The Haven Of Bridgeport
Inspection history, citations, penalties and survey trends for this long-term care facility in Bridgeport, Illinois.
- Location
- 900 East Corporation, Bridgeport, Illinois 62417
- CMS Provider Number
- 145918
- Inspections on file
- 30
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at The Haven Of Bridgeport during CMS and state inspections, most recent first.
The facility failed to provide sufficient nursing staff to meet residents’ needs, resulting in delayed call light response and incontinence care for multiple cognitively intact residents with conditions such as morbid obesity, myasthenia gravis, diabetes, heart disease, and chronic incontinence. Care plans required Q2–3H and PRN incontinence checks, barrier cream application, and prompt call light response, yet one resident was found with a saturated brief and moisture-associated skin damage, and several residents and a roommate reported waiting from 30 minutes to a couple of hours for assistance after soiling or for morning and nighttime care. CNAs and other staff reported that there were often only four CNAs on duty, especially on the 2 pm–10 pm shift and on weekends, that many residents required two-person assist, and that this made it difficult to answer call lights and provide incontinence care timely, even as some nursing leadership asserted staffing was adequate and unchanged.
Multiple cognitively intact residents who were incontinent or dependent on staff for toileting reported that their call lights were not answered promptly, with some describing waits of 30 minutes to over an hour after soiling themselves. Staff care plans required that call lights be kept within reach and answered promptly, and the facility’s policy directed staff to answer calls as soon as possible. CNAs and other staff acknowledged that call lights were not always answered timely, especially on the evening shift when only four CNAs were working, many residents required two-person assist, and nurses were occupied with med passes, leading to delays in providing needed care.
The facility failed to reasonably accommodate the needs of two cognitively intact residents who were incontinent of bowel and bladder by not consistently providing correctly sized incontinence briefs. One resident with morbid obesity reported that briefs were too tight and had to be torn at the sides to fit, while another resident dependent on staff for toileting stated that the correct size was never available and that she would wet through the briefs used. A CNA supervisor identified both residents as using extra-large briefs, yet a supply check showed only medium and large packages and just two individual extra-large briefs, with no extra-large or double extra-large packages available. Multiple CNAs reported that correct sizes were not always on hand and that residents sometimes had to use incorrect sizes, while nursing leadership and the administrator stated they had not received any concerns about brief sizing.
Two residents experienced moisture-associated skin damage (MASD) that was not properly identified, assessed, or documented despite existing care plans and physician orders for barrier creams and skin assessments. One resident, occasionally incontinent and ordered Calmoseptine twice daily with weekly skin checks, was later observed with red, irritated buttocks, scrotum, and thighs with open bleeding spots, without corresponding detailed wound documentation or timely recognition by the wound nurse. Another resident, always incontinent and care planned for potential skin impairment, reported soreness in the peri area that appeared red and irritated during incontinence care, but this change was not reported to the wound nurse or documented in progress notes. These failures occurred despite a facility protocol requiring comprehensive skin assessments and documentation of skin condition.
Two residents with bowel and bladder incontinence did not receive incontinence care consistent with facility policy and current standards of practice. For one resident with multiple comorbidities and occasional incontinence, staff removed a saturated brief, used the same side of a washcloth on different perineal areas, did not perform hand hygiene between glove changes, and the resident was found with red, irritated skin and open bleeding spots consistent with moisture-associated skin damage, despite a care plan and orders for regular barrier cream use. For another resident who was always incontinent and dependent for toileting, staff provided perineal care and changed gloves multiple times but failed to use hand sanitizer between glove changes, contrary to the facility’s hand hygiene policy requiring alcohol-based hand rub use before and after PPE, including gloves.
A resident with significant mobility and cognitive deficits, requiring two-person assistance for mechanical lift transfers, was transferred by a CNA alone who failed to secure a lift strap, resulting in the resident being guided to the floor. The resident was assessed and found to have no injuries, but the facility's policy requiring two staff for such transfers was not followed.
Multiple residents who were alert and oriented reported consistently waiting approximately 30 minutes for staff to respond to their call lights. Direct observation confirmed a prolonged wait time, and resident council meeting minutes documented repeated complaints to administration about slow call light response. The DON acknowledged awareness of the issue.
A facility failed to properly restrain residents in a transportation van, leading to significant injuries for one resident during an accident. The resident, with Parkinson's disease, was only secured with a lap belt, contrary to safety protocols. The CNA responsible for the transport admitted to not receiving training on the new van's restraint system. Another resident also reported being transported without a shoulder belt, indicating a pattern of improper restraint use.
Two residents in the facility did not receive timely assistance with activities of daily living (ADLs). One resident, with multiple health issues, was found sitting in urine-soaked clothing without help, despite needing substantial assistance for toileting. Another resident, dependent on staff for showers, did not receive any documented assistance with bathing during their stay. The facility's policies for bowel and bladder care and showering were not followed, leading to deficiencies in resident care.
The facility failed to properly label and cover food items and prevent cross-contamination in the kitchen. Observations included unlabeled drink pitchers, dessert bowls, shredded cheese, and salad, as well as an uncovered cake. The bulk sugar container had a cup with no handle and food debris inside, and its lid was sticky with dust and food substances. The cook acknowledged these issues, citing the recent loss of their dietary manager.
The facility failed to refer three residents for Level II PASARR despite their documented diagnoses indicating the need for such a referral. The responsible staff were unaware of the need for Level II screenings until the surveyors' findings were presented.
The facility failed to provide timely toileting assistance to two residents, leading to episodes of incontinence. Both residents, who are cognitively intact and require substantial or dependent assistance, reported waiting up to 30 minutes to one hour for staff to respond to call lights. The facility's policy and resident council meeting minutes highlighted ongoing issues with delayed responses.
A resident with unsteadiness and mobility issues fell and sustained injuries after a CNA let go of him to turn off a call light. The CNA had not worked with the resident before and did not use a gait belt, contrary to facility policy. The resident required supervision and assistance, which was not adequately provided.
A resident with multiple health conditions did not receive the prescribed No Added Salt (NAS) diet on multiple occasions due to recent changes in the dietary department and issues with food ordering. The resident consistently received incorrect meals, and the facility staff acknowledged the discrepancies and attributed them to leadership changes and ordering errors.
Insufficient Staffing Leading to Delayed Call Light Response and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to ensure timely response to call lights and incontinence care. One resident with morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis was care planned as occasionally incontinent of bowel and bladder, with interventions including check and change every 2–3 hours, PRN, application of barrier cream after each incontinent episode, and prompt call light response. During observation, this resident’s incontinence brief was found saturated with urine, and the buttocks, scrotum, and upper thighs were red, irritated, and had open bleeding spots, which the wound nurse identified as moisture-associated skin damage. The resident reported that staff applied cream at times but was unsure how often, and also stated that it sometimes took a long time for staff to answer the call light, recalling a wait of about an hour and a half on one occasion. Another resident with myasthenia gravis, diabetes, heart disease, unsteadiness on feet, neuropathy, and atrial fibrillation was cognitively intact and dependent on staff for toileting, with a care plan directing check and change every 2–3 hours and PRN and prompt call light response. A family member reported that the facility was short staffed on weekends at times. The resident’s cognitively intact roommate stated that on one occasion it had taken an hour for staff to answer the call light after the resident had soiled himself, and that the CNA explained there were only four CNAs working at the time. A third cognitively intact resident, dependent on staff for toileting and always incontinent of bowel and bladder, was care planned for barrier cream and perineal cleaning with each incontinent episode and prompt call light response. This resident reported that when there was not enough staff, call lights were not answered timely, resulting in long waits to get up in the morning and waits of a couple of hours for incontinence care at night. A fourth cognitively intact resident, always incontinent of bowel and bladder and care planned for prompt call light response, stated that when staffing was low, she had to wait 30 to 45 minutes for care. Multiple CNAs reported that there were not enough staff to meet residents’ needs timely, particularly on the 2 pm–10 pm shift and on weekends, noting that around 4 pm they must get residents ready for supper, answer call lights, and that call lights were not always answered timely. Staff described having four CNAs on weekends, one per hall, and difficulty providing timely assistance to residents requiring two-person assist, which delayed getting such residents to bed after dinner and delayed call light response. Another staff member stated that call lights were answered as timely as possible but acknowledged that with many residents needing two-person assist and nurses occupied with medication pass, call lights could be delayed and residents might sit longer after incontinence episodes before care was provided. While some nursing leadership staff stated they believed staffing was sufficient and that call light response had improved, one RN acknowledged that the 2 pm–6 pm period was very busy and that they could use a couple more CNAs, and the administrator reported that staffing had not changed since the last survey.
Delayed Response to Call Lights for Incontinent and Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ call lights were answered promptly, as required by resident care plans and the facility’s “Answering the Call Light” policy. Multiple cognitively intact residents with bowel and bladder incontinence or dependence on staff for toileting reported extended waits after activating call lights. One resident, occasionally incontinent of bowel and bladder, stated that it sometimes took a long time for staff to answer his call light and recalled waiting an hour and a half on one occasion. Another resident, dependent on staff for toileting and frequently incontinent of bowel and occasionally incontinent of bladder, had a roommate who reported that staff took about an hour to respond to the call light after the resident had soiled himself, with the CNA explaining that only four CNAs were working at the time. Additional residents with incontinence and dependence on staff for toileting also reported long waits for call light responses. One resident, always incontinent of bowel and bladder, stated that there were not enough staff and that they had to wait a long time for call lights to be answered. Another resident, always incontinent of bladder and bowel, reported having to wait 30 to 45 minutes for care when staffing was low. CNAs interviewed confirmed that call lights were not always answered timely, particularly on the 2 pm to 10 pm shift when only four CNAs were working and they were simultaneously responsible for getting residents ready for supper and answering call lights. An anonymous staff member stated that call lights were answered as timely as possible but acknowledged delays when many residents required two-person assistance and nurses were occupied with medication passes. The Assistant DON and the Administrator both acknowledged that call lights were not always answered timely, although they believed there had been some improvement.
Failure to Provide Correctly Sized Incontinence Briefs for Residents
Penalty
Summary
Failure to reasonably accommodate residents’ needs and preferences occurred when the facility did not consistently provide appropriately sized incontinence briefs for two cognitively intact residents with bowel and bladder incontinence. One resident with morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis, who was care planned as occasionally incontinent, reported that the facility recently did not have the correct size briefs and that the briefs available were too tight, requiring him to rip the sides so they would fit. Another resident, dependent on staff for toileting and always incontinent of bowel and bladder, reported that the facility never had the right size briefs, that staff used whatever size was available, and that she would wet through them. Staff interviews and supply observations further demonstrated the deficiency. The CNA Supervisor stated that the residents in question used extra-large briefs and asserted that the facility had enough supplies, including in an outside shed, but later acknowledged there were no briefs in the shed at the time of the survey and that she had to go back to rooms to locate more briefs. A supply closet check revealed multiple packages of medium and large briefs but only two individual extra-large briefs and no packages of small, extra-large, or double extra-large briefs, despite residents requiring extra-large sizes. Several CNAs reported that the correct sizes were not always available, that residents sometimes had to use incorrect sizes, and that supplies ran low before new orders arrived. Nursing leadership and the administrator reported they had not received concerns about incorrect brief sizes, despite resident and CNA reports to the contrary.
Failure to Prevent and Assess Moisture-Associated Skin Damage
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate skin care and prevent moisture associated skin damage (MASD) in accordance with physician orders and care plan interventions for two residents. One resident was admitted with morbid obesity, unsteadiness, heart disease, and osteoarthritis, and was documented as cognitively intact and occasionally incontinent of bowel and bladder. The resident’s care plan required barrier cream application after each incontinent episode and routine checks and changes every 2–3 hours and as needed. Despite a standing order for Calmoseptine ointment to be applied to the buttocks every day and night shift for excoriation, and a weekly skin assessment order, the resident was later observed with red, irritated buttocks, scrotum, and upper thighs, with open bleeding spots, and the resident was unsure how often cream was applied. During an observed peri-care episode, the CNA supervisor and CNA exposed the resident’s buttocks and genital area, revealing significant MASD that had not been reported to or recognized by the wound nurse/ADON until that time. The wound nurse documented MASD to bilateral buttocks, upper thighs, and scrotum in a progress note after being called to assess the resident. A prior skin observation tool entry indicated that one or more wounds or injuries were present, but it did not identify the wound type, location, or include an assessment. The treatment administration record showed that Calmoseptine was signed out as administered every day and night shift in the prior month and in the current month except for one missed administration, and weekly skin assessments were signed as completed with no corresponding progress note documenting skin breakdown on the date a “yes” was recorded. The wound nurse later stated that the last time she assessed the resident’s buttocks was several days earlier and that weekly skin assessment orders were not carried over when the facility switched systems, and there were no new skin assessments documenting the MASD. A second resident, with diagnoses including diabetes, malignant neoplasm of the left breast, osteoarthritis, hypertension, and stress incontinence, had a moderate cognitive deficit and was always incontinent of bowel and bladder and dependent on staff for toileting. The resident’s care plan identified a potential for impaired skin integrity related to aging and disease processes, including redness/gaulding to the buttocks, with an intervention to assess and record changes in skin status. During observed incontinence care, the resident reported soreness in the peri area and asked if it was red; the CNA supervisor confirmed it was a little red and stated she would get cream, and the surveyor observed the peri area to be red and irritated. The wound nurse/ADON later stated that this redness, irritation, and soreness had not been reported to her, although she would have expected such a report. There was no documentation in the resident’s progress notes regarding the peri area being red and sore at the time of the observation, despite a prior facility-wide skin sweep note indicating no new skin issues. The facility’s own pressure/skin breakdown clinical protocol required full assessment and documentation of skin condition, including location and characteristics, which was not reflected in the records for these residents.
Failure to Follow Incontinence Care and Hand Hygiene Standards
Penalty
Summary
The deficiency involves failure to provide incontinence care and perineal care according to current standards of practice, including hand hygiene and skin protection, for two residents who were incontinent of bowel and bladder. One resident, admitted with morbid obesity, unsteadiness on feet, heart disease, and osteoarthritis, was documented on the MDS as cognitively intact and occasionally incontinent of bowel and bladder, with a care plan directing staff to apply barrier cream after each incontinent episode and to check and change every 2–3 hours and as needed. During observed peri care, the CNA removed a saturated incontinence brief and cleansed the resident’s penis, groin, and scrotum using washcloths with warm water and no-rinse peri solution, wiping up and down and at times using the same side of the cloth on different areas. The CNA changed gloves between cleaning the groin/penis and buttocks and again before drying, but did not perform hand hygiene between glove changes. The resident’s buttocks, scrotum, and upper thighs were red, irritated, and had open bleeding spots; the resident reported that cream was applied at times but was unsure how often. The ADON/wound nurse, when called to assess, identified the condition as moisture associated skin damage (MASD) and stated this was the first time she was aware of it, and the resident’s nurse also reported not being aware of the MASD, despite an existing order for cream twice daily to prevent further skin breakdown. The second resident, admitted with acute pyelonephritis, heart failure, hypertension, respiratory failure, joint stiffness, and scoliosis, was documented as cognitively intact, always incontinent of bowel and bladder, and dependent on staff for toileting. The care plan for this resident included interventions to apply barrier cream after each incontinent episode and to clean the peri area with each incontinent episode. During observed incontinence care, the CNA changed gloves after cleaning the peri area, after cleaning the buttocks, and after drying, but did not perform hand hygiene after removing soiled gloves or before donning clean gloves. Both CNAs later stated they did not hand sanitize between glove changes because they forgot. The facility’s Hand-Washing/Hand Hygiene Policy requires use of alcohol-based hand rub before and after putting on and upon removal of PPE, including gloves, when hands are not visibly soiled, and the ADON stated she would expect staff to hand sanitize between glove changes.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with a history of peripheral vascular disease, below-knee amputation, hypertension, anemia, chronic kidney disease, unsteadiness, and a history of falls was not provided adequate supervision and assistance during a mechanical lift transfer. The resident was care planned to require a mechanical (Hoyer) lift with the assistance of two staff members for all transfers due to their high level of dependency and cognitive impairment. Despite this, a CNA attempted to transfer the resident alone using the mechanical lift. During the transfer, the CNA failed to properly connect one of the lift straps, resulting in the resident beginning to fall backward. The CNA intervened by holding and guiding the resident to the floor. Upon assessment, the resident was found lying on their back, denied pain, and exhibited no injuries, though it was noted that the resident's head made contact with the floor. Vital signs and neurological checks were within normal limits, and the resident's power of attorney and physician were notified. The CNA later confirmed that this was the first time they had attempted a mechanical lift transfer without a second staff member present. The facility's policy clearly required two staff for all mechanical lift transfers, and this policy was not followed at the time of the incident. There were no other reported complaints or concerns related to unsafe transfers prior to this event.
Delayed Call Light Response Times
Penalty
Summary
The facility failed to answer call lights in a timely manner for three residents who were alert and oriented, as evidenced by direct observation, resident interviews, and review of resident council meeting minutes. One resident activated her call light and waited 28 minutes before the DON responded, and reported routinely waiting 25-30 minutes for assistance regardless of time of day or staff on duty. Two other residents also reported consistently waiting about 30 minutes for their call lights to be answered. Resident council meeting minutes from two separate months documented repeated complaints to administration regarding delayed call light response times. These findings indicate that the facility did not honor residents' rights to prompt communication and response to their needs.
Improper Restraint in Facility Van Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure that residents were properly restrained while being transported in the facility van, resulting in significant injuries to one resident. The incident involved a resident with Parkinson's disease and difficulty walking, who was being transported in a wheelchair in the facility van. During the transport, the van hydroplaned and was involved in an accident, causing the resident to be thrown from her wheelchair. The resident sustained a laceration to her head requiring 14 staples and 8 sutures, a fracture to the second digit of the right foot, a left nasal bone fracture with deviation of the septum, and bruising to the lower abdomen and upper thighs. The investigation revealed that the resident was only restrained by a lap belt and not a shoulder belt, contrary to the facility's safety protocols and the manufacturer's instructions for securing passengers. The Certified Nursing Assistant (CNA) responsible for the transport initially stated that the resident was only secured with a lap belt, but later changed her statement to say that the resident was wearing a shoulder belt. However, the Chief of Police and the Registered Nurse who assessed the resident after the accident both noted the absence of shoulder belt bruising, supporting the initial claim that the resident was not properly restrained. Additionally, another resident reported being transported in the same van without a shoulder belt, indicating a pattern of improper restraint use. The CNA admitted to not receiving training on how to properly secure residents in the new transportation van, which had been in use since the end of October 2024. This lack of training and failure to follow proper restraint procedures directly contributed to the accident and the resulting injuries.
Failure to Provide Timely Assistance with ADLs
Penalty
Summary
The facility failed to provide timely assistance with toileting and showers for two residents, R1 and R4, as observed during the survey. R4, who was admitted with multiple diagnoses including sepsis, heart disease, and polyosteoarthritis, was found sitting in a recliner covered with a blanket and emitting an odor of urine. R4 reported sitting in wet clothes since the morning without assistance, despite requiring substantial assistance for toilet transfer. The CNA responsible for R4's care admitted to not assisting R4 with toileting since the start of her shift and had turned off the call light without providing help. Upon inspection, R4's gown and chair were saturated with urine, indicating a lack of timely care. R1, another resident with diagnoses including diabetes, cirrhosis of the liver, and heart failure, was documented as being dependent on staff for showers. However, there was no record of R1 receiving assistance with a shower or bath during her stay from September 19 to September 25, despite the facility's policy to offer showers twice a week. The Director of Nurses confirmed the lack of documentation for R1's showers, which was contrary to the facility's hygiene policy. The facility's policies for bowel and bladder assessment and showering were not adhered to, as evidenced by the lack of timely assistance and documentation for R4 and R1. The Director of Nurses stated that residents should be checked every two hours, but this was not followed in R4's case. Similarly, the facility's shower policy was not implemented for R1, leading to a deficiency in maintaining proper hygiene and dignity for the residents.
Improper Food Labeling and Storage
Penalty
Summary
The facility failed to properly label and cover food items and prevent cross-contamination in the kitchen. During an initial tour of the kitchen, surveyors observed several items in the refrigerators that were not labeled or covered, including drink pitchers, dessert bowls, shredded cheese, and salad. Additionally, a cake was found uncovered on a tray. The bulk sugar container had a cup with no handle inside, and other food debris was seen in the container. The lid of the sugar container was sticky and had dust and food substances stuck to it. The cook acknowledged these issues and mentioned that they were working through them due to the recent loss of their dietary manager. The facility's food storage policy requires all food items to be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Failure to Refer Residents for Level II PASARR
Penalty
Summary
The facility failed to refer three residents for a Level II Preadmission Screening and Resident Review (PASARR) despite their documented diagnoses indicating the need for such a referral. Resident 40 had diagnoses of Bipolar Disorder, Major Depressive Disorder, and Unspecified Dementia, but only had a Level I PASARR completed. Resident 43 had diagnoses of Major Depressive Disorder and Psychotic Disorder with delusions, but the Level I PASARR did not include the psychotic disorder and incorrectly stated that no Level II was required. The facility's administrator and staff responsible for PASARR screenings were unaware of the need for Level II screenings for these residents until the surveyors' findings were presented to them. Resident 15 had diagnoses of visual hallucinations and bipolar disorder, but the PASARR Level I was outdated and did not reflect these mental health conditions. The bookkeeper, responsible for submitting PASARR screenings, was unaware of the new diagnoses and had not submitted a Level II PASARR. The facility's policy on PASARR, which aims to ensure appropriate care for individuals with mental illness and intellectual disabilities, was not followed, leading to these deficiencies in the residents' assessments and care planning.
Delayed Response to Call Lights for Toileting Assistance
Penalty
Summary
The facility failed to ensure that dependent residents received timely assistance for toileting needs, as evidenced by the experiences of two residents. One resident, admitted with diagnoses including Parkinson's Disease and blindness, reported that it took staff an average of 30 minutes to one hour to respond to call lights, leading to episodes of incontinence. This resident, who is cognitively intact and requires substantial assistance for toileting, found the delays frustrating and embarrassing. The resident's care plan documented the need for substantial assistance with toileting, but the facility did not meet this requirement in a timely manner. Another resident, admitted with diagnoses including morbid obesity and chronic kidney disease, also reported experiencing incontinence while waiting for staff to respond to call lights. This resident, who is also cognitively intact and dependent on staff for toileting, noted that it could take up to 30 minutes for staff to respond. The resident's care plan indicated a need for dependent assistance with toileting, including the use of a sit-to-stand lift with two people. Despite the facility's policy that call lights should be answered promptly, the resident council meeting minutes from several months documented ongoing concerns about delayed responses to call lights.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to prevent falls with injuries for a resident (R169) who was admitted with diagnoses including unsteadiness on feet, abnormalities of gait and mobility, and lack of coordination. The resident's admission MDS indicated that he was cognitively intact and required supervision or touching assistance for activities. Despite this, the resident experienced a fall on the night of his admission while being assisted to the restroom by a CNA (V11). The CNA let go of the resident to turn off the call light, resulting in the resident falling backward, hitting his head, and sustaining a laceration and a skin tear. The resident was sent to the emergency room for evaluation and returned to the facility with no new orders or injuries other than the initial wounds. The CNA admitted to not having worked with the resident before and not using a gait belt during the transfer, which was against the facility's policy for manual transfers and gait belt use. The Director of Nursing (V2) confirmed that the CNA let go of the resident to turn off the call light and mentioned that the resident might have been groggy from a line placement earlier that day. The Therapy Director (V15) stated that a resident requiring supervision or touching assistance should not be left unattended and that a gait belt should be used due to the resident's unsteadiness. The facility's Fall Prevention Program and Transfers-Manual Gait Belt and Mechanical Lift policies were not followed, as the resident was left unattended and a gait belt was not used during the transfer, leading to the fall and subsequent injuries.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to ensure therapeutic diets were provided as ordered for a resident with multiple health conditions, including atrial fibrillation, atherosclerotic heart disease, heart failure, and essential hypertension. The resident's physician had ordered a No Added Salt (NAS) diet, but the resident reported consistently receiving incorrect meals. Observations confirmed that the resident received meals that did not match the dietary orders on multiple occasions. For example, on one day, the resident received ravioli instead of meatballs with spiral noodles, and on another day, the resident received bratwurst instead of hot pork on a bun. The discrepancies were attributed to recent changes in the dietary department's leadership and issues with food ordering. The Director of Nursing acknowledged that residents should receive the diet printed on their cards and that any menu changes should be communicated to them. The cook confirmed that the menu was altered due to the previous dietary manager's failure to order the correct food items, leading to substitutions with available alternatives. These actions and inactions resulted in the resident not receiving the prescribed therapeutic diet, highlighting a failure in the facility's dietary management and communication processes.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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