Staunton Health And Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Staunton, Illinois.
- Location
- 215 West Pennsylvania Avenue, Staunton, Illinois 62088
- CMS Provider Number
- 145286
- Inspections on file
- 18
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Staunton Health And Rehab Ctr during CMS and state inspections, most recent first.
The facility failed to maintain an operational call light system for most residents, leaving many without a functioning way to summon assistance from their rooms and bathrooms. Several residents reported that their call lights did not work and that tabletop bells provided by the facility were either not heard by staff or not available at the bedside. Surveyor observations confirmed the presence of bells in some rooms and the absence of a bell in at least one room. Facility records documented a family grievance about the call light system being down and a testing log showing that numerous call lights failed during checks, despite facility policy requiring that activated call lights illuminate in the room, outside the room, and on a central panel.
The facility failed to revise and update fall care plans with progressive interventions for two residents after multiple documented falls. One resident with systemic lupus, epilepsy, altered mental status, tremors, a BIMS score of 9, and extensive ADL assistance needs had a fall from a wheelchair while washing her face and later a witnessed fall forward from a wheelchair, both resulting in head impact; fall investigations identified intent to get out of the wheelchair and poor safety awareness, yet no new care plan interventions were added. Another resident with Parkinson’s disease, confusion, an indwelling catheter, and dependence for mobility was found on the bathroom floor with a detached catheter and blood present, and later found on a floor mat next to the bed with a facial reddened area; investigations cited confusion, poor safety awareness, and attempts to get out of bed without assistance, but the care plan did not reflect specific new interventions after these events, despite facility policy requiring investigation and implementation of appropriate interventions.
Two residents with cognitive impairment, significant mobility limitations, and known fall risks experienced multiple falls, including unwitnessed falls from wheelchairs and falls from bed to the floor, resulting in head impact and catheter trauma. Although both residents had existing fall-risk care plans with general interventions such as low beds, non-skid footwear, floor mats, and alarms, the facility did not document new or revised care plan interventions after each fall, despite fall investigations identifying behaviors such as leaning forward, attempting to get out of the w/c, confusion, and poor safety awareness as contributing factors. This lack of progressive, individualized interventions occurred even though facility policy requires immediate investigation, IDT review, determination of root cause, and implementation of appropriate interventions to prevent further falls.
Surveyors found that expired and discontinued medications, including insulin pens and suppositories, remained in medication storage areas after they should have been removed and destroyed. An LPN and the DON confirmed that these medications, some belonging to deceased or discharged residents, were not properly discarded as required by facility policy.
Surveyors found that several residents receiving oxygen therapy or nebulizer treatments did not have their respiratory equipment, such as nasal cannulas, humidification containers, and nebulizer parts, properly dated or changed as required by physician orders and facility policy. Staff interviews confirmed that equipment should be changed and dated weekly, but this was not consistently done or documented.
A CNA was observed repeatedly touching her hair, face, glasses, clothing, and cell phone, then serving coffee and passing meal trays to multiple residents without performing hand hygiene, despite the availability of alcohol-based hand rub and facility policy requiring hand hygiene before and after assisting with meals.
The facility did not provide required Medicare non-coverage notices to three residents, as confirmed by the inability of staff to locate the necessary documentation when requested by surveyors. Facility policy requires that the NOMNC be delivered at least two days before Medicare-covered services end, but this was not done for the affected individuals.
A resident with Alzheimer's and other conditions had a rash that was not treated as per physician's orders due to a communication lapse. The prescribed medications, Triamcinolone and Clotrimazole, were not documented or administered, despite the facility's policies requiring clear processing of such orders.
The facility failed to maintain and sanitize the ice machine properly, leading to water damage and potential mold growth. The drainage pipe lacked an air gap, risking backflow. Staff were unaware of the issue's cause, and the problem persisted for weeks, affecting all 45 residents.
The facility failed to develop an ongoing infection control program that effectively collected and analyzed infection data. The infection control logs were incomplete, and the newly hired DON admitted to lacking comprehensive surveillance data. The facility did not adhere to its Infection Control Program Policy, potentially affecting all 45 residents.
The facility failed to ensure correct antibiotic use for residents, administering antibiotics without proper lab confirmation of infections. This led to inappropriate antibiotic use, increasing the risk of resistance and adverse effects. The Director of Nursing acknowledged systemic issues in obtaining necessary lab results.
The facility failed to supervise two residents to prevent wandering and did not respond to a pressure alarm for a high-risk fall resident. One resident with Alzheimer's frequently wandered into female residents' rooms, causing distress, while another resident with a recent hip fracture was observed getting up unassisted without staff responding to the alarm.
A resident with a history of chronic UTIs and severe cognitive impairment was left in saturated pants and a wet wheelchair seat for over four and a half hours. CNAs admitted to being behind schedule but acknowledged the resident should have been checked and changed every two hours as per facility policy. The DON confirmed this expectation.
Failure to Maintain Operational Call Light System for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with a working call light system in resident bathrooms and bathing areas for 22 of 23 residents reviewed for physical environment. Multiple residents reported that their call lights did not work, including one resident who stated that neither her room nor bathroom call lights functioned and that a tabletop bell provided by the facility was not heard by staff, and another resident who reported her call light did not work and that she could not locate her bell. Surveyor observations confirmed the presence of tabletop bells in some residents’ rooms and the absence of a bell in at least one resident’s room. Facility documentation showed that a grievance had been filed by a resident’s daughter-in-law regarding the call light system being down, and a Call Light Testing Log indicated that 22 residents’ call lights failed during testing. The facility’s own Call Light Guidance Policy stated that when initiated, the system should light up in the room, outside the room, and on a central panel, but interviews with the Maintenance Supervisor and Administrator confirmed that the existing call light system was not functioning and that parts for the old system were unavailable, necessitating full replacement. These findings collectively show that the facility did not maintain an operational call light system as required by its policy, instead relying on tabletop bells that were inconsistently available and reportedly ineffective for alerting staff, resulting in residents lacking a reliable means to summon assistance from their rooms and bathrooms.
Failure to Revise Fall Care Plans With Progressive Interventions After Multiple Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to revise and update fall care plans with progressive interventions for two residents after multiple falls, despite facility policy requiring immediate investigation and implementation of appropriate interventions following accidents and incidents. For one resident with systemic lupus erythematosus, epilepsy, altered mental status, and a BIMS score of 9, the care plan identified fall risk related to medications, tremors, and a history of falls with head injuries and a displaced dens fracture. The care plan listed several fall-prevention interventions such as keeping the bed in the lowest position, ensuring proper footwear, instructing the resident to avoid sudden position changes, orienting the resident to the room, providing adequate lighting, encouraging sitting on the side of the bed before standing, use of assistive devices, non-skid footwear and socks in bed, and Dycem in the wheelchair. However, after subsequent falls, no new or revised interventions were added to the care plan. This resident experienced an unwitnessed fall on one occasion when a CNA found her on the floor at 7:15 AM. She reported that she had been washing her face and attempting to place a towel on the dresser when her wheelchair slid out from under her, causing her to hit the right side of her head, with blood noted on her hand, the floor, and the towel. Vital signs were documented, she was noted to be alert and oriented x2, and she was transferred to bed and then sent to the ED for further evaluation. The facility’s fall investigation documented that the fall occurred in the resident’s room while sitting, with the cause and root cause identified as the resident attempting to get out of the wheelchair. Despite this, there was no care plan intervention documented for this fall. Later, another fall occurred when the resident was observed leaning forward in the wheelchair and falling forward out of the chair, hitting her head on the leg of a sit-to-stand device. The fall investigation again identified the cause and root cause as the resident’s intent to get out of the wheelchair, with poor safety awareness and a BIMS score of 9, but again no new care plan interventions were documented. The second resident involved had diagnoses including Parkinson’s disease, was on palliative/hospice care, had an indwelling catheter, and was dependent for several mobility tasks. His care plan identified fall risk related to psychotropic and opioid medications, Parkinson’s disease, involuntary movements, and a history of falls, including sliding out of bed. Interventions included keeping the bed in the lowest position, encouraging call light use, placing a floor mat at bedside, keeping the environment free of clutter, keeping personal belongings within reach, providing adequate lighting, adding a bolster on the mattress, and using a personal alarm. Despite these measures, the resident was later found on the bathroom floor on his right side during midnight rounding, with his indwelling catheter detached and a large amount of blood on the floor and penis. The fall investigation documented confusion, poor safety awareness, and attempts to get out of bed without assistance as the problem and root cause, but although it stated the care plan was updated, no specific new interventions were documented in the care plan. On another occasion, this same resident was found lying on the floor mat next to the bed and window, on his stomach with arms at his side and legs extended, with a small red area to the left cheekbone and an indwelling catheter still patent. He was transferred back to bed via full mechanical lift and neuro checks were initiated. The fall investigation documented that the fall occurred in the resident’s room, with the resident found on the floor mat and no injuries noted. Again, no new or revised care plan interventions were documented following this fall. The DON later stated that some of the falls occurred before she was hired and that the care plan coordinator was new and learning. The facility’s Accidents & Incidents policy required the charge nurse to conduct an immediate investigation and implement appropriate interventions, and required the DON and IDT to review the incident, determine root cause, and implement appropriate interventions to attempt to prevent further falls, but the record review showed that progressive care plan interventions were not added after these falls for the two residents.
Failure to Implement Progressive Fall-Prevention Interventions After Repeated Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to provide progressive fall-prevention interventions for two residents with known fall risks and repeated falls. For one resident with systemic lupus erythematosus, epilepsy, altered mental status, a BIMS score of 9/15, and a need for substantial/maximal assistance with bed mobility and transfers, the care plan identified fall risk related to medications, tremors, and a history of falls with head injuries and a displaced dens fracture. The care plan listed general interventions such as keeping the bed in the lowest position, ensuring proper footwear, instructing the resident to avoid sudden position changes, orienting the resident to the room, providing adequate lighting, reinforcing sitting on the side of the bed before standing, and use of assistive devices, as well as non-skid footwear and Dycem in the wheelchair. However, after subsequent falls, no new or revised care plan interventions were documented. This same resident experienced an unwitnessed fall from the wheelchair in the resident room while washing her face and reaching to place a towel on the dresser, during which the wheelchair reportedly slid out from under her and she hit the right side of her head, with blood noted on her hand, the floor, and the towel. The facility’s fall investigation documented that the fall occurred while the resident was sitting, that it was related to patient intent or behavior, and that the resident had just gotten out of bed and was sitting in the wheelchair. The problem statement and root cause both identified the resident’s attempt to get out of the wheelchair, but there is no documentation of any new care plan interventions being added in response to this fall. Later, the resident had another fall when she leaned forward in the wheelchair and fell forward out of the chair, hitting her head on the leg of a sit-to-stand device. The investigation again attributed the fall to patient intent or behavior, poor safety awareness, and the resident’s intention to get out of the wheelchair to get to bed, yet again no care plan interventions were documented for this fall. A second resident, with Parkinson’s disease, palliative care, malignant neoplasm of the renal pelvis, a BIMS score of 12/15, dependence for multiple mobility tasks, and an indwelling catheter, was also care planned as being at risk for falls due to psychotropic and opioid medications, Parkinson’s disease, involuntary movements, and a history of falls. The care plan noted that the resident had a low bed, double mattresses, a floor mat at bedside, and later a bolster on the mattress and a personal alarm. Despite these measures, the resident was found on the bathroom floor at night with the indwelling catheter detached and a large amount of blood on the floor and penis, and the fall investigation identified confusion, poor safety awareness, and attempts to get out of bed without assistance as the problem and root cause. Although the investigation form stated that the care plan was updated, there is no specific care plan intervention documented for this fall. The same resident was later found lying on the floor mat next to the bed and window, on his stomach with slow responsiveness and a small red area on the left cheekbone, and again no new care plan intervention was documented for this fall. The DON later stated that some of the falls occurred before she was hired and that the care plan coordinator was new and learning, while the facility’s accidents and incidents policy requires immediate investigation and implementation of appropriate interventions, with IDT review to determine root cause and implement appropriate interventions to attempt to prevent further falls.
Failure to Remove and Destroy Expired and Discontinued Medications
Penalty
Summary
Surveyors observed that the facility failed to properly store and discard expired and discontinued medications. During an inspection of the medication cart, opened and labeled multi-dose insulin pens for a resident were found, even though the medications had been discontinued in January. The LPN confirmed that these insulin pens should have been removed and destroyed after discontinuation. Additionally, in the medication room refrigerator, an opened box of Bisacodyl suppositories and a bottle of Glycerin suppositories belonging to a deceased resident were found, both past their appropriate use period. The LPN acknowledged that these medications should have been removed and destroyed following the resident's death. The Director of Nursing stated that expired, discontinued, or deceased residents' medications are expected to be removed from circulation and destroyed. The facility's own medication storage policy requires that discontinued, outdated, or deteriorated drugs be returned to the pharmacy or destroyed, and that medications be administered only prior to the manufacturer's expiration date. These observations and staff interviews confirm that the facility did not follow its policy or accepted professional standards regarding medication storage and disposal.
Failure to Date and Change Respiratory Equipment as Required
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not ensuring that nasal cannulas, oxygen humidification containers, and nebulizer administration equipment were properly dated for five residents who required respiratory support. Observations revealed that multiple residents had oxygen and nebulizer equipment in use without any date labels, despite physician orders and facility policy requiring weekly changes and dating of this equipment. In several cases, the care plans for residents receiving oxygen therapy did not include documentation of oxygen use, and treatment administration records did not reflect that equipment changes had occurred as ordered. For example, one resident with diagnoses including pulmonary hypertension and heart failure had orders for oxygen therapy and weekly tubing changes, but their oxygen tubing, humidification container, and nebulizer equipment were not dated during multiple observations. Another resident with chronic obstructive pulmonary disease and acute respiratory failure had a humidification bottle dated from a previous week and undated nasal cannula tubing. Additional residents were observed with undated oxygen tubing or equipment, and in one case, a nebulizer mouthpiece and tubing were dated over a month prior to the observation, with no documentation of recent changes as required by physician orders. Interviews with nursing staff, including LPNs and an RN, confirmed that the expectation was for all oxygen and nebulizer equipment to be changed and dated weekly, with the night shift responsible for this task. The DON also acknowledged that equipment for some residents was not dated as required. The facility's own policy specified that oxygen use should be care planned, humidifiers labeled with the date opened, and tubing changed and dated weekly, but these procedures were not consistently followed for the residents reviewed.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
A Certified Nurse Assistant (CNA) failed to perform hand hygiene during meal service for 18 residents. The CNA was observed repeatedly touching her hair, face, glasses, nose, clothing, and cellular phone with bare hands, and then serving coffee, passing meal trays, and assisting residents with their meals without using hand hygiene at any point during the entire meal service. The alcohol-based hand rub dispenser was operational and available at the kitchen opening, but was not used by the CNA. Interviews with other CNAs indicated that they were aware of the requirement to perform hand hygiene after touching hair, clothes, or cell phones and before and after assisting residents with meals. The facility's hand hygiene policy also documented the need for hand hygiene after contact with objects in the resident's vicinity and before and after assisting with meals. Despite this, the observed CNA did not follow these protocols, resulting in a failure to implement the infection prevention and control program as required.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide required notice of Medicare non-coverage to three residents who were reviewed for beneficiary notices. Surveyors requested the relevant documentation from the Director of Nurses and the Administrator, but the facility was unable to produce the Beneficiary Notices for these residents, only being able to locate one unrelated notice. According to the facility's own instructions, the Notice of Medicare Non-Coverage (NOMNC) must be delivered to beneficiaries at least two calendar days before the end of Medicare-covered services, but this process was not followed for the affected residents.
Failure to Administer Prescribed Medications for Rash
Penalty
Summary
The facility failed to follow physician's orders for a resident with a rash, identified as R3, who was admitted with diagnoses including Alzheimer's disease, aphasia, Parkinson's disease, and dementia. Despite a skin inspection assessment noting a rash on R3's bilateral upper and lower extremities and torso, and a physician's order to discontinue Clopidogrel and start Triamcinolone and Clotrimazole topically twice a day, these medications were not documented in the Physician's Order Sheet or administered according to the Treatment Administration Record from 11/18/2024 to 11/27/2024. The Director of Nurses (DON) acknowledged that the nurse had sought clarification on the dosage for the medications on 11/18/2024, but the communication was not completed, resulting in the medications not being ordered or administered. During an observation on 11/27/2024, a Certified Nurse Aide noted a red raised rash on R3's back, abdomen, and legs, and stated that only regular lotion was applied, with physician-prescribed lotion to be applied by the nurse. The facility's policies on physician and medication orders emphasize the need for clear documentation and processing of orders, which was not adhered to in this case.
Improper Maintenance and Sanitation of Ice Machine
Penalty
Summary
The facility failed to ensure proper maintenance and sanitation of the ice machine located in the dining area. Observations revealed water on the floor behind the ice machine, with two orange cones indicating a wet floor. The ice machine's drainage pipe was directly connected to the floor drain without an air gap, which could lead to backflow or back siphonage. Additionally, the pipe and surrounding area were covered with black spots and moisture, and the drywall behind the machine was damaged and puffy, indicating water damage and potential mold growth. Staff interviews confirmed that the wet floor condition had been ongoing for several weeks, and there was a lack of awareness and action to address the issue. The Dietary Manager and Environmental Health Director were unaware of the cause of the moisture and the presence of the cones. The President of Operations Maintenance acknowledged the water issue and the non-compliant air gap, attributing the moisture to temperature differences. The ice machine, which is the only one in the facility, is used for meal preparations and services, as well as for providing ice and water to residents. The facility did not have a specific policy on air gaps but claimed to follow state and local ordinances. The deficiency has the potential to affect all 45 residents in the facility.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to adequately develop an ongoing infection control program that effectively collected data to calculate and analyze infection rates. The infection control log provided on 5/2/2024 did not have any dates or organisms listed or documented. The Director of Nursing (DON), who was newly hired and had just completed the Infection Control Preventionist (ICP) course, admitted that the provided surveillance was the only one available and lacked comprehensive data. A second infection control log was provided, but it was incomplete, with only two out of ten documented urinary tract infections having the organisms listed. The facility's Infection Control Program Policy, dated 09/15/2020, outlined the procedures for infection surveillance, including the collection, analysis, and reporting of infection data on a monthly, quarterly, and annual basis. However, the facility did not adhere to these guidelines, as evidenced by the incomplete and inadequate infection control logs. The policy also required the Infection Control Coordinator to track and trend infections, ensure proper staff training, and implement ongoing interventions to prevent the spread of infections, which was not effectively operationalized. This deficiency has the potential to affect all 45 residents living in the facility.
Inappropriate Antibiotic Use Due to Lack of Proper Lab Confirmation
Penalty
Summary
The facility failed to ensure that residents were given the correct antibiotics for the organism causing infection. For Resident 25, a lab report indicated mixed genital flora, which is not indicative of a urinary tract infection (UTI), yet the resident was administered Nitrofurantoin for seven days without a culture and sensitivity (C&S) report. Similarly, Resident 150 was given cefdinir for a UTI without a documented C&S report to confirm the presence of an infection or the appropriateness of the antibiotic. The Director of Nursing acknowledged that the facility often does not receive C&S reports from hospitals and has to follow up, indicating a systemic issue in obtaining necessary lab results before administering antibiotics. Resident 8 was given Keflex daily for nearly a year without any documented diagnosis of a UTI or abnormal urinalysis, and the antibiotic was only discontinued after the Director of Nursing intervened. Resident 31 was administered Acyclovir and Cefdinir for a UTI despite a urinalysis culture showing mixed genital flora, which is not indicative of a UTI. The facility's antibiotic stewardship policy emphasizes the importance of using antibiotics appropriately to prevent resistance and adverse drug reactions. However, the facility's actions did not align with this policy, as antibiotics were frequently prescribed without proper lab confirmation of an infection. This led to the inappropriate use of antibiotics for multiple residents, increasing the risk of antibiotic resistance and other adverse effects. The Director of Nursing admitted to challenges in obtaining C&S reports from hospitals and mentioned issues with hospice care, further highlighting gaps in the facility's antibiotic stewardship practices.
Failure to Prevent Wandering and Respond to Fall Alarms
Penalty
Summary
The facility failed to ensure adequate supervision to prevent wandering for two residents. One resident with Alzheimer's and dementia, who has a history of wandering and aggressive behavior, was not properly monitored. Despite being on one-on-one supervision, the resident frequently wandered into female residents' rooms, causing distress and fear among them. The facility did not have any abuse investigations or incident reports for several documented incidents involving this resident, including physical altercations and inappropriate behavior in other residents' rooms. The facility also lacked a policy on supervision, as confirmed by the administrator. Another resident reported feeling unsafe due to the wandering resident entering her room multiple times. Despite the resident's complaints and a temporary measure of placing a banner in her doorway, the wandering resident continued to enter her room, causing further distress. The resident's progress notes and statements from her Power of Attorney confirmed that the issue was reported to the administrator, but no effective measures were taken to prevent the wandering resident from entering her room. Additionally, the facility failed to respond to a pressure alarm for a resident with a high risk of falling and a recent hip fracture. The resident was observed multiple times getting up unassisted, with the pressure alarm either not sounding or not being responded to by staff. The resident had a history of falls and was supposed to be monitored closely, but the facility's staff did not adequately check or maintain the pressure alarm. The Director of Nursing acknowledged the issue with the alarm and the need for staff to respond promptly, but the problem persisted, putting the resident at risk of further injury.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for a resident (R8) who was observed with saturated pants and a wet wheelchair seat. The incident occurred when a CNA transferred R8 to the toilet and found her adult incontinence brief soaked with urine, emitting a strong foul odor. The CNAs involved admitted that R8 had not been checked or changed since before 7:00 AM, which was over four and a half hours prior to the observation. The facility's policy mandates that incontinent residents should be checked and changed every two hours to keep their skin clean, dry, and free of irritation and odor. R8's medical records indicate a history of chronic urinary tract infections (UTIs) and severe cognitive impairment, making her always incontinent of bowel and bladder. The CNAs acknowledged that they were running behind schedule due to staffing issues but admitted that R8 should not have been left wet for such an extended period. The Director of Nursing confirmed that the expectation is for staff to make rounds at least every two hours and provide incontinent care as needed, regardless of staffing challenges.
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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