen lying in bed and unable to move their right arm, which was flaccid. The resident indicated that staff had not been exercising or providing range of motion to the right arm. The resident's Minimum Data Set indicated severe cognitive impairment, and their care plan required passive and active range of motion exercises to the affected site daily. The Licensed Practical Nurse (LPN) responsible for restorative care confirmed the resident's paralysis and acknowledged the lack of documentation for range of motion exercises being completed by staff. The LPN stated that the facility prioritized two restorative programs at a time, which did not include range of motion for this resident, despite it being part of the care plan. The facility's policy required the Restorative Nurse to initiate a care plan and for Certified Nursing Assistants to carry out restorative services, which was not adhered to in this case.
Inappropriate Use of Antipsychotic Medication for Dementia Patient
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of dementia received antipsychotic medication only when medically necessary. The resident, who was part of a sample of 62, was prescribed RisperDAL, an antipsychotic medication, for behavioral disturbances despite not having a documented diagnosis that warranted its use. The resident's admission record indicated diagnoses of unspecified dementia with other behavioral disturbance, major depressive disorder, and apraxia following a nontraumatic intracerebral hemorrhage, but did not include any psychiatric diagnoses that would justify the use of antipsychotics. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment with no noted behavioral symptoms during the lookback period. Interviews with facility staff revealed a lack of awareness regarding the black box warning associated with the use of antipsychotic medications in patients with dementia. The Assistant Director of Nursing and the Director of Nursing both confirmed that the medication was prescribed for behavioral disturbances related to dementia, but neither could provide documentation of behaviors that would necessitate such medication. The facility's policy on psychotropic medication use emphasized appropriate dosing, monitoring, and reduction or discontinuation when clinically indicated, which was not adhered to in this case.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to administer medications according to physician orders for three residents, resulting in a 25% medication error rate. For one resident, a registered nurse mistakenly identified another resident as the intended recipient and nearly administered the wrong medications, including Benztropine, Lisinopril, Magnesium Oxide, Sennosides, and Oxybutynin Chloride ER. The error was prevented by a surveyor's intervention, who confirmed the nurse's failure to verify the resident's identity before administering the medications. Another resident did not receive their prescribed dose of AmLODIPine 2.5 mg due to an empty medication card, and no replacement was available in the medication cart. Additionally, a third resident received only half of the prescribed dose of Vitamin D3, as the nurse administered a 25 MCG tablet instead of the ordered 50 MCG. The Director of Nursing acknowledged that all nurses should adhere to the facility's policy of using the five rights of medication administration, which includes verifying the correct resident, medication, and dose.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that residents requiring Enhanced Barrier Precautions (EBP) were provided with appropriate signage and personal protective equipment (PPE). Specifically, two residents, R54 and R126, who were on the EBP list, did not have EBP signs posted outside their rooms. Additionally, the PPE bins outside their rooms lacked gowns, which are essential for the precautions. This deficiency was observed during a survey conducted on June 2, 2024, when the Assistant Director of Nursing (V11) confirmed the absence of EBP signs and gowns in the PPE bins. The Director of Nursing (V2) acknowledged the lack of EBP signs, stating that they had been ordered but not yet delivered. The Infection Preventionist (V27) explained the importance of EBP for residents with conditions such as wounds, indwelling catheters, and tracheostomy tubes, emphasizing the need for PPE to prevent the spread of infections. Both R54 and R126 had wounds that required EBP to prevent fluid splashes during treatment, yet the necessary precautions were not in place. R54's medical records indicated a chronic ulcer on the right lower leg, requiring daily dressing changes, and R126 had peripheral vascular disease with a wound on the left lower extremity. Both residents had active orders for EBP due to their wounds, with care plans emphasizing the use of gowns and gloves for high-contact activities. Despite these documented needs, the facility did not provide the required PPE or signage, failing to adhere to their own policies and procedures for infection prevention and control.
Pest Control Deficiency in Resident's Bathroom
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of a swarm of gnats in a resident's bathroom. The incident was brought to the attention of a surveyor by a resident who was visibly upset and reported that the issue was persistent, with gnats, mice, and bed bugs being a common problem. The surveyor observed numerous gnats in the bathroom and noted missing tiles and holes, which could potentially allow pests to enter. The resident involved, who is cognitively intact with a BIMS score of 15, has a medical history that includes chronic obstructive pulmonary disease with acute lower respiratory infection, acute bronchitis, acute respiratory distress, and shortness of breath. Interviews with facility staff revealed a lack of clarity regarding responsibility for pest control. A housekeeper acknowledged the presence of gnats and suggested that a hole in the bathroom might be the source. The Director of Nursing indicated that housekeeping was responsible for pest control, while the facility's pest control policy stated that the facility should maintain an ongoing program to keep the building free of insects and rodents. A recent pest control document recommended repairs to prevent pest entry, highlighting gaps and damage that could allow pests access. The job description for the Director of Housekeeping included maintaining the pest control program, but the deficiency suggests this responsibility was not effectively managed.
Failure to Address Bed Bug Infestation and Timely Prescribe Treatment
Penalty
Summary
The facility failed to ensure that a resident (R3) remained free from bed bug bites and did not timely prescribe medications to relieve itching and inflammation. This resulted in R3 sustaining multiple bed bug bites on various parts of the body, including the hands, arms, feet, legs, and abdomen, leading to severe itching, open bleeding wounds, and scarring. Despite R3's intact cognition and ability to communicate the issue, the facility staff did not take immediate action to address the bed bug infestation or provide appropriate medical treatment until prompted by a surveyor's inquiry. On 4/2/24, a surveyor observed R3 with open bleeding wounds and inflamed areas on the skin. R3 confirmed the presence of bed bugs and the lack of prescribed treatment for the bites. The Licensed Practical Nurse (V5) inspected R3's skin and acknowledged the bites and itching but had not called the doctor until the surveyor's inquiry. The facility's progress notes from March to April 1, 2024, did not document the bed bug bites or skin assessments. It was only after the surveyor's intervention that the doctor was called, and orders for Bacitracin and Hydrocortisone were prescribed. The facility's change in condition policy requires staff to call the physician when a resident's condition changes, which was not followed in this case.
Failure to Maintain Clean and Safe Environment Due to Bed Bug Infestation
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the presence of bed bug eggs and excrement in a resident's room. The deficiency was observed when a resident on the 5th floor pointed out several large circular areas with speckled brown and black matter on the wall adjacent to his bed, which he identified as bed bug excrement. The resident reported having bed bugs all over his legs and feet. A Licensed Practical Nurse (LPN) confirmed the presence of what appeared to be bite marks on the resident's lower extremities. Despite these observations, the staff did not notify housekeeping to address the bed bug issue in the resident's room. A Certified Nursing Assistant (CNA) and the Director of Nursing (DON) also acknowledged the presence of bed bug eggs and excrement but did not take immediate action to clean the affected area. The facility's housekeeping staff were found to be insufficiently staffed to thoroughly clean resident rooms, including moving furniture and cleaning walls. One housekeeper reported being responsible for cleaning two floors due to staff shortages, which made it difficult to maintain cleanliness standards. The housekeeping policy, which follows CDC recommendations, did not specifically include cleaning walls, contributing to the oversight. The facility census indicated that the resident had been transferred to the current room eight days prior to the survey, suggesting that the bed bug issue had been present for some time without being addressed. This failure to maintain a clean and safe environment has the potential to affect all 152 residents in the facility.
Failure to Follow Physician Orders and Address Family Concerns
Penalty
Summary
The facility failed to follow physician orders, provide timely podiatry services, document services rendered in the progress notes, obtain physician consult orders prior to receiving podiatry services, implement a concern/resolution form, timely schedule a care plan meeting as requested, and document specific health/well-being concerns for one resident reviewed for physician services. Specifically, a resident with a history of type II diabetes mellitus and other circulatory problems did not receive timely podiatry services as ordered. The resident's toenails were debrided by a podiatrist two months after the required timeframe, and the services were not documented in the progress notes. Additionally, the physician consult orders were obtained several days after the podiatry services were provided. The facility also failed to address concerns raised by the resident's family member, who is the Power of Attorney (POA). The family member had reported concerns about the resident's well-being and requested a care plan meeting. Although the Director of Nursing (DON) acknowledged receiving a call from the city of Chicago inspectors following up on the family member's request for medical records, there was no documentation of the specific health concerns, resolutions, or care plan meeting arrangements in the progress notes. The facility's grievance policy requires that concerns be documented and addressed within 72 hours, but this was not followed in this case.
Failure to Implement Bed Bug Policy and Ensure Proper Cleaning
Penalty
Summary
The facility failed to ensure they have a bed bug policy/procedure to prevent outbreaks, failed to ensure that staff report bed bug observations, and failed to remove bed bug excrement/eggs from the wall in residents' rooms prior to resident placement. This deficiency was observed in the case of a resident who was transferred to a room on the 5th floor, which had been previously treated for bed bugs. Despite the treatment, bed bug excrement and eggs were still present on the wall adjacent to the resident's bed. The resident, who had a BIMS score indicating intact cognition, reported the presence of bed bugs and pointed out the excrement on the wall to the surveyor. The Licensed Practical Nurse and Certified Nursing Assistant also observed the dark spots on the wall but did not report them or take action to clean them up. The Director of Nursing acknowledged the presence of bed bug litter but cited short staffing in the housekeeping department as the reason for the uncleaned wall. The housekeeping staff could not recall if they were made aware of the bed bug eggs and excrement on the wall. The facility's pest control invoices indicated that bed bug treatments were conducted, but the facility lacked a specific policy or procedure for bed bugs. The Director of Nursing confirmed that there was no corporate policy for bed bugs. The facility's pest control policy stated that the building should be kept free of insects, and the housekeeping policy required environmental surfaces to be cleaned and disinfected according to CDC recommendations. However, walls were excluded from the list of non-critical surfaces to be disinfected. This lack of a specific bed bug policy and failure to ensure proper reporting and cleaning of bed bug excrement and eggs led to the deficiency affecting the resident and potentially other residents in the facility.
Failure to Timely Notify Physician of Change in Condition
Penalty
Summary
The facility failed to timely notify the physician of a change in condition for a resident who had bed bug bites. The Illinois Department of Public Health (IDPH) received allegations of a bed bug infestation and that the resident had bug bites all over their body. Upon inspection by the surveyor, the resident had open bleeding and scabbed areas on their forearms, as well as small circular red raised areas on their hands, legs, and feet. The resident confirmed that they had not received any prescribed treatment for the bug bites. The Licensed Practical Nurse (LPN) inspected the resident's skin and acknowledged the presence of bites and open spots, stating that they needed to call the doctor. The physician was only contacted after the surveyor's inquiry, which was not in accordance with the facility's policy for timely notification of a change in condition. The facility's change in condition policy, dated March 2021, requires that the physician be notified when there is a change in the resident's condition, such as an incident resulting in injury that requires physician intervention or a need to alter treatment. The Medical Director confirmed that staff are supposed to call the doctor in such situations. However, the delay in notifying the physician about the resident's bed bug bites and the need for treatment indicates a failure to adhere to this policy, leading to the deficiency noted in the report.
Failure to Timely Release Trust Funds Upon Discharge
Penalty
Summary
The facility failed to follow its policy procedures regarding the timely release of trust funds to a resident (R2) upon discharge. R2 was discharged on 2/29/24, but the facility did not provide the trust fund check until 3/15/24, and there was no evidence that R2 received the check until it was cashed on 3/27/24. Additionally, the check issued was for $1,061.00, while the trust fund account had a balance of $1,061.36, leaving $0.36 unaccounted for. The facility's Business Office Manager position was vacant at the time, and the Director of Nursing and Corporate Business Office Manager could not provide evidence that R2 received the check on the day of discharge as required by the facility's policy. The Corporate Business Office Manager acknowledged the discrepancy and attributed it to an oversight in writing the check amount incorrectly. The facility's policy, dated 8/1/15, states that trust fund balances should be released to residents via check on the day of discharge, or sent to a forwarding address if the discharge occurs on a weekend. However, this policy was not followed in R2's case, resulting in a delay and an incomplete disbursement of funds. The surveyor's investigation revealed that the facility staff, including the Assistant Administrator and Director of Nursing, were unable to provide adequate documentation or explanation for the delay and the missing $0.36 from R2's trust fund account.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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