Symphony Northwoods
Inspection history, citations, penalties and survey trends for this long-term care facility in Belvidere, Illinois.
- Location
- 2250 Pearl Street, Belvidere, Illinois 61008
- CMS Provider Number
- 145312
- Inspections on file
- 30
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Symphony Northwoods during CMS and state inspections, most recent first.
The facility failed to consistently provide and care plan restorative walking programs for three residents with mobility limitations and muscle weakness. One resident on a twice-daily walking program reported staff no longer walked him, and CNA documentation showed many days marked as not applicable, with no restorative walking reflected in his care plan. Another resident with multiple medical conditions had an order for walking twice daily; although an LPN documented walks on the MAR, the resident and a CNA reported he was walked only a few times over two weeks, and his CNA tasks lacked walking on even surfaces and his care plan lacked a restorative program. A third resident with a care-planned ambulation goal had walking tasks documented as not applicable most days and was walked only once daily on limited dates. Staff interviews revealed that the restorative CNA had stepped down, there was no designated restorative staff, floor CNAs were expected to provide restorative services when able, and leadership acknowledged that restorative programs should be in care plans and documented but were not consistently implemented.
A resident with dementia, confusion, repeated falls, and multiple comorbidities was identified by staff as a very high fall risk who was agitated, attempting to crawl out of bed, and unable to walk independently. Progress notes and staff interviews showed the resident experienced several falls, including a witnessed slide from bed causing a skin tear and subsequent falls resulting in head trauma and other injuries. Although the care plan called for a 1-inch floor mat beside the bed, staff reported that mats were not initially used and were not consistently in place, citing concern the resident might trip. An LPN described hearing a thud and finding the resident face down on the floor with blood around the head and no mat present. The DON acknowledged that the mat intervention was implemented only after multiple falls, and hospital records documented multiple cervical vertebral fractures and other injuries from three falls within 24 hours, with the resident’s death certificate attributing death to complications from these fall-related fractures.
Surveyors identified multiple dietary service failures, including expired refrigerated foods left in storage beyond their labeled use-by dates, a cook working without a required hair net, and improper manual sanitizing of a blender that was washed and rinsed without immersion in sanitizer or air drying, while sanitizer solution was absent from the third sink compartment. The same cook prepared pureed vegetables in the inadequately sanitized blender, with solution dripping from the blender onto the counter during use. Additionally, required food temperatures for hot and cold items were not taken or documented on the meal temperature log, despite facility policies and staff statements that all foods must be temped and recorded. These issues had the potential to affect all residents receiving meals from the kitchen.
The facility failed to follow its own policy and CMS requirements to educate staff on COVID-19 vaccination, offer the COVID-19 vaccine, and document each employee’s vaccination status. The Infection Prevention Nurse reported that the facility does not offer the COVID-19 vaccine to employees and does not keep records of who has been vaccinated. A restorative CNA stated she had not been offered the vaccine, had not been asked about her vaccination status, and had not received education on the current COVID-19 vaccine. An RN and an LPN reported they work throughout the building without designated areas, while the written policy requires annual offering of CDC-recommended vaccines, provision of vaccine education, completion of declination forms, and maintenance of a staff vaccination list and education forms.
The facility failed to provide meaningful, resident-centered activities for several residents with dementia. A resident with Alzheimer’s disease was kept in a dining room for hours with a TV program she disliked, minimal staff interaction, and no individualized engagement, and her care plan lacked activity interests. Another resident with dementia lost access to a baby doll she was nurturing when another resident took it without staff noticing, then sat idle after an activity aide removed nearby comfort items, despite her documented interests in socializing, going outside, dogs, and card games. Two additional residents with dementia were left to wander or sit facing away from the TV with no individualized activities, even though their care plans identified preferences such as arts and crafts, music, religious observance, TV, walking the unit, and visiting others. The activity director reported that, despite a posted calendar of group programs, no communal activities were being conducted and staff were supposed to provide one-on-one activities during an influenza outbreak, which were not observed.
Staff failed to follow PPE and hand hygiene protocols for residents on contact and droplet isolation for influenza. An LPN wore an improperly secured N95 mask, did not remove the mask or face shield when exiting an isolation room, and then entered a non-isolation room wearing the same PPE to administer medications. In a separate event, an activity aide entered an isolation room of a resident with influenza wearing only a mask, without a gown or face shield, and did not perform hand hygiene when entering or exiting before proceeding to deliver a meal tray to another resident who was not on isolation.
A resident admitted from a rehab hospital with anoxic brain injury and bipolar disorder had a PASARR Level I screening that authorized only a 60-day convalescent stay and indicated possible serious mental illness or IDD. After the 60-day approval period ended, no follow-up PASARR screening was completed as required. The Social Service Director reported that corporate staff handled initial PASARRs while social services was supposed to track and follow up on 60-day approvals, but the responsible social services staff at that time did not complete the needed follow-up, and the current director was unaware it was required.
A resident with an indwelling urinary catheter and a history of UTI was observed on multiple occasions lying in bed with the catheter drainage bag resting on the floor, including instances where the bedside table wheels were running over the bag. A CNA reported that staff were responsible for all catheter care for this resident and acknowledged that the drainage bag should not touch the floor to prevent contamination or infection. The facility’s written catheter care policy required that drainage bags be kept off the floor, but this was not followed in the resident’s care.
A resident with poor oral intake and identified risk for malnutrition had physician orders and a care plan directing fortified foods three times daily, including fortified mashed potatoes at lunch and dinner. During a meal observation, the resident’s tray did not contain any potatoes, and the resident reported this omission occurred from time to time. The dietitian confirmed the resident should have received fortified mashed potatoes, which are prepared with whole milk and protein powder to help manage weight. The dietary manager stated that fortified items are identified on meal tickets, reviewed the resident’s lunch ticket, and confirmed it did not indicate fortified foods despite both mashed potatoes and a baked potato being selected, resulting in the resident not receiving the ordered fortified potatoes.
A resident with liver failure and complications including hepatorenal syndrome, metabolic encephalopathy, and portal hypertension had an order for midodrine three times daily with instructions to hold the dose if systolic BP was greater than 120 mm Hg. Review of the MAR showed that on multiple days the resident’s systolic BP exceeded this parameter, yet midodrine was still documented as given. An LPN confirmed that check marks on the MAR indicated the medication was administered, and the DON stated that nurses were expected to follow ordered parameters, while facility guidelines required medications to be given according to prescriber orders.
Surveyors found that several opened insulin pens on a medication cart, including Lantus, Glargine, and Humalog pens used by multiple residents, were not labeled with the date of opening as required. An LPN confirmed that all insulin pens must be dated when opened and are only usable for 28 days, and the DON verified that facility policy requires documenting both the opening date and the 28-day expiration date. This omission resulted in noncompliant labeling and storage of insulin medications.
The facility failed to follow its pneumococcal vaccination policy for two residents by not assessing or documenting their pneumococcal (PNA) vaccine status at admission and not offering the vaccine at move-in as required. Review of vaccine and admission records showed no pneumococcal vaccine information for these residents, and the Infection Prevention Nurse confirmed they had not been offered the vaccine before the surveyor interview, despite stating that all residents are to be screened on admission and offered the vaccine if due.
The facility did not ensure that nurse staffing information was posted and updated each day as required. A scheduler reported that the ADON is responsible for posting daily staffing on the bulletin board, but the staffing information observed on the board was several days out of date. This practice did not follow the facility’s written policy, which requires completion and daily updating of the staffing report, including census and date, in a prominent and accessible location.
A resident with severe cognitive impairment and total care needs was found with new bruising to her left shoulder. Facility staff did not notify the physician or NP or obtain an X-ray order, instead waiting for hospice direction, which led to a delay of over 24 hours before the injury was properly assessed. The X-ray, eventually ordered by hospice, revealed a shoulder dislocation, and the resident was sent to the hospital for evaluation. Facility documentation and staff interviews confirmed a lack of timely assessment, physician notification, and follow-up as required by policy.
A resident with severe cognitive impairment and total dependence on staff for care suffered a left shoulder dislocation after being repositioned in bed by a CNA working alone, despite the care plan requiring two staff for safe repositioning. The injury was discovered when bruising and swelling were noted, and subsequent assessment and imaging confirmed the dislocation. Staff interviews confirmed the resident could not move independently and that the care plan protocol was not followed.
Facility staff did not inform a resident's POA of new bruising and a shoulder dislocation, despite discovering the injury and initiating medical interventions such as an X-ray and hospital transfer. The POA was only notified by the hospice agency, not by facility staff, which was contrary to facility policy requiring immediate notification of responsible parties following a change in condition.
A resident with a history of falls and multiple comorbidities experienced an unwitnessed fall, after which only a urinalysis was performed to rule out infection due to confusion, with no additional fall prevention interventions implemented. The resident subsequently suffered another fall resulting in multiple rib fractures and required hospital evaluation. Staff confirmed that no further interventions were put in place between the two incidents.
A resident with a history of psychosis, recent medication changes, and acute delusions was placed at the nurses station for monitoring but was able to leave the facility unsupervised in her wheelchair when staff supervision lapsed. The resident was found outside without injury after staff initiated a search, revealing a deficiency in maintaining adequate supervision for residents experiencing acute cognitive changes.
A resident with a history of aggressive behavior and undergoing a gradual dose reduction of quetiapine unexpectedly slapped another resident in the dining room, causing her glasses to fall. A CNA witnessed the incident and noted the aggressive resident's frequent behaviors. The facility's administrator acknowledged the incident, which coincided with a recent medication adjustment.
A resident with severe cognitive impairment and mobility issues fell from bed during incontinence care, resulting in multiple fractures and a laceration. The CNA involved was unsure if the resident was rolled too far, and staff interviews revealed the resident's care needs were underestimated, leading to inadequate supervision during the incident.
A resident with severe cognitive impairment was physically harmed by another resident with known behavioral issues in an LTC facility. Despite the facility's abuse prevention policy, the two residents continued to share a bathroom, contributing to the incident. The harmed resident sustained cuts and bruises, and expressed feeling unsafe.
The facility failed to timely identify and address pressure injuries for two residents, leading to advanced-stage ulcers. One resident, at high risk due to immobility and cognitive issues, developed multiple stage 3 pressure injuries. Another resident with a stage 4 heel ulcer did not receive required offloading interventions. The facility's skin care policy was not adequately followed.
A resident with cognitive and swallowing disorders experienced significant weight loss, but the facility failed to notify the dietician promptly, delaying dietary interventions. The resident lost 8 lbs. over 24 days and an additional 3.4 lbs. in the following week. The facility's policy requires notifying the dietician for weight changes of 5% or more in a month, but this was not done until later, resulting in a delay in implementing necessary dietary measures.
A resident with a non-pressure wound on the left foot did not have her dressing changed as per physician orders, which required daily changes. The wound care nurse forgot to input the orders, and the responsible nurse did not change the dressing due to the absence of an order. The resident's care plan highlighted the need for treatment as ordered, considering her condition of congestive heart failure.
The facility failed to safely transfer a resident, resulting in bruising, and improperly used a non-medical grade power strip for medical devices. A CNA used a sit-to-stand lift instead of a mechanical lift, contrary to the resident's care plan. Additionally, a resident's bed and air mattress were plugged into a non-medical grade power strip, with no facility policy available.
A resident with a history of pneumonia and respiratory issues did not receive proper respiratory care due to the facility's failure to maintain bedside suction equipment. The equipment was improperly stored and not dated, and staff were unaware of maintenance protocols. The resident's care plan lacked interventions for oral suctioning, and there were no physician orders for PRN suctioning. The facility did not provide a relevant policy during the survey.
Two CNAs failed to wear gowns while providing care to residents on Enhanced Barrier Precautions, despite facility policy requiring PPE for high-contact care. One resident had a pressure ulcer, and another had a suprapubic catheter and a healing pressure ulcer. The facility's policy mandates gowns and gloves for such care, but the CNAs did not comply, as confirmed by the DON.
A resident with multiple health issues developed a necrotic pressure ulcer on the right heel due to the facility's failure to identify and treat it in a timely manner. Despite being at risk, the resident's care plan lacked specific interventions for heel protection, and staff did not conduct adequate skin checks or documentation, leading to the ulcer becoming unstageable.
Failure to Provide and Care Plan Restorative Walking Programs for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document restorative services, particularly walking programs, to maintain or improve residents’ range of motion and mobility. One resident, who was alert and oriented and used a wheelchair and walker, reported that he had been "cut out of therapy" and that staff did not walk him because they were too busy, despite his desire to ambulate with assistance. His restorative progress note showed he was on a walking program twice daily with specific instructions for ambulation using a two-wheeled walker, yet CNA nursing rehab task documentation for walking showed that on 11 out of 30 days the service was marked not applicable, indicating it was not provided. Additionally, his current care plan did not include his restorative walking program or the services to be provided. Another resident with multiple diagnoses including muscle weakness, malnutrition, metabolic encephalopathy, atrial fibrillation, and dizziness had a physician order for restorative walking 15–20 minutes on first and second shifts. The MAR reflected that an LPN documented the resident was being walked twice per day, including during the survey period. However, the resident stated he was no longer walked daily since the previous restorative CNA stepped down, reporting that he previously completed 12 laps but had only been walked about three times in the last two weeks for only three laps each time. His assigned CNA confirmed that restorative walking was not occurring consistently, that no staff had walked him that day, and that staffing levels made it difficult to walk residents. CNA task documentation for this resident did not include walking on even surfaces, only on uneven or sloping surfaces, and his care plan did not include a restorative program despite an ADL self-care deficit related to limited mobility and impaired balance. A third resident, admitted with conditions including primary disorder of muscle, difficulty in walking, abnormal posture, and muscle weakness, had a care plan for a restorative ambulation program with a goal to ambulate 110–200 feet using a four-wheeled walker with extensive assist and wheelchair follow. CNA task documentation for walking 150 feet twice daily showed the task was marked not applicable 22 out of 26 times in the last 14 days, and when the resident was walked, he required maximal assistance or was dependent. Documentation of minutes spent in walking training showed he was walked only once daily on several specific dates rather than twice daily as planned. The resident reported that staff did not walk him, while an LPN stated he was able to walk with staff assistance. Facility leadership, including the DON, ADON, and nursing staff, acknowledged that the previous restorative CNA had stepped down, that there was no designated restorative staff, that floor CNAs were now responsible for restorative services, and that there was uncertainty about which residents were on restorative programs. The facility’s Nursing Rehab policy required the interdisciplinary team to develop and implement care-planned interventions and to record nursing rehab tasks as part of daily care, which was not consistently done for these residents.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions to prevent and/or minimize injury for a resident identified as very high risk for falls, resulting in multiple unwitnessed and witnessed falls. Staff interviews and record review showed that the resident had dementia, confusion at baseline, insomnia, hearing loss, major depressive disorder, adjustment disorder with depressed mood, and a history of repeated falls. Progress notes documented that the resident was aggravated and attempting to crawl out of bed, had a witnessed slide from bed with a resulting skin tear, and later experienced additional falls. Nursing staff, including LPNs and the DON, acknowledged that the resident was a definite fall risk, was very agitated, kept trying to get out of bed, and was unable to walk independently. Despite this, the resident did not have floor mats in place at the time of at least one fall, and staff reported that fall mats were not used initially because they believed the resident would trip over them. The resident’s care plan identified a potential to fall and risk of injury from falls, with an intervention for a one‑inch floor mat to be placed beside the bed beginning on a specified date. However, staff statements and documentation showed that the floor mat intervention was not consistently implemented, including after the resident returned from the hospital with a scalp laceration requiring staples and other injuries from a prior fall. One LPN reported hearing a “thud” from the nurse’s station and finding the resident face down on the floor with blood around the head, noting that no fall mat had been placed because of concern the resident would trip. The DON stated that a one‑inch floor mat was implemented only after the second fall that shift, and the resident subsequently fell again about an hour after returning from the hospital. Hospital records confirmed that the resident sustained multiple cervical vertebral fractures, nasal and septal fractures, a tooth fracture, scalp laceration, and blunt head trauma as a result of three falls within 24 hours, and the death certificate linked the resident’s death to multiple vertebral fractures due to falls.
Food Safety, Sanitation, and Hair Restraint Failures in Dietary Services
Penalty
Summary
The deficiency involves multiple failures in food storage, preparation, sanitation, temperature monitoring, and use of hair restraints in the facility kitchen, with the potential to affect all 81 residents. During a kitchen tour, surveyors observed several refrigerated food items past their labeled use-by dates, including applesauce and sliced apples dated 12/3–12/9, shredded cheddar cheese with a use-by date of 1/3, and half a ham dated 12/28–1/3, despite facility policy requiring refrigerated foods to be covered, labeled, and dated with a use-by date. The Dietary Manager confirmed that staff write use-by dates on containers and that these foods should have been used by those dates. The menu review showed that Caribbean pork roast was served on a different day than originally scheduled because the roasts were not available on the planned day. Surveyors also observed a cook working in the kitchen without a hair net, instead wearing a winter stocking hat, contrary to the facility’s Hair Restraints/Jewelry/Nail Polish Policy requiring hairnets at all times in the kitchen. The same cook was seen washing and rinsing a dirty blender and lid in the three-compartment sink, then using a sanitizer hose to rinse them without submerging them in sanitizer solution for at least one minute, and without allowing them to air dry, even though the sanitizer compartment contained no solution. After preparing pureed green beans in the blender, solution was seen dripping from the bottom of the blender onto the counter as the food was poured into a pan. When the lunch meal was being plated and sent to the units, the food temperature log for that meal had no recorded temperatures, and the cook stated he forgot to record them, despite facility policy and another cook’s statement that all hot and cold foods should be temperature-checked and documented at the end of cooking. The Dietary Manager later stated that anyone entering the kitchen must wear a hair net and that equipment must be fully submerged in sanitizer for at least one minute and then air dried, consistent with posted manufacturer instructions and the facility’s manual sanitizing policy.
Failure to Educate, Offer, and Document Staff COVID-19 Vaccination
Penalty
Summary
The facility failed to provide COVID-19 vaccination education, offer the COVID-19 vaccine, and document vaccination status for its employees, contrary to its own policy and CMS regulations. The CMS-671 dated 1/5/26 showed a facility census of 81 residents. During an interview, the Infection Prevention Nurse stated that the facility does not offer the COVID-19 vaccine to employees and does not keep records of which employees have or have not received the vaccine. The facility’s written policy, reviewed in 10/25, states that employees will be offered CDC-recommended vaccines annually, including COVID-19, that staff will be provided information and education regarding the vaccine, that declination forms will be completed and filed for those who refuse, and that a list of vaccinated employees will be maintained by the Infection Prevention Nurse designee. The policy also states that CMS regulations require staff to receive education on COVID-19 and be offered the vaccine, with staff completing a COVID-19 staff education form as proof. Staff interviews confirmed that the facility was not implementing these requirements. A restorative CNA who had worked at the facility for 13 years reported that the facility was not currently offering COVID-19 vaccines to employees, that no one had asked about her current COVID-19 vaccination status, and that she had not received any education regarding the current COVID-19 vaccine. An RN and an LPN both reported that they work throughout the building without designated areas, indicating that staff who move across all units were not being tracked or documented for COVID-19 vaccination status. These observations and interviews demonstrate that the facility was not following its own policy or CMS requirements to educate staff on COVID-19 vaccination, offer the vaccine, and maintain documentation of each employee’s vaccination status.
Failure to Provide Resident-Centered, Dementia-Appropriate Activities
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident-centered, meaningful activity program for multiple residents with dementia. One resident with late-onset Alzheimer’s disease was repeatedly placed in the dining room for extended periods, seated at a table with many other residents while a 1990s Western drama played on the television that she did not like and did not watch. Activity staff were seated in a corner with only one resident coloring, and most residents were asleep. This resident was observed propelling herself in her wheelchair, asking how long she had to sit there, stating she wanted to return to her room to watch TV, and describing the situation as “torture” and that residents were left with “no water.” Staff initially refused to let her return to her room due to fall risk, left her without engagement, and later only provided coloring materials at a table in the corner. Her care plan did not address her activity interests or abilities. Another resident with unspecified dementia sat in the dining room in a wheelchair holding a baby doll, kissing and cradling it, until another resident took the doll away without staff noticing or intervening. This resident then sat without any activity, commented to another resident that they were just “set out here,” and placed a small activity blanket on the floor, stating someone else would pick it up. An activity aide later removed the stuffed animal, pillow, and blanket from the area and put them away, and the resident was turned to face the table as preparations for lunch began. No structured or individualized activities were provided during this time, despite the resident’s care plan noting that she likes to sit and talk with others, go outside, loves dogs, and enjoys card games such as poker and rummy. Two additional residents with dementia were also not provided with meaningful, individualized activities. One resident repeatedly walked between her room and the dining room, briefly sitting and then leaving, and when she asked for help finding food, staff confirmed she had already eaten and only offered cookies before seating her in front of the same television program that had been playing all day; no staff attempted to engage her in activities consistent with her care plan, which documented interests in arts and crafts, music, bowling, and Catholic faith, and noted that she primarily speaks Spanish. Another resident with dementia spent the morning hours seated in a wheelchair in the dining room with her back to the television, mostly asleep, with no staff engagement and no access to the TV she could not see, despite a care plan stating she would attend meaningful activities such as watching TV, listening to music, going outside, walking the unit, and visiting other residents. The activity director later stated that due to an influenza outbreak there were to be no communal activities, that staff were instructed to focus on one-on-one activities, and that the posted activity calendar listed multiple group activities that were not observed occurring on the days of the survey.
Failure to Follow PPE and Hand Hygiene Protocols for Residents on Influenza Isolation
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to PPE use and hand hygiene for residents on contact and droplet isolation for influenza. One resident had active orders for contact and droplet isolation for influenza, with signage posted instructing staff to remove PPE before exiting the room. An LPN entered this resident’s room wearing the required PPE, including an N95 mask, but the N95 was not properly secured because the top loop was not in use and there was no surgical mask over it. After administering medications, the LPN removed only the gown and gloves when exiting the isolation room and did not remove the face shield or N95 mask, despite posted instructions and facility signage stating that the face shield and mask are considered contaminated and should be removed when exiting an isolation room. The same LPN then entered another resident’s room, who was not on isolation, wearing the same face shield and N95 mask that had been used in the isolation room, and administered medications. In a separate incident, another resident with a positive test for Influenza A and on droplet and contact precautions had a door sign instructing staff to perform hand hygiene before entering and exiting, to fully cover eyes, nose, and mouth, to remove face protection before exiting, and to don gloves and gown before entry. During lunch service, an activity aide entered this resident’s room wearing only a mask, without a gown or face shield, and did not perform hand hygiene upon entering or exiting. The aide then delivered a lunch tray to another resident who was not on isolation and did not have influenza. The infection control nurse confirmed the facility was in a flu outbreak and stated that all staff entering the isolation room should wear a mask (preferably N95), face shield, gown, and perform hand hygiene as preventative measures.
Failure to Complete Required PASARR Follow-Up After 60-Day Convalescent Approval
Penalty
Summary
The facility failed to ensure that a required PASARR (Preadmission Screening and Resident Review) follow-up screening was completed for a resident whose initial PASARR Level I determination authorized only a 60-day convalescent stay. The resident was admitted from a rehabilitation hospital with diagnoses including anoxic brain injury and bipolar disorder, and the PASARR Level I screening dated 11/29/23 documented a convalescence categorical determination with an approval period of 60 days, noting that the resident may have a serious mental illness or intellectual/developmental disability and could remain in the nursing facility for up to 60 days without further PASARR assessment. After this 60-day approval period expired, no subsequent PASARR screening was completed as required. According to the Social Service Director, corporate staff had been completing the initial PASARR screenings and social services staff were responsible for following up on cases with a 60-day limit, but the social services staff member in place at that time did not complete the follow-up screening, and the current Social Service Director, who started in April, was unaware that it needed to be done.
Failure to Keep Indwelling Catheter Drainage Bag Off the Floor
Penalty
Summary
The facility failed to ensure proper management of an indwelling urinary catheter drainage bag for one resident, resulting in the bag resting on the floor on multiple occasions. The resident had an indwelling urinary catheter and a history of urinary tract infection, as documented in a care plan reviewed on 01/05/26. On 01/05/26 at 8:58 AM, the resident was observed in bed with the indwelling urinary drainage bag positioned at the side of the bed, with the bottom portion of the bag resting on the floor. On 01/06/26 at 8:38 AM, the resident was again observed in bed with the drainage bag not hanging from any support and lying flat on the floor, while the wheels of the bedside table were running over the drainage bag. During an interview on 01/06/26 at 11:04 AM, a CNA stated that staff provided all indwelling urinary catheter care and management for the resident and acknowledged that a drainage bag should not touch the floor to prevent contamination or infection. The facility’s Indwelling Catheter Care and Maintenance policy, reviewed in 03/2025, directed staff to keep the drainage bag off the floor. These observations and statements show that staff did not follow the facility’s catheter care policy or accepted practices for maintaining the drainage bag off the floor for this resident with an indwelling urinary catheter and a history of urinary tract infection.
Failure to Provide Ordered Fortified Foods for Nutritionally At-Risk Resident
Penalty
Summary
The facility failed to provide ordered fortified foods to a resident identified as being at risk for malnutrition. The physician order summary dated 01/07/26 directed that the resident receive fortified food three times daily for poor oral intake, specifically super cereal at breakfast and fortified mashed potatoes at lunch and dinner. The resident’s dietary profile effective 12/23/25 documented a nutritional supplement of fortified foods and a preference for potatoes, and the care plan initiated 4/18/25 identified the resident as at risk for malnutrition with an intervention to provide fortified foods three times a day, including fortified mashed potatoes at lunch and dinner. On 01/05/26 at 11:47 AM, surveyors observed the resident in his room with a covered meal tray; when the lid was removed, there were no potatoes on the tray. The resident stated he was supposed to receive potatoes and that not receiving them happened from time to time. On 01/06/26 at 11:55 AM, the dietitian explained that fortified mashed potatoes are prepared with whole milk and protein powder and are used to help manage a resident’s weight, and confirmed the resident should have received fortified mashed potatoes. At 12:59 PM the same day, the dietary manager stated that the kitchen relies on the meal ticket to identify fortified foods, reviewed the resident’s lunch meal ticket from 01/05/26, and confirmed it did not indicate fortified foods. She reported assisting the resident in filling out the meal ticket, with both mashed potatoes and a baked potato circled, and acknowledged the resident should have received mashed potatoes and a baked potato.
Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not follow ordered blood pressure parameters for administering a prescribed medication. A resident with liver failure who was not a transplant candidate, and who had complications including hepatorenal syndrome, metabolic encephalopathy, and portal hypertension, had a provider order for midodrine to be given three times daily for portal hypertension, with instructions to hold the medication if the systolic blood pressure exceeded 120 mm Hg. Review of the resident’s December 2025 MAR showed that on ten days during the month, the resident’s systolic blood pressure was above 120 mm Hg, yet midodrine was documented as administered. An LPN who gave several of these doses confirmed that a check mark on the MAR indicated the medication was given, and the DON stated that nurses were expected to follow medication parameters when administering medications. The facility’s written Medication Administration – General Guidelines, dated November 2021, required that medications be administered in accordance with the prescriber’s written orders, but the documented administration of midodrine despite blood pressure readings above the ordered threshold on multiple days demonstrated noncompliance with these guidelines and the provider’s parameters.
Failure to Date Opened Insulin Pens per Policy
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage practices when multiple opened insulin pens on a first-floor medication cart were not dated in accordance with facility policy and professional standards. During a medication storage review, an LPN and the surveyor observed that insulin pens assigned to three residents, including Lantus KwikPens for morning and bedtime administration and a Glargine KwikPen for morning use, as well as a Humalog KwikPen used per sliding scale, had been opened but were not labeled with the date of opening. The LPN acknowledged that all insulin pens were required to be dated when opened and stated that these pens were only good for 28 days, so without dates they did not know when to discard them or whether the insulin was still effective. The DON also confirmed that all insulin pens should be dated upon opening because they are only good for 28 days after opening, and the facility’s written policy on insulin pen usage required pens to be labeled with the date of opening and the expiration date, defined as 28 days after opening. This failure to date opened insulin pens for these residents constituted noncompliance with the requirement that drugs and biologicals be labeled in accordance with accepted professional principles and facility policy.
Failure to Assess and Offer Pneumococcal Vaccinations on Admission
Penalty
Summary
The deficiency involves the facility’s failure to assess and offer pneumococcal vaccinations upon admission as required by its own policy. Record review on 1/6/26 showed that two residents’ vaccine records contained no information regarding their pneumococcal vaccine status. Admission records indicated both residents had been admitted prior to that date, yet there was no documentation that they had been screened for or offered the pneumococcal vaccine at the time of admission. During interviews, the Infection Prevention Nurse stated that all residents are supposed to be screened on admission for pneumococcal vaccine status and that, if due, the vaccine can be ordered and administered in the facility, with offers continued annually as applicable. However, the Infection Prevention Nurse acknowledged that these two residents had not been offered the pneumococcal vaccine prior to the day of the interview, despite the facility’s Pneumovax Vaccine Policy stating that all guests will be offered the pneumococcal vaccination at the time of move-in. This failure to follow the established pneumococcal vaccination policy for these two residents at admission, and the lack of documentation of their pneumococcal vaccine status, led to the cited deficiency.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information on a daily basis as required, affecting a census of 81 residents. On review of the CMS-671 dated 1/5/26, the facility census was confirmed as 81. During an interview on 1/6/26 at 9:19 AM, the scheduler stated that the ADON is responsible for posting the daily staffing on the bulletin board. However, at 10:09 AM on the same day, the nurse staffing information posted on the facility’s bulletin board was found to be dated 1/2/26, indicating that it had not been updated daily. The facility’s Posting of Staffing Report Policy, reviewed in 2/25, states that staff will complete and update the daily Staffing Report each day and post it in a prominent, readily accessible place with the daily census and date displayed, which was not followed in this instance. This failure to update and post the staffing report daily was identified through observation, staff interview, and record review, and was determined to be inconsistent with the facility’s own policy and applicable state and federal requirements for daily staffing postings.
Failure to Timely Assess and Treat New Shoulder Injury
Penalty
Summary
Facility staff failed to assess, intervene, and implement timely treatment for a resident who was found with new bruising to her left shoulder. The resident, who was severely cognitively impaired, nonverbal, and dependent on staff for all care due to Alzheimer's disease, was discovered with a large, purple bruise on her left upper arm during the early morning hours. Despite this significant change in condition, facility staff did not notify the resident's physician or nurse practitioner, nor did they attempt to obtain an order for an X-ray. Instead, staff notified the hospice agency and waited for their direction, resulting in a delay of over 24 hours before an X-ray was performed. The X-ray, eventually ordered by the hospice nurse after her own assessment, revealed a dislocated left shoulder with a possible glenoid fracture. The resident was subsequently sent to the hospital for evaluation, where surgical intervention was recommended but declined by the resident's power of attorney. The resident was returned to the facility with orders for conservative management and comfort care. Throughout this period, facility progress notes showed no documentation of reassessment of the injury, no follow-up with the mobile X-ray company to expedite imaging, and no direct communication with the resident's primary medical providers regarding the acute change in condition. Interviews with facility staff, including the RN, ADON, and DON, confirmed that none of them contacted the resident's physician or nurse practitioner after discovering the injury. Staff indicated they were waiting for hospice to take the lead, despite facility policy requiring immediate notification of the attending physician for acute changes in condition. The facility's own policy emphasized the need for prompt assessment, physician notification, and documentation when a resident experiences an acute change, none of which were followed in this case.
Failure to Follow Care Plan Results in Resident Shoulder Dislocation
Penalty
Summary
A deficiency occurred when staff failed to provide care in accordance with a resident's care plan, resulting in a left shoulder dislocation. The resident was severely cognitively impaired, nonverbal, and fully dependent on staff for all activities of daily living due to Alzheimer's disease. The care plan specified that two staff members were required to safely reposition the resident in bed. However, a CNA reported providing incontinence care and repositioning the resident alone on multiple occasions during a night shift, contrary to the care plan instructions. The incident was discovered when the CNA noticed bruising and swelling on the resident's left shoulder while dressing her. The CNA reported the finding to the RN, who assessed the resident and found the area to be purple and warm to the touch. The hospice nurse was notified and, upon assessment, found the shoulder to be floppy and unstable, prompting an X-ray order. The X-ray revealed a dislocated left shoulder with a possible glenoid fracture, and the resident was subsequently sent to the hospital for evaluation. Interviews with facility staff confirmed that the resident was unable to move independently and had no history of falls or injuries during the relevant period. The nurse practitioner and hospice nurse both stated that the injury could not have occurred spontaneously and must have resulted from trauma or force. The DON confirmed that staff are expected to follow the care plan, which required two staff for repositioning, and that this protocol was not followed in this case.
Failure to Notify POA of Resident's Injury and Change in Condition
Penalty
Summary
Facility staff failed to notify a resident's Power of Attorney (POA) of a significant change in the resident's condition, specifically the discovery of new bruising and a subsequent shoulder dislocation. On the early morning of 9/5/25, staff discovered new bruising on the resident's left upper arm and shoulder. The hospice agency was notified, and an X-ray was ordered, which later revealed a dislocated shoulder. The resident was then sent to a local hospital for further evaluation. Throughout this period, there was no documentation or evidence that the resident's POA was informed by facility staff about the new injury, the X-ray, or the change in condition. Interviews with facility staff, including the RN, Assistant Director of Nursing (ADON), and Director of Nursing (DON), confirmed that none of them notified the POA of the new bruising or the subsequent medical interventions. The facility's own policy requires immediate notification of the responsible party when a resident experiences an acute change in condition. Despite this, the POA only learned of the injury and the need for hospital evaluation from the hospice agency, not from the facility. Documentation showed that the POA was contacted about a room change, but not about the resident's injury or medical status.
Failure to Implement Fall Prevention Interventions After Initial Fall
Penalty
Summary
The facility failed to implement additional fall prevention interventions after a resident experienced a fall. Following an unwitnessed fall in the resident's room, the resident was found on the floor next to his bed, having attempted to get up and slid to the floor. The care plan identified the resident as high risk for falls with a history of previous falls, and the only intervention initiated after the incident was a urinalysis to rule out infection due to observed confusion. No other interventions were documented or put in place to address the resident's fall risk after the initial event. Subsequently, the resident experienced another unwitnessed fall while attempting to self-transfer to the restroom, resulting in four fractured ribs and requiring transfer to the emergency department for further evaluation and treatment. The resident's medical history included chronic obstructive pulmonary disease, chronic kidney disease, difficulty walking, unsteadiness on feet, depression, history of falling, and metabolic encephalopathy. Staff interviews confirmed that no additional fall prevention measures were implemented between the two falls, despite the resident's high risk status and recent change in mental status.
Resident Elopement Due to Inadequate Supervision During Acute Delusional Episode
Penalty
Summary
A deficiency occurred when a resident with a history of unspecified psychosis, cerebral infarction, hypertension, adjustment disorder with depressed mood, weakness, and unsteadiness on her feet was not adequately supervised, resulting in her leaving the facility unsupervised. The resident, who had recently been admitted from the hospital and had a recent urinary tract infection and changes to her antipsychotic medications, exhibited acute delusions and agitation during the night. Despite being placed at the nurses station for monitoring due to her behaviors, staff supervision lapsed when a CNA left to answer a call light, and the resident was able to leave the facility in her wheelchair without being noticed. Staff interviews revealed that the resident was being checked every 15 minutes and was considered calm and not displaying exit-seeking behaviors prior to the incident. However, during a period when the CNA was away from the nurses station, the resident left the area and exited the building. The staff initiated a search and found the resident outside on the sidewalk, approximately 130 feet from the facility, fully dressed and in her wheelchair. The resident was returned to the facility without injury. The facility's records indicated that the resident was previously assessed as alert, oriented, and free from confusion, qualifying her for independent pass privileges. However, during the incident, she was experiencing acute cognitive changes, including delusions and agitation, which were not adequately addressed through increased supervision. The facility's elopement policy outlines procedures for searching and notification in the event of a missing resident, but the lapse in supervision allowed the resident to leave the facility unsupervised.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents. During a meal in the dining room, one resident, who has a history of aggressive behaviors and was undergoing a gradual dose reduction of quetiapine, unexpectedly slapped another resident, causing her glasses to fall to the floor. A Certified Nursing Assistant witnessed the incident and noted that the aggressive resident frequently exhibits such behaviors. The facility's administrator acknowledged the incident, noting that it was unexpected and coincided with a recent medication adjustment for the aggressive resident.
Resident Injury Due to Inadequate Incontinence Care
Penalty
Summary
The facility failed to ensure safe incontinence care for a resident, resulting in the resident rolling off the bed and sustaining multiple injuries, including a cervical fracture, a left clavicle fracture, and a laceration to the left eyebrow requiring sutures. The resident, who was admitted with severe cognitive impairment and required substantial assistance for bed mobility, was being changed by a CNA when the incident occurred. The CNA reported that the resident continued to roll after being turned, leading to the fall. The resident's care plan indicated a need for extensive assistance with bed mobility and incontinence care. However, the CNA involved in the incident was unsure if the resident was rolled too far and noted that the resident was a difficult turn, requiring more assistance than listed. The RN who responded to the incident emphasized the importance of ensuring stability when turning residents, highlighting a lapse in supervision and care during the incident. Interviews with facility staff revealed that the resident's condition had been declining, making incontinence care more challenging. Despite this, agency staff often attempted care without seeking additional help until realizing the difficulty. Following the incident, the facility updated the resident's care plan to require two-person assistance for bed mobility and incontinence care, indicating a previous oversight in assessing the resident's needs.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R1, from physical abuse by another resident, R2. R1, who was admitted with severe cognitive impairment and various medical conditions including dementia, was found to have been physically harmed by R2. R2, also with severe cognitive impairment and a history of behavioral disturbances, was noted to have grabbed R1's wrists and caused injuries, including cuts and bruises, during an incident in R1's room. This incident occurred after R2 mistakenly believed R1 was in her bed, leading to aggressive behavior. The incident was reported to the Director of Nursing, and upon investigation, it was found that R1 had sustained a scratch on her left wrist and pinky, a bruise on her left hip, and complained of pain in her left hip and shoulder. X-rays were performed, which showed no acute findings. R1 expressed feeling scared and unsafe following the incident. The facility's investigation revealed that R2 had been aggressive throughout the day and had previously shown physical aggression towards staff but not towards other residents. Despite the incident, R1 and R2 continued to share a connecting bathroom, which both residents believed was theirs. The facility's policy on abuse prevention was in place, but the shared bathroom arrangement and R2's known behavioral issues contributed to the failure to prevent the abuse. Staff interviews indicated that R2's confusion and aggression were known issues, yet the environmental setup remained unchanged, leading to the incident where R1 was harmed.
Failure to Identify and Address Pressure Injuries
Penalty
Summary
The facility failed to identify and address pressure injuries in a timely manner for two residents, leading to the development and worsening of pressure ulcers. One resident, who was at high risk for pressure injuries due to cognitive impairment, immobility, and nutrition issues, developed multiple pressure injuries that were not identified until they reached advanced stages. Despite being completely dependent on staff for care, including repositioning and incontinence care, the resident's pressure injuries were not discovered until they had progressed to stage 3, with some wounds containing necrotic tissue. The facility's former wound care nurse was let go, and the new wound care nurse confirmed that the pressure injuries should have been identified earlier. Another resident with an active stage 4 pressure injury to the left heel did not receive appropriate pressure relief interventions. The care plan required the use of protective heel boots to offload pressure, but the resident was observed with heels flat against the mattress without any offloading measures in place. This oversight occurred despite the resident being at high risk for pressure injuries, as indicated by their Braden Scale score. The facility's Skin Care Prevention policy, which mandates daily evaluation of residents' skin conditions and specific interventions for those at risk, was not adequately followed. The failure to implement these interventions and promptly identify pressure injuries contributed to the deficiencies observed in the care of these residents.
Delayed Notification of Significant Weight Loss
Penalty
Summary
The facility failed to notify the dietician in a timely manner regarding a significant weight loss experienced by a resident, identified as R77. R77, who has diagnoses including cognitive communication deficit, other disorders of the brain, need for assistance with personal care, and dysphagia, experienced an 8 lbs. (6.2%) weight loss over 24 days, followed by an additional 3.4 lbs. (2.81%) weight loss in the subsequent week. Despite the facility's policy requiring notification of the dietician and healthcare provider for significant weight changes of 5% or more in one month, the dietician was not informed until the evening of 10/21/24, delaying the implementation of dietary interventions. The delay in notification resulted in a lack of timely dietary interventions, which included a high-calorie drink and double portions at meals, only being implemented on 10/22/24. The Director of Nursing, who was new to the facility, admitted to being unsure of the process for reporting weight loss to the dietician. The dietician confirmed that she was not notified of the significant weight loss until 10/21/24 and stated that earlier notification would have allowed for earlier intervention. The facility's Weight Change Investigation policy, reviewed in 7/14, outlines the procedure for addressing significant weight changes, which was not followed in this instance.
Failure to Change Wound Dressing as Ordered
Penalty
Summary
The facility failed to change a non-pressure wound dressing for a resident, R83, according to physician orders. R83, who has a diagnosis of local infection of the skin, cellulitis of the left lower limb, and chronic embolism and thrombosis of unspecified deep veins, reported that her wound dressing had not been changed over the weekend. The dressing on her left foot was last changed on October 18, 2024, despite the physician's order to change it daily. The treatment administration record showed no treatment orders for the wound since October 13, 2024, except for a PRN dressing change, which had not been utilized since it was ordered on October 5, 2024. The wound care nurse, V3, acknowledged noticing the unchanged dressing on October 21, 2024, and admitted to forgetting to input the orders on October 18, 2024, when the wound care doctor was present. The nurse responsible for changing the dressing did not do so, citing the absence of an order. R83's care plan, dated August 19, 2024, indicated the need for treatment as ordered by the physician, highlighting the resident's condition of congestive heart failure as a factor inhibiting wound healing. The facility's policies emphasize the importance of accurate documentation of physician orders and appropriate care to prevent skin breakdown, which was not adhered to in this case.
Deficiencies in Resident Transfer and Medical Device Safety
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, resulting in a large bruise on the resident's left chest and rib area. The incident occurred when a CNA, in a hurry to get the resident up for breakfast, used a sit-to-stand lift instead of the required mechanical lift (hoyer lift) for a two-person assist. The CNA admitted to transferring the resident alone and without proper knowledge of the transfer procedure, which was against the resident's care plan and the facility's safe resident policy. The resident, who is mildly impaired, was sent for further evaluation due to the bruising. Additionally, the facility failed to ensure that a resident's medical devices were plugged into a medical-grade power strip. An extension cord and non-medical grade power strip were used to power the resident's bed and pressure-relieving air mattress, which was necessary due to a pressure wound on the resident's heel. The facility did not have a power strip policy available at the time of the survey, and the issue was observed on consecutive days without correction.
Failure to Maintain Proper Respiratory Care for Resident
Penalty
Summary
The facility failed to maintain appropriate respiratory care for a resident with a history of pneumonia, as evidenced by the improper maintenance of bedside suction equipment. The resident, a female with a history of hemiplegia/hemiparesis following a cerebral infarction and dysphagia, was readmitted with pneumonia, sepsis, and acute respiratory failure. Observations revealed that the suction canister was full of a clear liquid, likely water, and the equipment, including the tubing and yankauer, was not dated. The tubing and yankauer were improperly stored, with the yankauer tip resting against the nightstand. The resident, despite communication difficulties, indicated through gestures that staff had used the suction equipment for her. Interviews with facility staff, including an LPN and the Assistant Director of Nursing, revealed a lack of knowledge regarding the maintenance and exchange frequency of suction equipment. The resident's care plan did not include focuses or interventions related to oral suctioning and airway management, and there were no physician orders for PRN oral suctioning. The Director of Nursing confirmed the absence of such orders and emphasized the need for an order and proper maintenance of the equipment. The facility did not provide a policy on oral suctioning or suctioning equipment during the survey.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that the required Personal Protective Equipment (PPE) was worn by staff when providing care to residents on Enhanced Barrier Precautions. During an observation, two Certified Nursing Assistants (CNAs) were seen providing care to two residents without wearing gowns, despite the presence of an enhanced barrier sign on the door indicating the need for gowns and gloves during high-contact care. The CNAs assisted one resident, who had a pressure ulcer on her heel, by transferring her using a mechanical lift and changing her brief without wearing gowns. Similarly, they provided incontinence care to another resident with a suprapubic catheter and a healing pressure ulcer, again without wearing gowns. The facility's Enhanced Barrier Precautions policy, last reviewed in April 2024, mandates the use of gloves and gowns for residents with urinary catheters and wounds during specific care activities. The Director of Nursing confirmed that staff should wear gowns and gloves when providing direct care to residents on Enhanced Barrier Precautions. One of the CNAs admitted feeling overwhelmed and acknowledged the failure to adhere to the PPE requirements. The deficiency was identified through observation, interview, and record review, highlighting a lapse in following established infection control protocols.
Failure to Prevent and Identify Pressure Ulcer
Penalty
Summary
The facility failed to identify and treat a pressure ulcer for a resident who was dependent on staff for care, resulting in the ulcer becoming necrotic and unstageable. The resident, who had multiple diagnoses including Type 2 Diabetes, Atrial Fibrillation, and Morbid Obesity, was admitted to the facility without any mention of a pressure sore. However, on 3/17/24, necrotic tissue was noted on the resident's right heel, and by 3/18/24, the wound was unstageable and necrotic, prompting a transfer to the ER for further evaluation. Interviews with staff revealed that the resident was resistive to care, including wearing foam boots and having heels elevated, which contributed to the development of the pressure ulcer. The wound nurse, who was responsible for dressing changes, noted that the resident's legs were weeping and that the wound likely developed over the weekend when she was not present. Despite the resident's non-compliance, there was a lack of documentation and proactive measures to prevent the ulcer, such as orders for heel lift boots or off-loading of the heels. The facility's policy on skin management required regular assessments and preventative measures for residents at risk of pressure injuries, as indicated by a Braden Scale score of 18 or less. However, the resident's care plan did not include specific interventions for heel protection, and the staff failed to conduct adequate skin checks and documentation, leading to the oversight of the pressure ulcer until it became severe.
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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