The Haven Of Farmer City
Inspection history, citations, penalties and survey trends for this long-term care facility in Farmer City, Illinois.
- Location
- 404 Brookview Drive, Farmer City, Illinois 61842
- CMS Provider Number
- 146104
- Inspections on file
- 25
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Haven Of Farmer City during CMS and state inspections, most recent first.
A resident with multiple conditions including dementia, CKD stage 3, and type 2 DM with hyperglycemia refused a blood glucose (BG) check and insulin, but an LPN, citing the POA’s wishes, obtained the BG and administered insulin despite the refusal. According to CNAs, this occurred in the dining room, where the LPN pulled back the resident’s cover, exposed the arm, and gave the injection without privacy, after which the resident stated that her rights were violated. The DON confirmed that residents have the right to refuse care and that BG checks and insulin injections should not be done against a resident’s wishes or without privacy.
A deficiency was cited when a nursing home area was found to have accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet safety standards, and supervision was insufficient to prevent incidents.
A resident with diabetes and a foot wound was discharged from a facility without a proper discharge plan, medication, or wound care supplies. The resident, who was unable to read or write, signed an AMA form and was taken to a homeless shelter. The facility did not consult the physician or make referrals to outside agencies. The resident later sought medical help and was admitted to a hospital for wound care.
The facility failed to monitor refrigerator and freezer temperatures and improperly stored utensils in food containers, potentially affecting all 44 residents. Temperature logs were incomplete, and utensils were found with handles in direct contact with food, violating facility policies.
The facility failed to notify the physician of a new pressure ulcer and nausea/stomach pain for two residents. A resident with high risk for pressure ulcers had an open area noted but the physician was not informed. Another resident with a history of wound infection complained of nausea, and although the nurse faxed the primary care provider, no further action was documented. The facility's policy requires prompt notification of changes in resident status.
A facility failed to ensure the least restrictive restraint was used for a resident with severe cognitive impairment. The resident was observed with multiple restraints, including a safety belt, busy tray, reclining wheelchair, and trunk supports, which were not fully addressed in the care plan. Staff indicated these were used to prevent falls, but the Director of Nursing and Administrator did not consider them restraints, despite being coded as such in the MDS.
A resident with Epileptic Syndrome and Mild Neurocognitive Disorder, who is dependent on staff for personal care, reported that staff did not assist with daily hygiene tasks such as brushing teeth and washing the face. The resident's hair was dirty, nails were unclean, and clothing was stained. The DON confirmed the resident sometimes refuses showers but should receive them weekly, and staff should assist with morning care. The facility's A.M. Care policy was not consistently followed.
A resident with a history of urinary tract infections did not receive proper infection control during catheter irrigation. An LPN failed to wash hands and cleanse the catheter connection site with antiseptic wipes, contrary to facility protocol. The oversight was acknowledged by the LPN during the procedure.
The facility failed to maintain sanitary conditions for respiratory care equipment for two residents. One resident had oxygen tubing on the ground and an empty humidifier bottle with residue. Another resident had oxygen tubing hanging with the nasal cannula touching the floor. The DON confirmed that staff should store tubing in plastic bags, refill humidifier bottles, and change equipment weekly, documenting these changes.
A facility failed to provide trauma-informed care for a resident with PTSD due to spousal abuse. Despite the facility's policy requiring such care, the resident's care plan lacked interventions for PTSD. Observations showed the resident was anxious without staff intervention. The Social Service Director and DON confirmed awareness of the PTSD diagnosis and the need for a care plan addressing triggers.
A facility failed to maintain a secure bed rail for a resident with a history of falling and behavioral disturbances, including Alzheimer's and bipolar disorder. The resident's bed rail was found to be extremely loose, creating a gap between the mattress and rail. The Maintenance Director acknowledged the issue and noted the resident's behaviors increased fall risk. Bed rails were not routinely checked unless new or if the resident moved, relying on staff to report issues. The Administrator confirmed the need for frequent checks due to the resident's condition.
A facility failed to dispose of a medication for a deceased resident as per its policy. During an inspection, Bisacodyl Suppositories labeled with the resident's name were found in the medication refrigerator. The DON confirmed the resident had expired and the medication should have been disposed of.
A facility failed to maintain a medication error rate below five percent, resulting in a 12% error rate. A resident received medications outside the one-hour window stipulated by the facility's policy. The medications, including Tramadol, Tylenol, and Gabapentin, were administered at 9:20 AM instead of the scheduled 8:00 AM time. The DON confirmed the acceptable administration window is one hour before and after the ordered time.
A facility failed to provide necessary dental services for a resident with Epileptic Syndrome and Mild Neurocognitive Disorder. Despite a physician's order for dental services, the resident's care plan did not address his dental needs. The resident reported not receiving assistance with dental hygiene and had not seen a dentist since admission, resulting in multiple broken teeth affecting his diet. Observations confirmed poor dental hygiene, and facility staff acknowledged the lack of regular dental services.
The facility failed to arrange dental services for a resident with broken dentures, despite the care plan indicating the need for dental health maintenance. The resident's family member repeatedly requested dental care, but the facility only provided ground food, which the resident disliked. The DON acknowledged that arrangements should have been made, as the resident had been at the facility for several years, and denied knowledge of any existing dental service arrangements.
A facility failed to maintain effective communication with a hospice provider, resulting in the absence of an up-to-date Hospice Plan of Care for a resident with dementia and Alzheimer's. The hospice RN did not document visits or changes in care in the communication binder, and the Resident Care Coordinator confirmed inadequate communication methods, violating the facility's agreement with the hospice provider.
The facility failed to make survey results easily accessible to residents, affecting all 44 residents. During a resident council meeting, residents were unaware of the State inspection book's location. The Administrator revealed it was placed on a top shelf, not at wheelchair eye level, and surrounded by other books, making it difficult to access. This does not comply with residents' rights to view facility review reports.
The facility failed to provide the services of a qualified director of food and nutrition services, impacting all 44 residents. The Administrator confirmed the absence of a qualified Dietary Manager since the previous one quit. A new Dietary Manager was hired and began work but was still undergoing training. The new manager was observed supervising meal service, and the facility's application confirmed 44 residents at the time.
Failure to Honor Treatment Refusal and Provide Privacy During Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to refuse treatment and to receive care in privacy during blood glucose monitoring and insulin administration. Facility policies on resident rights state that residents have the right to make their own choices and to request, refuse, or discontinue any treatment, and the Medication Administration policy states that residents may actively refuse medications. The resident involved had multiple diagnoses, including cerebral infarction, dysphagia following cerebral infarction, hypertension, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, chronic kidney disease stage 3, and type 2 diabetes mellitus with hyperglycemia. On the date of the incident, the facility’s incident report documented that the resident was refusing to have her blood glucose level taken, yet an LPN took the resident’s hand and obtained the blood glucose level while the resident was refusing, and then administered insulin after the resident had stated she did not want it completed. The LPN stated she was doing what the resident’s POA wanted done. A CNA reported that at breakfast the resident refused the blood glucose check and insulin, and that after an RN left the dining room, an LPN returned and stated that the POA wanted the blood glucose checked and insulin given. The CNA stated the LPN pulled the cover back from the resident, checked the blood glucose using blood obtained from the resident’s finger, left, then returned with a syringe, again pulled the cover back, peeled up the resident’s sleeve, and administered insulin, all while the resident had refused. The CNA reported that the resident then looked at another CNA and stated that her rights were violated. The DON stated that staff should not perform cares or medical tests such as blood glucose monitoring or administer medications if a resident does not want it done, and that nurses should not be checking blood glucose levels or injecting medications such as insulin in the dining room, emphasizing that residents should be provided privacy for medication administration.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could lead to accidents, and that supervision measures in place were insufficient to prevent such incidents. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Develop Discharge Plan for Resident
Penalty
Summary
The facility failed to develop a discharge plan for a resident, identified as R2, who required diabetic medication management and wound care. R2 was admitted to the facility from a hospital and had a history of homelessness. The facility's Transfer and Discharge Policy mandates that discharges should maintain continuity of care, but R2's medical record lacked a discharge plan or physician notification. R2 was discharged against medical advice (AMA) without proper planning or consultation with the physician or law enforcement, following the discovery of a past conviction that made him ineligible to stay at the facility. The facility administrator, identified as V1, informed R2 about the need to find alternative placement due to his conviction. R2, unable to read or write, was read the AMA paperwork and signed it, leading to his discharge to a homeless shelter without necessary medications or wound care supplies. R2 later sought medical assistance from a nurse practitioner, V12, who admitted him to the hospital for wound care. The facility did not make any referrals to outside agencies or initiate discharge planning, assuming the AMA discharge absolved them of further responsibility. R2's inability to manage his medical care was evident when he walked to the nurse practitioner's office for help, resulting in his hospital admission. The hospital social worker, V4, expressed concerns about R2's ability to manage his care at the shelter, as he required insulin and dressing changes. The nurse practitioner, V12, highlighted the risks posed by the facility's discharge process, emphasizing R2's vulnerability due to his medical conditions and lack of resources at the shelter.
Improper Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to adhere to its policies regarding food storage and temperature monitoring, which could potentially affect all 44 residents. Observations revealed that utensils were improperly stored in bulk food containers, with handles in direct contact with food items such as thickener, oatmeal, brown sugar, and hot cocoa. This practice is against the facility's Storage policy, which mandates that utensils should not be left in food containers to prevent contamination. Additionally, the facility did not consistently monitor and record the temperatures of the walk-in refrigerator and freezer as required by their Equipment Temperatures policy. The temperature logs for December 2024 were incomplete, with several days missing entries for both the morning and evening shifts. The Dietary Manager confirmed that the dietary staff should complete these logs twice daily and acknowledged the improper storage of utensils in food containers.
Failure to Notify Physician of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician of a new pressure ulcer and nausea/stomach pain for two residents. Resident 5, who is at high risk for pressure ulcers due to osteoarthritis, weakness, and incontinence, had an open area noted on the right coccyx on 12/8/24. The registered nurse applied a barrier and covered the area with an absorbent foam dressing but did not document further or notify the physician or responsible party as required by the care plan. The Resident Care Coordinator was unaware of the open area and stated that the nurse should have filled out a new skin sheet and notified the doctor. Resident 247, with a history of a wound infection related to a tibia/fibula fracture, complained of nausea and stomachache on 12/13/24. The nursing notes indicate that the nurse faxed the primary care provider about the change but did not document any further action or resolution regarding the nausea. The Director of Nursing stated that the nurse should have called the doctor or on-call nurse to obtain an order. The facility's policy requires prompt notification of changes in a resident's status to the appropriate parties.
Failure to Properly Assess and Document Restraint Use
Penalty
Summary
The facility failed to ensure the least restrictive restraint was used for the least amount of time for a resident identified as R8. The facility's policy on physical restraints, revised in 2018, mandates that residents should be free from physical restraints unless required for medical symptoms or therapeutic intervention. However, R8, who is severely cognitively impaired and has multiple diagnoses including dementia and anxiety, was observed with several restraints, including a self-releasing safety belt, a busy tray, a reclining seat wheelchair with bilateral trunk supports, and a lap tray. These devices were not fully addressed in R8's care plan, which only mentioned the seat belt. The care plan did not include the reclining wheelchair, trunk supports, or lap tray, and the facility's evaluation of restraint use did not cover these additional devices. During an observation, R8 was transferred to a wheelchair with these restraints in place, and staff members indicated that the restraints were used to prevent R8 from falling, as R8 had previously fallen and sustained injuries. Despite this, the Director of Nursing and the Administrator did not consider these devices as restraints, even though they were coded as such in the Minimum Data Set (MDS). The facility's failure to properly assess and document the use of these restraints, as well as to update the care plan accordingly, led to the deficiency identified by the surveyors.
Failure to Maintain Personal and Oral Hygiene for a Resident
Penalty
Summary
The facility failed to consistently maintain good personal and oral hygiene for a resident diagnosed with Epileptic Syndrome with Seizures and Mild Neurocognitive Disorder. The resident, who is cognitively intact but totally dependent on staff for oral care, bathing, and dressing, reported that staff never offered to assist with brushing teeth, washing the face, applying deodorant, or cleaning the beard. The resident also mentioned that showers were offered at inconvenient times, leading to refusals, and no alternative times were provided. Observations confirmed the resident's hair appeared dirty and greasy, nails were long with dirt underneath, the beard contained food debris, and clothing was stained. The Director of Nursing confirmed that the resident sometimes refuses showers but should be receiving them at least once per week according to preference. It was also confirmed that the resident needs new, unstained clothing and that staff should be offering assistance with morning care, including face washing, brushing of teeth, combing hair, and cleaning hands and nails. The facility's A.M. Care policy requires nursing assistants to provide daily care, including oral hygiene, washing, and dressing in clean clothing, which was not consistently followed for this resident.
Infection Control Lapse in Catheter Care
Penalty
Summary
The facility failed to maintain infection control standards during catheter irrigation for a resident with multiple diagnoses, including Spastic Quadriplegic Cerebral Palsy and a history of urinary tract infections. The Medication Administration Record for the resident indicated an order to flush the indwelling catheter twice daily with normal saline. During an observation, a Licensed Practical Nurse (LPN) did not wash their hands before performing the catheter irrigation. Additionally, the LPN disconnected the catheter from the drainage tubing without cleansing the connection site with antiseptic wipes, as required by the facility's protocol. The LPN acknowledged the oversight when questioned about the procedure. The facility's policy on the irrigation of indwelling catheters, last reviewed in March 2018, mandates handwashing and cleansing of the connection site with antiseptic wipes before reconnecting the tubing to the catheter using aseptic technique. The failure to adhere to these infection control practices was observed during the procedure, contributing to the deficiency noted in the report.
Failure to Maintain Sanitary Conditions for Respiratory Care Equipment
Penalty
Summary
The facility failed to maintain sanitary conditions for respiratory care equipment for two residents. One resident, diagnosed with Congestive Heart Failure and Atrial Fibrillation, had oxygen tubing lying on the ground, with an undated nasal cannula attached to a concentrator running at two liters per minute. The humidifier bottle was empty, undated, and had white dried residue at the bottom. Another resident, diagnosed with Chronic Obstructive Pulmonary Disease, had oxygen tubing hanging over the concentrator with the nasal cannula touching the floor. The Director of Nurses confirmed that staff should store oxygen tubing in plastic bags, refill humidifier bottles as needed, and change tubing and humidifier bottles weekly, dating and documenting these changes in the Treatment Administration Record.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD) as a result of decades of spousal abuse. The facility's Trauma Informed Care Policy requires that residents who are trauma survivors receive care that accounts for their experiences and preferences to prevent re-traumatization. However, the resident's care plan did not include interventions related to their PTSD, despite the interdisciplinary team being aware of the diagnosis. Observations revealed that the resident appeared anxious and expressed uncertainty about their actions, yet no staff intervened to assist or redirect them. Interviews with the Social Service Director and the Director of Nursing confirmed that the resident's PTSD diagnosis was known, and a care plan should have been in place to address identified triggers. The lack of a trauma-informed care plan for the resident represents a deficiency in the facility's compliance with its own policy and professional standards of practice.
Failure to Maintain Secure Bed Rail for Resident with Behavioral Disturbances
Penalty
Summary
The facility failed to maintain a safe and secure bed rail for a resident diagnosed with a history of falling, mixed Alzheimer's vascular dementia with behavioral disturbances, insomnia, anxiety, psychotic disorder, bipolar disorder with psychotic features, attention concentration deficit, and chronic obstructive pulmonary disease. The resident was prescribed the use of a right 1/2 side transfer bar for bed mobility. During an observation, the resident's side rail was found to be extremely loose, moving from side to side and front to back, creating a significant gap between the bed mattress and the side rail. The Maintenance Director acknowledged the looseness of the bed rail and noted that the resident's behaviors, including aggression and shaking the bed rail, increased the risk of falls. The Maintenance Director also stated that bed rails are not routinely checked unless they are new or the resident changes rooms or beds, and expected staff to notify him if a bed rail needed fixing. The Administrator confirmed the need for frequent checks of the resident's bed rail due to her cognitive and behavioral issues and fall risk.
Failure to Dispose of Medication for Deceased Resident
Penalty
Summary
The facility failed to properly dispose of a medication for one resident reviewed for medication administration. According to the facility's Drug Release/Destruction Policy, discontinued medications or those belonging to discharged residents should be destroyed as soon as practical and within seven days of discharge or drug discontinuation. During an inspection of the medication room, a zip lock package of Bisacodyl Suppositories labeled with the resident's name was found in the medication refrigerator. The Director of Nursing confirmed that the resident had expired and acknowledged that the medication should have been disposed of according to the facility's policy.
Medication Administration Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12% error rate. This was due to three medication errors out of 25 opportunities, affecting one resident. The facility's Medication Administration policy requires medications to be administered within one hour of the designated time. However, on December 16, 2024, a registered nurse administered seven medications to a resident at 9:20 AM, which included Tramadol, Tylenol, and Gabapentin, not within the one-hour window of the scheduled 8:00 AM time. The Director of Nursing confirmed the acceptable administration window is one hour before and after the ordered time.
Failure to Provide Routine and Emergency Dental Care
Penalty
Summary
The facility failed to provide necessary dental services for a resident diagnosed with Epileptic Syndrome with Seizures and Mild Neurocognitive Disorder. The resident's Physician Order Sheet indicated a need for dental services as required, yet the Care Plan Summary did not address this need or the resident's broken teeth. The resident, who is cognitively intact, reported that staff never offered assistance with dental hygiene and that he had not seen a dentist since admission, despite having multiple broken teeth affecting his diet. Observations confirmed the resident's teeth and gums were coated with debris and had broken teeth. The Director of Nursing acknowledged the lack of regular dental services in the facility and confirmed the resident's need for dental care. The Administrator also confirmed the absence of contracted dental services for routine check-ups and treatment of dental issues.
Failure to Arrange Dental Services for Resident with Broken Dentures
Penalty
Summary
The facility failed to provide or assist in arranging dental services for a resident, identified as R24, who had broken dentures. R24's care plan, dated April 19, 2024, indicated the need for oral and dental health maintenance due to being edentulous, with instructions to coordinate dental care and transportation as needed. Despite these instructions, R24's family member, V20, reported on December 15, 2024, that R24 had not received new dentures after the previous set was broken at another nursing home. V20 had repeatedly requested dental services for R24, including speaking to the facility's administrator, but the facility only provided ground food, which R24 disliked. On December 16, 2024, the Director of Nursing, V2, acknowledged that arrangements for dental care should have been made by that time, as R24 had been at the facility for several years. V2 also denied knowledge of any existing arrangements with a dental service to provide care for residents at the facility.
Lack of Communication and Documentation in Hospice Care
Penalty
Summary
The facility failed to establish an effective communication process with the hospice service provider, resulting in the absence of an up-to-date Hospice Plan of Care for a resident diagnosed with Generalized Anxiety Disorder, Dementia, and Alzheimer's Disease. The resident's medical record lacked the necessary Hospice Plan of Care, and the communication binder used by the hospice service provider did not contain any nursing entries by the hospice RN for this resident. This indicates a breakdown in the communication and documentation process between the facility and the hospice service provider. The Resident Care Coordinator acknowledged that the hospice RN's method of communicating changes in orders or care was inadequate, as it involved merely repositioning the page in the resident's chart without notifying the nursing staff or documenting in the communication binder. The facility's agreement with the hospice provider required the designation of an interdisciplinary group member responsible for coordinating hospice care and communicating with facility representatives. However, this coordination and communication were not effectively implemented, leading to the deficiency.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to make the survey results readily accessible to residents, potentially affecting all 44 residents residing in the facility. During a resident council meeting, residents expressed that they were unaware of the location of the State inspection book. Upon inquiry, the Administrator indicated the survey book was located in a room off the front door, placed on the top shelf of a bookshelf, not at wheelchair eye level, and surrounded by many other books, making it not easily visible or accessible. This placement does not comply with the Illinois Department on Aging Residents' Rights, which states that residents have the right to see reports of all facility reviews from the most recent to the last three years.
Lack of Qualified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a qualified director of food and nutrition services, affecting all 44 residents residing in the facility. This deficiency was identified through observation, interview, and record review. On December 15, 2024, the Administrator acknowledged that the facility had been without a qualified Dietary Manager since the previous one quit. A new Dietary Manager was hired and began work on December 16, 2024, but was still in the process of being trained and qualified. On the same day, the new Dietary Manager was observed actively supervising and directing the meal service for lunch. The facility's application for Medicare and Medicaid confirmed the presence of 44 residents at the time of the survey.
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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