Springfield Suites Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Illinois.
- Location
- 3089 Old Jacksonville Road, Springfield, Illinois 62704
- CMS Provider Number
- 146160
- Inspections on file
- 26
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Springfield Suites Rehab And Nursing during CMS and state inspections, most recent first.
Two residents experienced increased pain due to the facility's failure to ensure timely availability of prescribed pain medications. One resident went without Hydrocodone-Acetaminophen for several days due to prescription delays, while another faced a similar issue due to a prescription error. The facility's medication management processes were insufficient to prevent these occurrences.
A resident with a history of falls and fractures required assistance from two staff members for transfers, as documented in her care plan. However, she was assisted by only one CNA, resulting in a fall. A subsequent incident led to severe pain and hospitalization for a pulmonary embolism. Staff interviews revealed inconsistencies in understanding the resident's transfer needs.
Two residents experienced a lack of timely care and respect for dignity in an LTC facility. One resident faced prolonged pain due to delayed pain medication, while another was left in a saturated brief in front of visitors, causing embarrassment. The facility's policies on resident rights and call light response were not followed, leading to these deficiencies.
A resident with a left femur fracture and chronic pain syndrome experienced prolonged pain due to delayed administration of pain medication. Despite activating the call light, it took two hours for the resident to receive Oxycodone, during which their pain level increased significantly. The facility's pain management policy, which emphasizes timely assessment and self-reporting, was not effectively followed, as acknowledged by the DON.
The facility failed to post daily nursing staff hours, affecting all 58 residents. The survey team found the last update was several days old. The Administrator and Scheduler were unaware of the lapse, and there was no policy for posting staffing information.
The facility failed to properly prepare and store medications, as observed when an LPN administered medications from unlabeled cups without performing hand hygiene. Another LPN was seen with an unlabeled medicine cup and improperly stored medications, including a Tuberculin vial not refrigerated. Facility policies on medication storage and administration were not followed, potentially affecting all residents.
The facility failed to ensure proper food storage and hygiene practices in the kitchen, affecting all 58 residents. The Food and Beverage Manager did not wear a beard cover while preparing food, and several food items were found open, unsealed, and not dated or labeled. Additionally, the walk-in freezer had significant ice buildup and condensation issues, with condensation dripping onto food items. The facility's policy requires all open products to be sealed, labeled, and dated, and food should not be stored under leaking water lines or condensers.
The facility lacked a comprehensive QAPI policy and failed to sustain corrective actions for pharmacy services. The existing policy did not detail procedures for feedback, data collection, or monitoring concerns. An LPN was observed passing unlabeled medications, and the medication cart contained improperly stored items. Despite previous citations, the DON was unaware of ongoing issues, indicating insufficient oversight.
The facility failed to maintain an effective infection control program, with incomplete tracking of infections and outdated policies. The DON admitted to not tracking employee illnesses and the Administrator acknowledged the policies were old. Enhanced Barrier Precautions were not implemented, despite residents with medical devices at increased risk of infection. Specific instances included the absence of signage for precautions on residents' doors, and a nurse unaware of any residents requiring such measures.
The facility's infection control program was found deficient due to the Infection Preventionist's recent certification and lack of proactive measures, such as tracking employee illnesses and maintaining infection control logs. Two residents were on antibiotics without necessary tests, and Enhanced Barrier Precautions were not implemented for residents with indwelling devices. The facility also lacked a policy or job description for the IP role.
The facility failed to provide adequate incontinent care for several residents, leading to deficiencies in their care. A resident was found with a saturated brief and delayed assistance due to IV disconnection issues. Other residents received care with improper glove use, lack of drying, and inadequate cleaning, violating facility policies on incontinent care and hand hygiene.
The facility failed to develop comprehensive care plans for three residents, neglecting to address diagnoses such as major depressive disorder, anxiety, and dementia. One resident's care plan did not include interventions for a significant arm injury and subsequent skin graft. The facility's policy requires individualized care plans, which were not adequately implemented.
A resident at risk for falls due to dementia and impaired mobility fell after his wife left the room, closing the door and preventing staff from hearing the alarm. The facility failed to transfer the alarm from the bed to the chair and did not complete a Fall Risk Assessment after the incident, as required by their policy.
A facility failed to follow its tube feeding protocol for a resident receiving enteral nutrition. Observations revealed that feeding bottles and water bags were undated and lacked time stamps, contrary to the facility's policy requiring replacement every 24 hours. The DON confirmed the requirement for dating and timing, which was not adhered to.
The facility failed to provide proper respiratory care for two residents requiring oxygen therapy. One resident received inconsistent oxygen administration, with the nasal cannula often not in use and the humidified water bottle undated. Another resident received an incorrect oxygen dose, despite being aware of the discrepancy. The facility did not follow its own oxygen administration policy, as confirmed by the DON and an LPN.
The facility failed to re-evaluate psychotropic medication orders for two residents, leading to a deficiency. A resident was prescribed alprazolam without an end date, and another resident on hospice care was prescribed lorazepam without an end date. The DON was aware of the 14-day re-evaluation requirement but not its applicability to hospice residents. The facility lacked a policy on unnecessary or psychotropic medications.
The facility failed to ensure proper antibiotic stewardship for three residents, leading to the administration of antibiotics without appropriate indications. One resident received antibiotics without a urine culture or symptoms of a UTI, while another was prescribed multiple antibiotics without clear documentation of a culture. A third resident's records lacked a culture and sensitivity report to confirm the causative organism for a UTI. The facility's infection control policy was outdated, and there was no evidence of adherence to antibiotic stewardship protocols.
The facility did not follow its vaccination policy for two residents. One resident did not receive the influenza vaccine, with no documentation of declination or contraindication, despite a physician's order. Another resident received both vaccines, but the facility's policy requires documentation of education and administration, which was not confirmed.
Pain Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure that pain medications were readily available for administration, resulting in increased pain and discomfort for two residents. Resident R3, who suffers from arthritis and other medical conditions, did not receive her prescribed Hydrocodone-Acetaminophen for several days in December and February due to issues with obtaining a new prescription from her primary care provider. Despite multiple attempts by the facility to contact the physician's office and the on-call physician, the prescription was not filled in a timely manner, leading to R3 experiencing increased pain and difficulty functioning without her medication. Similarly, Resident R2, diagnosed with chronic pain syndrome and other conditions, did not receive her prescribed Hydrocodone-Acetaminophen for almost two days in March. The delay was caused by an error in the prescription sent to the pharmacy, which lacked the oral route specification. The facility contacted the physician and nurse practitioner to correct the script, but the medication was not delivered promptly, causing R2 to experience increased pain and inability to complete her therapy. The facility's policies on administering medication and pain management emphasize the importance of providing medications as ordered and ensuring residents do not experience unnecessary pain. However, the facility's inability to secure timely prescriptions and medication deliveries resulted in both residents experiencing increased pain and discomfort, highlighting a deficiency in the facility's medication management processes.
Inadequate Staffing for Resident Transfer Leads to Falls
Penalty
Summary
The facility failed to provide an appropriate number of staff to assist in a transfer for a resident, identified as R2, who was at risk for falls. R2 had a history of falls with fractures and required partial/moderate assistance with transfers. The care plan indicated that R2 needed assistance from two staff members for transfers due to an activities of daily living deficit. However, during an incident, R2 was assisted by only one CNA, resulting in R2's knees giving out and her sitting on the floor. This incident was documented in a progress note, and the physician was notified, but no new orders were given. A subsequent incident occurred when R2 fell again while being transferred off the toilet, resulting in severe pain and a large red spot on her hip and back. This time, R2 was sent to the hospital and admitted for a pulmonary embolism. The facility's fall event investigation documented that R2 fell due to increased weakness and loss of balance. Interviews with staff revealed inconsistencies in understanding R2's transfer needs, with some staff unsure of the required assistance level. The facility's fall policy aimed to prevent falls and minimize complications, but it was not effectively implemented in R2's case.
Failure to Provide Timely Care and Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure timely care and respect for residents' dignity, resulting in negative experiences for two residents. One resident, identified as R117, experienced prolonged pain due to a delay in receiving pain medication. Despite activating the call light at 7:45 PM, the resident did not receive the medication until 9:15 PM, leading to feelings of insignificance and being chastised by a nurse for frequent use of the call light. The resident, who is cognitively intact, documented the times of the call light activation and medication administration, highlighting the delay in care. Another resident, R11, was found in a state that compromised his dignity. R11, who has a moderate cognitive impairment and requires assistance with activities of daily living, was left sitting in a recliner with a saturated incontinence brief while visitors, including his wife, were present. The resident's wife had activated the call light for assistance, but there was a delay in response due to the need for an RN to disconnect the IV. The resident's brief fell to the floor due to its saturation when he was eventually assisted to the restroom, causing embarrassment. The facility's policies on resident rights and call light response were not adhered to, as evidenced by the delayed response to call lights and the lack of timely care provided to the residents. The facility's Resident Rights Policy emphasizes the importance of treating residents with dignity and respect, while the Call Lights policy mandates prompt response to residents' needs. These policies were not followed, leading to the deficiencies observed in the care of R117 and R11.
Failure in Timely Pain Management for Resident
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident, identified as R117, who was experiencing significant pain due to a left femur fracture and chronic pain syndrome. R117 reported turning on his call light to request pain medication, but it took approximately two hours before he received it. During this time, his pain level increased from a 7 to a 9 on a 1-10 pain scale. The resident was on scheduled Oxycodone for pain management, which was changed to a PRN order shortly before the incident. The Medication Administration Record confirmed that R117 received his Oxycodone at 1:07 PM and again at 9:07 PM on the day in question. Interviews with facility staff, including the Minimum Data Set and Care Plan Coordinator and the Director of Nursing, revealed that the facility's pain management policy was not followed effectively. The policy emphasizes the importance of timely pain assessment and management, with self-reporting as the preferred indicator of pain. However, R117 stated that nurses occasionally asked him to rate his pain, but not consistently. The Director of Nursing acknowledged that the nurse should have addressed the resident's pain more promptly, indicating a lapse in adherence to the facility's pain management guidelines.
Failure to Post Daily Nursing Staff Hours
Penalty
Summary
The facility failed to post the daily nursing staff hours, which has the potential to affect all 58 residents residing in the facility. On 11/19/24, the survey team observed that the posted daily nursing staffing hours by the front entrance were dated 11/14/24. The Administrator, V1, acknowledged that the nursing department hours are supposed to be posted daily and was unaware of why they had not been updated since 11/14/24. V21, the Scheduler responsible for posting the hours, stated she did not know who was responsible for posting on weekends and was unsure why the last update was on 11/14/24. Additionally, both V1 and the Director of Nursing, V2, confirmed that the facility does not have a policy for posting staffing information.
Medication Preparation and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication preparation and storage protocols, as observed during a survey. An LPN was seen with five unlabeled medication cups containing multiple pills on top of a medication cart. The LPN admitted to not labeling the cups and administering medications in order by room number without performing hand hygiene before or after administering medications to residents. Additionally, the LPN did not document the medication administration immediately after giving the medications to the residents. Another LPN confirmed that pre-pouring medications is not the facility's procedure and emphasized the importance of hand hygiene and checking medications against the MAR. Further observations revealed that another LPN was seen administering medications to residents without performing hand hygiene before or after the process. This LPN also had an unlabeled medicine cup with pills in the medication cart, which was intended for a resident who had initially refused the medication. The LPN admitted to documenting the medication as given despite the resident's refusal. Additionally, a Basaglar Insulin pen without a name or date and a Tuberculin vial without an open date were found in the medication cart, with the latter not stored in the refrigerator as required. The facility's policies on medication storage and administration were not followed, as evidenced by the presence of unlabeled and improperly stored medications. The facility's policy requires drugs and biologicals to be stored in locked compartments under proper conditions and labeled correctly. The policy also mandates hand hygiene between residents during medication administration and documentation immediately after giving medications. The survey findings indicate a failure to comply with these policies, potentially affecting all residents in the facility.
Food Storage and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage and hygiene practices in the kitchen, which could potentially affect all 58 residents. During an initial tour, it was observed that the Food and Beverage Manager, who had a beard, was not wearing a beard cover while preparing food. Additionally, several food items in the dry storage area, walk-in refrigerator, and walk-in freezer were found open, unsealed, and not dated or labeled. This included bags of spaghetti noodles, dry cereals, flour, shredded cheese, barbeque sauce, chicken base paste, French fries, garden vegetables, and egg omelets. The facility's policy requires all open products to be sealed, labeled, and dated to ensure quality and prevent contamination. Furthermore, the walk-in freezer had significant issues with ice buildup and condensation. There was condensation dripping from a light fixture onto a box of chocolate shakes, and the pipes under the condenser fan were covered with ice. The freezer's light fixture was covered with icicles, and there was ice buildup on the floor and the bottom of the freezer door. Despite these observations, the Food and Beverage Manager denied any current issues with the freezer, attributing the ice formations to frequent and prolonged access by staff. The facility's policy states that food should not be stored under leaking water lines, sprinkler heads, or condensers, and all open products should be sealed, labeled, and dated.
Inadequate QAPI Policy and Medication Labeling Issues
Penalty
Summary
The facility failed to develop a comprehensive policy and procedure for its Quality Assurance Improvement Plan (QAPI) and did not ensure that corrective actions and performance improvements were sustained. The existing policy, dated 11/28/16, was a one-page document that outlined the committee's responsibilities but lacked detailed procedures for obtaining feedback from residents and staff, collecting and monitoring data, and identifying, reporting, tracking, and monitoring concerns. The administrator confirmed that this was the only policy available and acknowledged the absence of documentation regarding the process. Additionally, during a survey, it was observed that the facility had ongoing issues with pharmacy services, specifically related to the labeling and storage of medications. An LPN was found passing medications without labeling the cups with residents' names, and there were unlabeled medications and improperly stored items in the medication cart. Despite previous citations for similar issues, the facility's Director of Nursing was unaware of the current problems with pre-pouring and labeling medications, indicating a lack of sustained corrective action and oversight.
Inadequate Infection Control Program and Lack of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of ongoing tracking and trending of infections among residents and employees. The Director of Nursing (DON) admitted that the infection control log for November 2024 was incomplete and that employee illnesses were not being tracked. Additionally, the facility's infection control policies were outdated and undated, with some policies dating back to 2001 and last revised in 2012. The Administrator acknowledged the policies were old and stated they would update them if issues arose. Furthermore, the facility did not implement Enhanced Barrier Precautions, despite the presence of residents who could benefit from such measures. Specific instances of non-compliance were observed, including the absence of signage for Enhanced Barrier Precautions on the doors of residents with medical devices that increased their risk of infection. One resident with a suprapubic catheter had no documentation of being on Enhanced Barrier Precautions, and the nurse on duty was unaware of any residents requiring such precautions. The facility's policies did not address Enhanced Barrier Precautions, which are recommended by the CDC to prevent the spread of multidrug-resistant organisms. These deficiencies have the potential to affect all 58 residents in the facility.
Deficiencies in Infection Control Program
Penalty
Summary
The facility was found to have deficiencies in its infection prevention and control program, primarily due to the lack of a fully qualified and proactive Infection Preventionist (IP). The Director of Nursing (DON), who also serves as the IP, had only recently obtained her certification and admitted to not tracking or trending employee illnesses as part of the infection control program. Additionally, there was no infection control log available for November 2024, and the process of maintaining such logs was described as a work in progress. The facility's administrator confirmed that the DON was in charge of infection control, despite the administrator having prior experience in this area during the COVID pandemic. Further deficiencies were noted in the management of residents receiving antibiotics. Two residents were on antibiotics for urinary tract infections without accompanying urinalysis or culture and sensitivity tests in their medical records. The IP admitted to not consistently following up with hospitals for such information when residents were admitted on antibiotics. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, despite the IP acknowledging awareness of the requirement. The facility lacked a policy or job description for the IP position, indicating a need for further development in their infection control protocols.
Inadequate Incontinent Care and Hygiene Practices
Penalty
Summary
The facility failed to provide complete and timely incontinent care for several residents, leading to deficiencies in their care. Resident R11 was found sitting in a recliner with a saturated incontinence brief, which dropped to the floor due to its weight when he stood up. Despite his wife's attempts to get assistance, there was a delay in care because the CNA could not disconnect the IV, and the RN was not immediately available. Additionally, R11's chair alarm did not activate, and there was no proper cleaning of his anal area after using the toilet. Resident R48 received inadequate incontinent care when CNAs used soiled gloves to handle clean supplies, contaminating them. The CNAs failed to clean R48's penis properly, including retracting the foreskin, and did not change gloves between dirty and clean tasks. Similarly, R176's care was compromised as CNAs used the same gloves to clean different areas, did not dry the resident, and failed to apply barrier cream, despite the presence of a yeast infection. Resident R27's care was also deficient, as CNAs did not perform hand hygiene before and after care, failed to dry the resident's skin, and did not apply barrier cream to reddened areas. The facility's policies on incontinent care and hand hygiene were not followed, contributing to the inadequate care provided to these residents.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their medical needs. Resident 14, diagnosed with major depressive disorder and anxiety disorder, had physician orders for buspirone and citalopram, yet their care plan did not address these diagnoses or the need for prescribed psychotropic medication. Similarly, Resident 18, diagnosed with vascular dementia and altered mental status, exhibited agitation and noncompliance with CPAP and diet restrictions, but their care plan lacked documentation of care approaches for dementia. Resident 35, with a history of traumatic subdural hemorrhage, anemia, anxiety, and atherosclerotic heart disease, sustained an arm injury while propelling themselves in a wheelchair. Despite undergoing a skin graft procedure, the care plan did not document the arm injury or post-surgical care for the skin graft. Additionally, the facility failed to address the root cause of the injury or implement new interventions to prevent further skin impairments. The facility's care plan policy mandates individualized, person-centered care plans within seven days of assessment, but these requirements were not met for the residents in question.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement adequate safety measures to prevent a fall for a resident, identified as R11, who was at risk for falls due to multiple health conditions including dementia, Parkinson's disease, and impaired mobility. Despite having a care plan that included interventions such as a bed and chair alarm, the facility did not ensure these measures were consistently applied. On one occasion, R11 fell while attempting to self-transfer after his wife left the room and closed the door, preventing staff from hearing the alarm. The fall resulted in bleeding from his leg, and it was noted that the alarm was not transferred from the bed to the chair when R11 was moved, as it should have been. Additionally, the facility did not complete a Fall Risk Assessment after R11's fall, which is a requirement according to the facility's Falls Policy. The policy mandates that a licensed nurse complete a Fall Risk Assessment following any fall and implement relevant interventions to minimize serious consequences. Interviews with staff and R11's wife confirmed that the alarm was not consistently used as intended, and the Director of Nursing acknowledged that a Fall Risk Assessment should have been completed after the fall.
Failure to Follow Tube Feeding Protocol
Penalty
Summary
The facility failed to adhere to its policy regarding tube feeding administration for a resident receiving enteral tube feeding. During observations, it was noted that a bottle of enteral tube feeding and a bag of water were hanging without any indication of the date or time they were opened. This occurred on two separate occasions, with 200 milliliters of feeding and 100 milliliters of water remaining in the containers. The facility's protocol requires that containers, tubing, and syringes be replaced every 24 hours and that unused or open containers of feeding formula be discarded. The Director of Nursing confirmed that there should be a date and time to indicate when the tube feeding was opened, which was not followed in this instance.
Inadequate Respiratory Care for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, R170 and R175, who required oxygen therapy. R170, who was admitted with multiple diagnoses including congestive heart failure and esophageal cancer, was observed with inconsistent oxygen administration. The resident's care plan did not mention the need for oxygen, and observations showed that the oxygen nasal cannula was often not in use, with the humidified water bottle undated and not changed as per physician orders. The resident's oxygen saturation was recorded below the required level, and the oxygen flow was not adjusted accordingly. Similarly, R175, who had diagnoses including pneumonia and COPD, was found receiving an incorrect oxygen dose of 4 liters per minute, despite the physician's order for 2 liters per minute. The resident was aware of the discrepancy but continued to receive the incorrect dose. Additionally, there was no signage indicating oxygen use in the rooms of either resident, and the facility's policy on oxygen administration was not followed, as confirmed by the Director of Nursing and an LPN. The facility's failure to adhere to physician orders and its own policies resulted in inadequate respiratory care for these residents.
Failure to Re-evaluate Psychotropic Medication Orders
Penalty
Summary
The facility failed to re-evaluate the need for psychotropic medications for two residents, leading to a deficiency in medication management. Resident 19 was prescribed alprazolam 0.5 mg twice a day as needed, starting on 10/18/2024, without an end date. Similarly, Resident 6, who requires hospice care due to senile degeneration of the brain, was prescribed lorazepam 0.5 mg every four hours as needed, starting on 3/21/2024, also without an end date. The Director of Nursing acknowledged awareness of the requirement for psychotropic medication orders to be re-evaluated and re-written every 14 days but was unaware that the same rules apply to hospice residents. As of 11/25/2024, the facility had not provided a policy addressing unnecessary or psychotropic medications.
Failure in Antibiotic Stewardship and Documentation
Penalty
Summary
The facility failed to ensure proper antibiotic stewardship for three residents, leading to the administration of antibiotics without appropriate indications. For one resident, the Director of Nursing (DON) admitted that a urine culture was not completed before prescribing antibiotics for a suspected urinary tract infection (UTI), and the resident did not exhibit any symptoms of a UTI. Another resident was prescribed multiple antibiotics over a short period without clear documentation of a urine culture to justify the treatment. The DON acknowledged that when residents are hospitalized, culture results are not always obtained, and there was no policy in place for antibiotic stewardship. A third resident was admitted with a diagnosis of sepsis and a UTI, but the facility records did not include a culture and sensitivity report to confirm the causative organism. The facility's infection control log failed to document whether the criteria for antibiotic use were met. Additionally, the facility's infection control policy, last revised in 2012, required the review of culture reports, but there was no evidence that this was being done. The lack of documentation and adherence to antibiotic stewardship protocols contributed to the inappropriate use of antibiotics.
Failure to Follow Vaccination Policy for Two Residents
Penalty
Summary
The facility failed to adhere to its influenza and pneumococcal vaccination policy for two residents. For one resident, the physician's order indicated that the influenza vaccine should be administered annually unless contraindicated. However, the resident did not receive the vaccine, and there was no documentation of declination or contraindication. The administrator suggested that the resident, who was under hospice care, might have opted out, but there was no proof of this decision. The resident's records showed that the flu vaccine was not up to date since 2022. Another resident received both the influenza and pneumococcal vaccines, as documented in their progress notes. However, the facility's policy requires that the resident's clinical record reflect education provided about the benefits and potential side effects of the vaccines, as well as documentation of administration, contraindication, or refusal. The report does not confirm whether this documentation was completed as per the policy.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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