The Haven Of Tuscola
Inspection history, citations, penalties and survey trends for this long-term care facility in Tuscola, Illinois.
- Location
- 1203 Egyptian Trail, Tuscola, Illinois 61953
- CMS Provider Number
- 146086
- Inspections on file
- 35
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at The Haven Of Tuscola during CMS and state inspections, most recent first.
A dependent, cognitively intact resident with CHF, CKD III, Afib, lymphedema, chronic venous insufficiency, unsteady gait, and muscle wasting was transferred via mechanical lift to a manual wheelchair and taken to be weighed by a CNA who did not apply the wheelchair footrests. As the wheelchair was moved on and off the scale, the resident slipped down and her left foot became caught in the front wheel, causing pain and entrapment that the CNA freed but did not report to nursing or supervisors. Over the next days, the resident developed increasing left knee swelling, bruising, and pain, and the NP, unaware of any trauma, initially attributed symptoms to the resident’s chronic vascular and cellulitis history. The facility only learned of the wheelchair incident after hospital evaluation revealed a mildly displaced oblique fracture of the proximal left tibia, and the NP later stated the wheelchair trauma likely caused the fracture.
The facility did not ensure an RN was on duty for eight consecutive hours each day, as shown by multiple days without adequate RN coverage over a three-month period. The DON confirmed the facility was not meeting this requirement, affecting all 47 residents.
Due to a supply shortage, several residents who were incontinent of bowel and/or bladder were provided with incontinence briefs that were too small, leading to discomfort and skin irritation. CNAs reported using smaller briefs that were less absorbent and harder to manage, and residents expressed dissatisfaction and concern about skin breakdown. The issue persisted for weeks and was reported to the DON and ADON, but staff were instructed to use whatever sizes were available, contrary to facility guidelines requiring proper fit.
A resident with a history of stroke and on anticoagulants experienced an unwitnessed fall, hitting their head and sustaining a subdural hematoma. The facility failed to supervise the resident effectively and did not promptly document or investigate the incident, delaying necessary medical evaluation.
A resident experienced a fall, but the facility failed to promptly notify the resident's representative and provider. The fall occurred late at night, and the provider was informed the next day. There was no documentation of notification to the Administrator, DON, or the resident's representative. The responsible nurse did not make the required notifications, and the resident's representative learned of the fall only after speaking with the resident. This was against the facility's policy for prompt notification of changes in resident condition.
The facility failed to deliver mail on Saturdays, affecting several residents who reported not receiving their mail until Monday. Staff confirmed that only cards were distributed on Saturdays, while other mail was held for review. This practice potentially affected all residents, as it did not provide reasonable access to communication methods.
The facility did not verify the eligibility of two CNAs through the healthcare workers registry before they began employment. This oversight could potentially affect all 38 residents, as all CNAs have the potential to care for any resident.
The facility failed to label and store food appropriately, as observed during a kitchen tour. Various food items in the cooler, freezer, and outdoor cooler were not labeled with dates, including chopped lettuce, shredded cheese, and cottage cheese. The dietary manager confirmed the need for labeling and acknowledged the issue of limited space leading to unlabeled items. This deficiency potentially affects all 38 residents in the facility.
The facility failed to implement COVID-19 precautions, as staff worked with symptoms and without masks, and a COVID-19 positive resident was not consistently managed under transmission-based precautions. A CNA worked while symptomatic and unmasked, and an RN delayed testing despite symptoms. A resident was seen without a mask outside their room, and staff did not consistently wear PPE.
The facility failed to provide adequate respiratory care for several residents, including the lack of implementation of physician orders, insufficient supplies, and improper maintenance of equipment. Residents experienced issues such as empty oxygen humidification bottles, dirty nebulizer and CPAP equipment, and undocumented care plans. Staff acknowledged the deficiencies, citing supply shortages and lapses in routine care.
The facility did not provide RN services for eight consecutive hours on several days and lacked a full-time DON, affecting all 38 residents. The nursing schedule showed no RNs on duty for eight hours on specific days, and the Assistant DON confirmed the absence of a DON since early January. The facility's assessment indicated the need for a DON and RNs for residents with complex conditions.
A facility failed to administer medications as ordered for several residents, leading to a deficiency in pharmaceutical services. Residents did not receive their scheduled early morning medications, including Levothyroxine, Pregabalin, and Hydrocodone, due to an agency nurse's oversight. The facility's staff confirmed the omissions, and the responsible nurse was removed from duty.
The facility failed to offer pneumococcal vaccinations to four residents over 65, as required by CDC guidelines. The residents had no documentation of receiving or being offered the vaccine, and the facility's outdated policy did not align with current recommendations. The Assistant Director of Nursing confirmed the vaccine was not included in a recent clinic, and the Regional Clinical Nurse acknowledged the issue.
A facility failed to assess a resident's ability to self-administer medications, as required by policy. A resident was found with medications at their bedside without a physician's order or an assessment in their medical record. An LPN admitted to leaving medications for the resident to self-administer, and the ADON acknowledged the lack of necessary orders and assessments.
A resident at risk for skin abnormalities developed a wound due to the facility's failure to provide the correct size briefs. The resident was forced to wear smaller briefs, causing skin irritation and an open wound, which later became infected. Staff confirmed the frequent shortage of the correct size briefs.
A resident with hemiplegia was improperly transferred using a mechanical lift, resulting in a fall. The facility failed to secure the sling properly, leading to the incident. Additionally, the facility did not conduct a thorough investigation or document the fall details and physician notification in the resident's medical record, violating their fall prevention and notification policies.
A CNA failed to provide proper incontinence care to a resident, neglecting to thoroughly cleanse the pubic area, retract the foreskin, rinse after washing, and change gloves between contaminated and clean areas, as per facility policy.
A facility failed to monitor and document the enteral feeding process and weight checks for a resident receiving tube feedings. The resident's care plan required checks of tube placement and gastric contents, as well as daily or weekly weight monitoring, but these were not documented. The Assistant DON confirmed the lack of documentation and monitoring, indicating a failure to ensure proper nutritional and hydration status.
A facility failed to implement a gradual dose reduction (GDR) for a resident prescribed Sertraline, despite a pharmacy recommendation and acceptance by the provider. The facility's policy requires GDR for antipsychotic medications twice a year, but no documentation showed the GDR was attempted. The Assistant Director of Nursing confirmed the oversight.
A resident with severe cognitive impairment and aggressive behavior was involved in multiple incidents of physical aggression towards other residents, including kicking and hitting. Despite the facility's Abuse Prevention Program, the resident's aggressive actions were not immediately addressed with a discharge, although the resident was eventually placed in a memory care unit by their family.
A resident with diabetes and a healing foot wound did not receive assistance with wearing prescribed compression stockings, which were crucial for managing leg swelling. The LPN assumed CNAs had applied the stockings and signed off without verifying, leading to the resident being without them for two days. The resident had reported the issue, but it was not addressed, highlighting a lapse in staff communication and procedure adherence.
A resident with wounds on the right buttock and right breast, the latter infected with MRSA, received improper wound care from an LPN who failed to follow aseptic procedures. The LPN did not change gloves or perform hand hygiene after touching contaminated surfaces and used the same gloves and gauze for different wound sites, risking cross-contamination. The facility's policy on aseptic wound care was not adhered to, leading to a deficiency.
A resident with a MRSA infection was not properly isolated due to the absence of infection control signs and staff failing to wear gowns during high-risk care activities. Despite the resident's care plan indicating enhanced barrier precautions, CNAs provided care without gowns, and the LPN did not correct this oversight. The DON confirmed the need for gowns and signage, as per facility policy.
The facility failed to ensure timely physician visits for five residents, who had not been seen by a physician since their admission. Despite having a nurse practitioner with full practice authority, the facility lacked a policy requiring physician visits for new admissions or established residents. The medical director, the only physician for all residents, does not routinely see them, leading to a deficiency in care.
A resident in a LTC facility, who was cognitively intact and dependent on staff for personal hygiene, reported being left in urine overnight despite using the call light multiple times. CNAs admitted to not providing timely care, resulting in the resident's incontinence brief and bed sheets being soaked. The DON confirmed that residents should receive care every two hours, and the failure to do so compromised the resident's dignity and quality of life.
A resident with multiple medical conditions, including Cerebral Palsy, expressed a preference to use a commode instead of a bedpan for toileting. Despite being cognitively intact and having used a commode previously, the resident was denied this preference, leading to discomfort and sore spots. The facility lacked a policy on resident preferences, although staff were expected to honor reasonable requests.
A resident with a history of skin breakdown was left in urine-soaked conditions due to staff neglect in providing timely incontinence care. Despite activating the call light multiple times, the resident's needs were not addressed until hours later, resulting in saturated briefs and bedding. The DON confirmed the importance of regular care to prevent infections and maintain dignity.
A resident with multiple medical conditions received improper incontinence care due to a CNA's failure to wash hands and change gloves during the procedure. The CNA did not apply barrier cream after care, leading to a deficiency in infection control practices.
The facility failed to provide a clean and homelike environment for residents, with issues such as unclean bathrooms, delayed housekeeping, and maintenance problems like missing closet doors and peeling paint. Residents reported dissatisfaction with the cleanliness and timeliness of services, and the maintenance log had not been updated since 2020, indicating a lack of systematic problem resolution.
A facility failed to report an allegation of mental abuse involving a resident with multiple medical conditions, including Hypertension and Chronic Kidney Disease, who was cognitively intact and required maximum assistance. The incident, involving a CNA, was documented in a grievance report, but the facility did not report it to the State Agency as required by their Abuse Prevention Program policy.
A facility failed to investigate an allegation of mental abuse by a CNA towards a resident. The CNA allegedly made inappropriate comments and left the resident without a call light. The facility did not interview staff or suspend the CNA during the investigation, violating its abuse prevention policy.
Two residents with significant medical conditions were left without functioning call lights for three weeks, relying on an ineffective bell system that could not be heard by staff. Despite being cognitively intact, the residents' ability to communicate their needs was compromised, as confirmed by facility staff and a handwritten note at the nurses' station.
The facility failed to employ a clinically qualified director of food and nutrition services, affecting all 38 residents. On two consecutive days, there was no DM or CDM onsite from 10:00 AM to 4:00 PM. The administrator confirmed that the previous CDM left in February 2024 and had not been replaced.
The facility failed to employ dietary staff with safe food handling training, potentially affecting all 38 residents. Observations revealed that no dietary or ancillary staff had completed basic safe food handling training. The administrator acknowledged the issue and mentioned ongoing changes in dietary staff and efforts to get all staff trained.
The facility failed to dispose of expired food products, monitor food and dishwasher temperatures, and maintain a sanitary kitchen environment. Staff served expired food, did not check food temperatures, and used unsanitized dishes. The kitchen was observed to be dirty, with rotten food and improper storage of chemicals.
The facility failed to serve palatable, attractive, and timely meals to residents, with multiple complaints about cold, unappetizing, and late food. Observations and interviews revealed consistent issues with food quality, including unseasoned milk-based soup and burnt fish filets.
The facility failed to prepare pureed food in a safe texture for three residents with physician orders for pureed diets. The cook served lumpy coleslaw that did not meet the required consistency, leading to one resident coughing and others expressing difficulty in eating it.
Failure to Use Wheelchair Footrests and Report Incident Leads to Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe wheelchair transport and timely reporting of an accident, resulting in injury to a dependent resident. The resident had diagnoses including congestive heart failure, chronic kidney disease stage III, paroxysmal atrial fibrillation, lymphedema, chronic venous insufficiency of the lower extremities, unsteady gait, muscle wasting, and difficulty walking, and was documented on the MDS as cognitively intact but totally dependent on staff for wheelchair propulsion. On the day of the incident, two CNAs used a sling-type mechanical lift to transfer the resident to a manual wheelchair, and one CNA then transported the resident to be weighed without applying the wheelchair footrests. As the CNA pushed the wheelchair onto and off the scale, the resident slipped down in the chair and her left foot became caught in the left front wheel under the wheelchair. The resident reported saying she was tangled and expressed pain, and the CNA acknowledged hearing an “ouch” and knowing she should have used the foot pedals. Following the incident, the CNA did not report the event to nursing staff or supervisors, contrary to the facility’s Accident/Incident and Unusual Occurrence Policy that requires all employees to report any accident or incident that has or could have resulted in injury. The facility remained unaware of the wheelchair incident until after a left tibia fracture was diagnosed. In the interim, progress notes documented that the resident reported left knee swelling and bruising that had been present for three days, with pain and increasing difficulty with movement. The NP, not informed of any trauma, initially assumed the symptoms were related to the resident’s history of cellulitis, lymphedema, and vascular insufficiency and treated accordingly, later stating that knowledge of the trauma would have prompted an order for an X-ray. The NP indicated it was likely that the twisting of the resident’s foot under the wheelchair caused the leg fracture, and the DON confirmed that the incident was only reported after the fracture was identified.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for eight consecutive hours each day, seven days a week, as required. Review of the nursing schedules for October through December 2025 revealed multiple days where no RN was scheduled for the required eight consecutive hours. This deficiency was confirmed by the Director of Nursing (DON), who acknowledged that the facility was not meeting the RN coverage requirement. At the time of the deficiency, the facility had 47 residents, as documented in the Midnight Census Report dated 12/27/25.
Failure to Provide Correct Size Incontinence Briefs During Supply Shortage
Penalty
Summary
The facility failed to provide the correct size incontinence briefs for three residents who were either frequently or always incontinent of bowel and/or bladder. According to Minimum Data Set (MDS) assessments, all three residents had intact cognition and required 3X size incontinence briefs due to their body size and high urine output. Due to a shipment error and ongoing supplier issues, the facility experienced a shortage of 3X briefs, resulting in staff using smaller 2X or XL briefs that were less absorbent and more difficult to manage. Certified Nurse Assistants (CNAs) reported that this shortage had persisted for weeks, and that they had informed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) multiple times. During the shortage, CNAs were instructed to use whatever sizes were available, even if they did not fit the residents properly. Residents reported discomfort, skin irritation, and concerns about skin breakdown due to the use of improperly sized briefs. Multiple residents stated that the smaller briefs rubbed their skin, were less absorbent, and required more frequent changes. Staff interviews confirmed that the issue was ongoing and that residents were unhappy with the substitute briefs. The facility's own incontinence care guidelines require that briefs fit appropriately to maintain cleanliness, comfort, and prevent skin breakdown, but these guidelines were not followed during the supply shortage.
Failure to Supervise Resident Leads to Traumatic Fall
Penalty
Summary
The facility failed to effectively supervise a resident, R1, to prevent a traumatic fall and did not thoroughly investigate the incident. R1, who had a history of cerebral infarction, mild cognitive impairment, and was on anticoagulant medication, experienced an unwitnessed fall in their room. The fall resulted in R1 striking their head on a closet door, leading to a subdural hematoma that required emergency medical evaluation and treatment at two hospitals. Despite the facility's Fall Prevention Policy, which mandates immediate assessment and documentation after a fall, the necessary procedures were not followed promptly. R1's care plan identified them as high risk for falls due to gait and balance problems, requiring assistance for transfers. On the night of the fall, R1 was found on the floor with signs of confusion, having attempted to get out of bed unassisted. The incident was not reported or documented until two days later, and R1 was not sent for immediate evaluation despite being on blood thinners and having hit their head. The facility's staff, including the LPN and CNA on duty, failed to adhere to the protocol of sending residents with unwitnessed falls or head injuries for evaluation. Interviews with staff and R1's representative revealed that R1 had been confused, believing someone was breaking into their apartment, which contributed to the fall. The facility's Regional Director of Nursing confirmed that the fall packet and necessary documentation were not completed in a timely manner, highlighting a lapse in the facility's adherence to its fall prevention and response policies.
Failure to Notify of Resident Fall
Penalty
Summary
The facility failed to promptly notify the resident's representative and provider of a fall incident involving a resident. The fall occurred at approximately 10:30 pm on January 21, 2025, but the resident's provider was not informed until January 22, 2025. Additionally, there was no documentation indicating that the facility's Administrator, Director of Nursing, or the resident's representative were notified of the fall. Interviews revealed that the nurse responsible for making these notifications did not fulfill this duty, and the resident's representative only became aware of the fall the following day when they spoke with the resident. The facility's policy requires prompt notification of changes in a resident's condition, including accidents, to appropriate individuals, which was not adhered to in this case.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, affecting five residents specifically reviewed for mail and package delivery. During a Resident Council Meeting, several residents reported that they did not receive their mail on Saturdays, with mail being left on the Activity Director's desk and distributed on Mondays. The residents involved had varying cognitive abilities, with some being cognitively intact and others moderately impaired. This issue was confirmed through interviews with staff, who acknowledged that only cards were distributed on Saturdays, while other mail was held until Monday. The Business Office Manager and the Administrator both confirmed that not all mail was distributed on Saturdays, with some mail being held for review or for the residents' Power of Attorneys. This practice was acknowledged to potentially affect all 38 residents in the facility. The facility's failure to deliver mail on Saturdays was identified as a deficiency, as it did not provide residents with reasonable access to communication methods, which is a requirement for their care and well-being.
Failure to Verify CNA Eligibility Before Employment
Penalty
Summary
The facility failed to verify the eligibility for employment through the healthcare workers registry before commencing employment for two Certified Nurse's Aides (CNAs) out of five reviewed for Healthcare Worker Background checks. This oversight was identified in a sample list of 32 employees. Specifically, one CNA began employment on November 15, 2024, but their registry verification was not completed until November 19, 2024. Another CNA started on November 18, 2024, with their eligibility verified only on December 2, 2024. This lapse in procedure has the potential to affect all 38 residents residing at the facility, as confirmed by the facility's administrator, who acknowledged that all CNAs employed have the potential to care for any resident at the facility.
Failure to Label and Store Food Appropriately
Penalty
Summary
The facility failed to ensure that foods were labeled and stored appropriately, as observed during an initial tour of the kitchen. The inspection revealed that various food items in the upright cooler, upright freezer, chest freezer, and outdoor cooler were not labeled with dates, including individual plastic bags of chopped lettuce, shredded cheese, sliced cheese, cottage cheese, diced peaches, and a pitcher of orange juice. Additionally, hot dogs were found in a zip closing plastic bag dated but lacking a discard or expiration date. The upright freezer contained sealed plastic bags of frozen chicken wings, egg patties, crumbled sausage, sausage patties, and sausage links without expiration or use-by dates. Opened and unlabeled bags of breadsticks and chicken breasts were also found with ice crystallization, indicating exposure to air and contaminants. The dietary manager confirmed that all food and drinks should be labeled with opened and discard dates, acknowledging the need to discard the hot dogs and breadsticks. The manager explained that items are removed from their original packaging due to limited space, which contributed to the lack of date labels. The broccoli and cheese casserole and pork with gravy, prepared the previous day, were also not labeled with dates. This deficiency has the potential to affect all 38 residents residing in the facility, as documented in the facility's Long Term Care Application for Medicare and Medicaid.
Failure to Implement COVID-19 Precautions
Penalty
Summary
The facility failed to implement COVID-19 transmission-based precautions effectively, as evidenced by the actions and inactions of staff members. A Certified Nursing Assistant (CNA) worked with symptoms of sneezing and a runny nose, tested positive for COVID-19 during their shift, and was not wearing a mask. Another Registered Nurse (RN) worked for three days with symptoms they believed to be a sinus infection, only testing positive after a family member's positive result prompted them to do so. The facility's Assistant Director of Nursing/Infection Preventionist confirmed that the outbreak began when residents and staff tested positive, and masks were not initiated until after the outbreak was identified. Additionally, the facility failed to ensure that a COVID-19 positive resident, R14, was consistently managed under transmission-based precautions. Despite a sign indicating the need for Personal Protective Equipment (PPE) outside R14's room, staff were observed not wearing PPE, and R14 was seen without a mask when leaving the room to smoke. The Assistant Director of Nursing acknowledged that isolated residents should wear masks and staff should wear full PPE, but these procedures were not followed consistently. R14 tested positive for COVID-19 and was on isolation until a specified date, yet the precautions were not adequately enforced.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide adequate respiratory care for several residents, as evidenced by the lack of implementation of physician orders, insufficient supplies, and improper maintenance of equipment. For one resident, the oxygen humidification bottle was empty and had not been changed since the beginning of the month, despite the resident using oxygen continuously. The resident's care plan did not document oxygen use, and there was no active physician order for it. The Licensed Practical Nurse (LPN) acknowledged the issue, noting that the facility was out of humidification bottles and that the resident should have an order for oxygen. Another resident's room contained an oxygen concentrator and a nebulizer machine with dirty and uncovered equipment. The resident used oxygen nightly and had a nebulizer treatment earlier in the day, but the tubing and mask had not been changed as per the facility's policy. The resident's care plan did not address nebulizer or humidifier use, and the LPN admitted that the nebulizer equipment was not being cleaned or changed regularly. The Assistant Director of Nursing (ADON) confirmed that there should be physician orders for humidifier use and routine care, but was unaware of the resident's use of a humidifier. A third resident's CPAP mask was found uncovered and dirty, with the resident stating that the nursing staff did not clean it. The resident's care plan did not include CPAP use, and there were no physician orders for it. The LPN confirmed the lack of documentation and orders for CPAP use. Additionally, another resident's oxygen humidifier bottle was empty, and the resident reported dryness due to the lack of humidification. The ADON acknowledged a lapse in ordering supplies, leading to the deficiency in providing necessary respiratory care for the residents.
Failure to Provide RN Services and Employ Full-Time DON
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for eight consecutive hours each day, seven days a week, and did not employ a full-time Director of Nursing (DON). This deficiency potentially affects all 38 residents residing in the facility. The nursing work schedule for January 2025 revealed that there were no RNs on duty for eight consecutive hours on January 2, 4, 7, and 27. Additionally, the Assistant Director of Nursing confirmed that there has not been a DON on staff since January 10, 2025. The facility assessment indicated that the facility accepts residents with clinically complex conditions and that a DON and RNs are provided, which was not the case during the specified times.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications as ordered for four residents, leading to a deficiency in pharmaceutical services. The Medication Administration Policy requires medications to be prepared and administered within one hour of the designated time, with any omissions documented. However, on January 26, 2025, several residents did not receive their early morning medications as scheduled. Resident R2, diagnosed with Autoimmune Thyroiditis, did not receive her 5:00 AM dose of Levothyroxine. Similarly, Resident R33, who has multiple diagnoses including hypertension and chronic pain syndrome, did not receive her 5:00 AM medications, which included Levothyroxine, Pregabalin, Hydrocodone/APAP, and Lorazepam. The facility's staff, including V4 LPN and V5 RN, confirmed these omissions and noted that the night nurse, V24, failed to administer the medications. Additionally, Resident R28, who requires medications for rheumatoid arthritis and fibromyalgia, reported not receiving her 6:00 AM medications, including Lantus, Lyrica, and Omeprazole. The agency nurse, V24, who was new to the facility, was identified as responsible for the oversight. Resident R9 also reported not receiving the scheduled 5:00 AM dose of Hydrocodone/Acetaminophen. The facility's Assistant Director of Nursing, V2, acknowledged the issue and stated that V24 would no longer be working at the facility. These incidents highlight a significant lapse in medication administration, particularly involving agency nurses unfamiliar with the facility's procedures.
Failure to Offer Pneumococcal Vaccinations to Residents
Penalty
Summary
The facility failed to offer pneumococcal vaccinations to four residents over the age of 65, as required by CDC guidelines. The residents, identified as R1, R4, R28, and R31, were not documented as having received the pneumococcal vaccine, nor was there evidence that they were offered the vaccine prior to January 26, 2025. The facility's policy, dated November 2016, was outdated and did not align with current CDC recommendations, which may have contributed to the oversight. The Assistant Director of Nursing/Infection Preventionist confirmed that the pneumococcal vaccine was not included in the facility's recent immunization clinic and acknowledged the lack of prior offering or availability of the vaccine. The report highlights that R28 had previously received pneumococcal vaccinations in 2016, but there was no documentation of an offer for an updated vaccine. R31, R4, and R1 had no records of ever receiving a pneumococcal vaccination. R4's medical history included acute respiratory insufficiency and chronic obstructive pulmonary disease, conditions that increase the importance of receiving the vaccine. The Regional Clinical Nurse confirmed the absence of documentation and recognized the issue as a problem the facility is working to address.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, as required by their policy. During an observation, a resident was found with a Wixela inhaler, a bottle of Fluticasone, and a medication cup containing several pills on their bedside table. The resident stated they self-administered one puff of the inhaler daily and would take the morning medications after breakfast. However, there were no physician orders permitting the resident to self-administer these medications, nor was there an assessment in the medical record evaluating the resident's capability to do so. The facility's Medication Administration policy requires observing residents consume medications and prohibits leaving medications unattended unless there is a physician order. Despite this, a Licensed Practical Nurse admitted to leaving the medications at the resident's bedside for self-administration, citing the resident's refusal to take them under supervision. The Assistant Director of Nursing acknowledged the need for a physician's order and an assessment for self-administration but confirmed that these had not been completed for the resident in question.
Failure to Provide Correct Size Briefs Leads to Skin Breakdown
Penalty
Summary
The facility failed to provide the correct size briefs for a resident, leading to skin breakdown. The resident, identified as R33, was at an increased risk for skin abnormalities and required weekly monitoring and safety measures to prevent dermatologic reactions. Despite this, the facility did not ensure the availability of the correct size briefs, specifically 2XL, which resulted in the resident wearing smaller XL briefs. This improper fit caused the briefs to rub against the resident's skin, leading to an open wound under the left pannus. The wound was observed to be approximately one inch wide, red, and swollen, and was later found to be infected, requiring antibiotic treatment. The facility's records indicated that the last order for 2XL briefs was placed over a month prior, leading to a shortage and the use of ill-fitting briefs. Staff interviews confirmed the frequent unavailability of the correct size briefs, contributing to the resident's skin irritation and subsequent wound development.
Failure to Ensure Safe Mechanical Lift Transfer and Proper Documentation
Penalty
Summary
The facility failed to ensure a safe transfer for a resident using a full mechanical lift, which resulted in the resident falling and hitting their head. The resident, who has a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, was dependent on staff for transfers. During the transfer, the straps of the sling were not secured properly, causing the resident to fall out of the sling. The resident was sent to the hospital but did not sustain any injuries. The incident involved two CNAs, and it was noted that the sling used was too small for the resident, who now uses an extra-large sling. The facility also failed to thoroughly investigate the fall and document the details in the resident's medical record. There was no documentation of a fall investigation or physician notification in the resident's medical record, except for a nursing note indicating the resident was sent to the emergency room. The MDS/Care Plan Coordinator confirmed the absence of a fall packet or investigation for the incident. The CNAs involved in the transfer did not position the leg straps correctly, which contributed to the fall. The facility's policies on fall prevention and notification for changes in resident condition were not followed. The fall prevention policy requires a fall huddle and documentation of the fall circumstances and new interventions, which were not completed. Additionally, the notification policy mandates that the resident's physician be informed of incidents, which was not documented. The facility's user instructions for the mechanical lift emphasize the importance of using the correct size sling and ensuring it is properly attached, which was not adhered to in this case.
Inadequate Incontinence Care Provided to Resident
Penalty
Summary
The facility failed to provide proper hygienic incontinence care to a resident, identified as R7, who was dependent on staff for toileting. The facility's policy, dated December 2017, outlines the necessary steps for incontinence care, including washing the pubic area, retracting the foreskin, rinsing, and changing gloves between contaminated and clean areas. However, during an observation on January 28, 2025, a Certified Nursing Assistant (CNA), identified as V13, did not thoroughly cleanse R7's pubic area, failed to retract the foreskin for cleaning, did not rinse the area after washing, and did not change gloves before applying a clean brief. V13 later acknowledged the oversight in the care provided to R7.
Failure to Monitor Enteral Feeding and Weight for a Resident
Penalty
Summary
The facility failed to adequately monitor and document the enteral feeding process for a resident, identified as R30, who was receiving tube feedings. The resident's care plan required that tube placement and gastric contents/residual volume be checked and documented, and that the resident maintain adequate nutrition and hydration status as evidenced by stable weights. However, the Medication Administration Record, Treatment Administration Record, and food and fluid intake and output sheets did not document tube placement checks, residual checks, or intakes and outputs. This lack of documentation indicates a failure to ensure proper monitoring of the resident's nutritional intake and hydration status. Additionally, there was a discrepancy in the monitoring of the resident's weight. The care plan dated February 13, 2024, required daily weight checks, while a physician's order dated December 16, 2024, required weekly weights. Despite these orders, the weight sheets from October 2025 through January 2025 did not document any daily or weekly weights. The Assistant Director of Nursing confirmed that inputs and outputs should always be documented for residents with tube feeding and acknowledged that the resident's weights had not been obtained or monitored as ordered.
Failure to Implement Gradual Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to implement a gradual dose reduction (GDR) for a resident who was prescribed Sertraline, an antidepressant, at a dosage of 75 mg daily since November 2023. According to the facility's psychotropic medication policy, residents on antipsychotic medications should undergo a GDR at least twice a year. A pharmacy consultation report from September 2024 recommended a GDR for the resident, suggesting a reduction to 50 mg daily, which was accepted by the provider. However, there was no documentation in the resident's medical record indicating that the GDR was attempted as recommended. The Assistant Director of Nursing confirmed that the GDR should have been initiated in September 2024 but was not implemented.
Resident-to-Resident Abuse Due to Aggressive Behavior
Penalty
Summary
The facility failed to protect residents from abuse by another resident, identified as R2, who was severely cognitively impaired and exhibited aggressive behaviors. R2, who was independently mobile with a wheelchair, was involved in multiple incidents of physical aggression towards other residents. On one occasion, R2 kicked R1 on the lower leg while on the patio, causing R1 to experience pain, although no skin breakage was reported. R1, who is cognitively intact, reported frequent bruising due to blood thinners and poor circulation, and expressed feeling generally safe despite the incident. Another incident involved R2 hitting R3 on the arm after cursing at them. R3, who is also cognitively intact, reported feeling hurt and embarrassed by the slap. A witness, R5, confirmed the incident, noting R2's confusion and aggressive behavior. Additionally, R2 struck R4 in the shin during an episode of agitation with staff, despite R4's attempt to intervene and assist. R4, who is cognitively intact, recalled the incident and noted that R2 was usually friendly but was confused and upset at the time. The facility's staff, including V6 from Social Services and the Administrator, acknowledged R2's aggressive behavior, which included cursing, kicking, and hitting other residents and staff. The facility's Abuse Prevention Program outlines the residents' right to be free from abuse, defining abuse as willful actions causing physical harm, pain, or mental anguish. Despite these guidelines, the facility did not initiate R2's discharge, although R2's daughter eventually found placement in a memory care unit.
Failure to Assist Resident with Compression Stockings
Penalty
Summary
The facility failed to provide a dependent resident with the necessary assistance in dressing, specifically with the application of compression stockings, which are crucial for managing the resident's condition. The resident, who has a history of Diabetes Mellitus Type II, cerebral infarction with diabetic neuropathy, and morbid obesity, was observed without the prescribed compression hose. The resident's physician order summary indicated that the compression hose should be worn during the day and removed at bedtime to help manage swelling and prevent further complications. Despite these orders, the resident was found without the compression hose, which the resident reported had been missing for two days due to being sent to laundry. The resident's wound assessment documented a healing diabetic wound on the left foot, and the resident was noted to be at high risk for developing pressure ulcers, requiring moderate to maximum assistance with moving. During an observation, a Licensed Practical Nurse (LPN) acknowledged that the compression hose was not on the resident and admitted to signing off on the treatment sheet without verifying their application. The LPN assumed that the Certified Nursing Assistants (CNAs) had put them on, as was the usual practice, but failed to confirm this before documenting. The resident expressed awareness of the missing compression hose and had communicated this issue, indicating a lapse in communication and follow-through by the facility staff.
Failure to Prevent Cross-Contamination During Wound Care
Penalty
Summary
The facility failed to prevent cross-contamination between wounds during wound treatment for a resident identified as R3. The resident had specific physician orders for wound care on the right buttock and right breast, with the latter being treated for an abscess with MRSA. During an observation, a Licensed Practical Nurse (LPN) was seen performing wound care without adhering to proper aseptic techniques. The LPN entered the resident's room with gloves and a gown already on, contaminating the gloves by touching the door and other surfaces before proceeding with the wound care. The LPN did not change gloves or perform hand hygiene after touching potentially contaminated surfaces and before treating the resident's wounds. The LPN used the same gloves and gauze to clean both the new wound on the resident's right posterior upper thigh and the existing wound on the right buttock, thereby risking cross-contamination. The LPN also applied treatment creams with the same soiled gloves, further compromising the aseptic procedure. The facility's policy on aseptic wound and skin treatment was not followed, as it requires handwashing, establishing clean and dirty fields, and changing gloves between different wound sites. The LPN admitted to not washing hands or changing gloves during the dressing change, attributing the oversight to nervousness due to being observed by a surveyor. This failure to adhere to proper wound care procedures led to a deficiency in the care provided to the resident.
Failure to Implement Infection Control Precautions
Penalty
Summary
The facility failed to post infection control/contact isolation precaution signs to alert staff and visitors to wear personal protective equipment (PPE) and failed to ensure staff wore personal protective gowns during high-risk personal care activities. These failures were observed in the care of a resident (R3) who was on contact isolation precautions due to a MRSA infection in a breast wound. The resident's care plan indicated the need for enhanced barrier precautions, which were not followed by the staff. During an observation, it was noted that the infection control dresser outside R3's room was set up with gowns and gloves, but there was no sign indicating the resident was on any type of infection control isolation or enhanced barrier precautions. Two CNAs, V10 and V11, entered R3's room without wearing gowns and provided incontinence care, transferred the resident, and assisted with wound care without donning gowns, despite the resident being incontinent and having open wounds. The CNAs used hand sanitizer and gloves but did not adhere to the gown requirement. The LPN, V6, acknowledged that the CNAs should have worn gowns during the care activities and admitted to not instructing them to do so. The Director of Nursing/Infection Control Preventionist, V2, confirmed that enhanced barrier precautions, including the use of gowns, were required for residents with wounds and that appropriate signage should have been posted. The facility's policy on Enhanced Barrier Precautions outlined the need for gowns and gloves during high-contact care activities, which was not followed in this instance.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that five residents received timely physician visits, as required. The residents involved were admitted to the facility between December 2023 and July 2024, and their medical records did not document any physician visits since their admission. These residents had various medical conditions, including cognitive impairments, hypertension, hypothyroidism, cerebral palsy, diabetes, and dementia, among others. Despite the presence of a nurse practitioner with full practice authority, the facility did not have a policy requiring physician visits for new admissions or established residents. Interviews with the residents and staff revealed that the medical director, who is the only physician for all residents, does not routinely see residents and only visits the facility quarterly for meetings. The nurse practitioner handles all new admissions and follow-ups, but the facility was unaware that newly admitted residents needed to be seen by a physician. The administrator acknowledged the lack of a policy regarding physician visits and the need for the medical director to see all new residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to maintain a resident's dignity by not providing timely incontinence care for a resident who was cognitively intact and dependent on staff for dressing, toileting, and personal hygiene. The resident, who required assistance from two staff members and a mechanical lift for transfers, reported having to lay in urine all night despite using the call light multiple times. A CNA admitted to not checking on the resident every two hours, as required, and acknowledged turning off the call light without providing care. Further observations revealed that the resident's incontinence brief was fully saturated with urine, and the incontinence pad and bed sheets were wet. Multiple CNAs confirmed that they had not assisted the resident with care since the beginning of their shifts, indicating a lack of attention to the resident's needs. The resident expressed concern about developing bedsores due to prolonged exposure to urine. The Director of Nurses confirmed that residents should receive incontinence care every two hours and that call lights should remain on until care is provided. The DON acknowledged that leaving a resident in urine for hours is unacceptable and could lead to infections or pressure ulcers. The report highlights a failure to provide timely and adequate care, compromising the resident's dignity and quality of life.
Failure to Honor Resident's Toileting Preference
Penalty
Summary
The facility failed to honor a resident's preference for personal care, specifically regarding toileting. The resident, who is cognitively intact and has multiple medical diagnoses including Hypertension, Hypothyroidism, and Cerebral Palsy, expressed a preference to use a commode instead of a bedpan. Despite this preference, the resident was made to use a bedpan at night, which caused discomfort and sore spots due to prolonged use. The resident had previously used a commode and did not understand why this preference was not being honored. The issue was brought to the attention of the facility's administrator after the resident complained about being denied the use of a commode. The MDS/Care Plan Coordinator had informed the resident that a commode could not be used due to the frequency of use. The facility lacked a policy regarding resident preferences, although staff were expected to honor reasonable preferences as a standard of care. The administrator acknowledged the oversight and indicated that the resident would be assessed for the safe use of a commode.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was dependent on staff assistance for toileting, resulting in the resident laying in urine for extended periods. The resident, who was cognitively intact and had a history of skin breakdown, reported that on one occasion, they activated their call light four times throughout the night, but the CNA who responded did not change their incontinence brief or pad. The resident was eventually changed by two CNAs before the end of their shift, but by then, the resident's brief, pad, and bed sheets were soaked with urine. Further observations revealed that the resident's incontinence brief was fully saturated with urine, and the pad on their recliner chair had yellow spots. The CNAs assigned to the resident's hall confirmed that they had not assisted the resident with any care since the start of their shifts, indicating a lack of regular checks and changes. The resident expressed concern about the potential for developing bedsores again due to prolonged exposure to urine. The Director of Nurses acknowledged that all residents should receive incontinence care every two hours and as needed, and that call lights should remain on if care is not immediately provided. The DON confirmed that the CNAs assigned to the resident's hall were responsible for their care during the reported incidents, and emphasized the importance of timely care to prevent infections and maintain resident dignity.
Incontinence Care Deficiency Due to Improper Infection Control
Penalty
Summary
The facility failed to prevent cross-contamination during incontinence care for a resident who was dependent on staff for dressing, toileting, and personal hygiene. The resident, who was cognitively intact, had multiple medical diagnoses including acute systolic heart failure, chronic kidney disease, and pressure ulcers. During an observation, a Certified Nurse Aide (CNA) did not wash hands prior to providing incontinence care and wore the same pair of disposable gloves throughout the procedure. The CNA did not change gloves, wash hands, or use alcohol-based hand rub during the care of the resident's perineal and buttocks areas, and failed to apply barrier cream after the care. The Director of Nurses acknowledged that staff should follow infection control guidelines, emphasizing the importance of hand washing to prevent the spread of organisms. The facility's policy on perineal cleansing highlights the need to wash from the cleanest to the dirtiest area and to change gloves and wash hands when transitioning from contaminated to clean items. The CNA admitted to not following proper procedures, which contributed to the deficiency in care provided to the resident.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for four residents, as evidenced by observations, interviews, and record reviews. Residents reported issues such as aides placing clothes on the floor, unmade beds, delayed response to call lights, unchanged sheets, and visible bedpans. Housekeeping was noted to be inadequate, with trash not being picked up, floors not mopped, and bathrooms not cleaned properly. Specific incidents included a shared bathroom with paper debris, a full garbage can with soiled incontinence briefs, and a toilet riser with smeared stool, leading to a strong foul odor. Residents expressed dissatisfaction with the cleanliness and timeliness of housekeeping services. Additionally, one resident's room had maintenance issues such as a missing closet door, large areas of missing paint, and a hanging cable wire. The maintenance director acknowledged these issues, citing a lack of time to address them due to other responsibilities. The facility's maintenance report log had not been updated since 2020, indicating a lack of systematic tracking and resolution of maintenance problems. These deficiencies highlight the facility's failure to provide a safe, clean, and comfortable environment for its residents.
Failure to Report Alleged Mental Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident mental abuse to the State Agency for one resident, identified as R5, out of a sample of six residents reviewed for abuse. R5, who has medical diagnoses including Hypertension, Chronic Kidney Disease, Cardiovascular Disease, Anemia, Hyperlipidemia, Nocturnal Muscle Spasm, and Cerebral Vascular Accident, was documented as cognitively intact and requiring maximum assistance for transfers, bed mobility, personal hygiene, and toileting. On June 6, 2024, a grievance report documented that a Certified Nurse Aide (CNA) allegedly mentally abused R5. However, the facility was unable to provide documentation that this allegation was reported to the State Agency. The Administrator confirmed that the allegation was not reported, despite the facility's Abuse Prevention Program policy requiring such reports to be made within 24 hours.
Failure to Investigate Alleged Mental Abuse
Penalty
Summary
The facility failed to thoroughly and timely investigate an allegation of mental abuse by a staff member towards a resident, identified as R5. The incident involved a Certified Nurse Aide (CNA), V10, who allegedly told R5 to wait until 10:00 PM to be put to bed and made inappropriate comments about R5's inability to control her legs and roll over. The CNA also allegedly threatened to shove R5 off the bed and left R5 without a call light. Despite the report of this incident, the facility did not conduct a comprehensive investigation, as no staff or other residents were interviewed, and the accused CNA was not suspended during the investigation. The facility's policy on abuse prevention requires that employees accused of mistreatment or abuse be immediately removed from resident contact until the investigation is complete. However, this policy was not followed, as V10 continued to work without suspension and was only asked to provide a written statement without being informed of the specific allegations. The failure to adhere to the facility's abuse prevention policy and the lack of a timely and thorough investigation constitute a deficiency in the facility's handling of the abuse allegation.
Non-Functional Call Lights for Two Residents
Penalty
Summary
The facility failed to provide functioning call lights for two residents, identified as R1 and R2, in their shared room. Both residents have significant medical conditions, including acute kidney injury, chronic depression, and diabetes for R1, and osteoarthritis, urinary incontinence, and chronic pain for R2. Despite being cognitively intact, both residents reported that their call lights had been non-functional for three weeks. Instead, they were given a single bell to ring for assistance, which was ineffective as it could not be heard outside their room or at the nurses' station. This issue was confirmed by staff, including a Licensed Practical Nurse and a Certified Nurse Aide, who acknowledged the call lights had been out for weeks. The Maintenance Director confirmed that the call lights for R1 and R2 had been non-functional for three weeks and that an electrician was scheduled to fix them. A handwritten note at the nurses' station indicated that the call light for R1 and R2's room was not working outside their room or on the call light board, only sounding from the board. The Administrator also confirmed the non-functionality of the call lights, acknowledging the delay in repair. This deficiency highlights the facility's failure to ensure a working call system in the residents' bathroom and bathing area, compromising the residents' ability to effectively communicate their needs to the staff.
Lack of Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a clinically qualified director of food and nutrition services, which has the potential to affect all 38 residents residing in the facility. On two consecutive days, there was no Dietary Manager (DM) or Certified Dietary Manager (CDM) onsite from 10:00 AM to 4:00 PM. The facility's administrator confirmed that the previous CDM left in February 2024 and had not been replaced by the time of the survey. This deficiency was identified through observation, interview, and record review.
Lack of Safe Food Handling Training in Dietary Staff
Penalty
Summary
The facility failed to employ dietary staff who had completed safe food handling training, potentially affecting all 38 residents. Observations from 4/25/24 to 4/30/24 revealed that no dietary or ancillary staff assisting in the dietary department had completed basic safe food handling training. On 4/25/24, a housekeeper assisted in the kitchen during lunch service without a Food Handler's Certificate. Additionally, from 11:00 AM to 1:30 PM on the same day, three cooks, a dietary aide, and the housekeeper confirmed they did not have their Food Handler's Certificates. On 4/26/24, the administrator acknowledged that none of the dietary department employees had the required certification and mentioned that the facility was undergoing major changes in dietary staff and working on getting all staff trained.
Expired Food and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to ensure expired food products were disposed of and not served to residents. On multiple occasions, cooks were observed using expired tartar sauce and other food items, which were confirmed to be past their expiration dates. Despite recognizing the expiration, the cooks proceeded to serve these items to residents. Additionally, the facility did not monitor food temperatures properly, with cooks relying on visual cues rather than using thermometers to ensure food safety. This included both cooked and raw food items, which were not checked for appropriate temperatures before serving to residents. The facility also failed to maintain proper sanitation and hygiene standards in the kitchen. The dishwasher's sanitizer levels and temperatures were not adequately monitored, and the sanitizer container was found empty on several occasions. Staff admitted to not knowing how to operate or check the dishwasher properly, leading to potentially unsanitized dishes being used for resident meals. The kitchen environment was observed to be unsanitary, with rotten food items, unclean surfaces, and improper storage of food and chemicals. The walk-in cooler contained rotten bananas, tomatoes, and celery, which were leaking onto other food items, and the cooler itself had a musty odor and debris on the floor. Furthermore, the facility did not have a Certified Dietary Manager or a proper cleaning schedule in place. Staff admitted that the kitchen had not been managed or cleaned properly for an extended period. Food items in the reach-in cooler and freezer were not labeled with open or expiration dates, and chemicals were stored next to food storage areas. The kitchen walls, utensils, and storage areas were observed to be dirty, with food debris and splatters of unknown substances. The lack of proper management and cleaning schedules contributed to the overall unsanitary conditions in the kitchen.
Facility Fails to Provide Palatable and Timely Meals
Penalty
Summary
The facility failed to serve foods that were palatable, attractive, and at a safe and appetizing temperature to five residents. Observations and interviews revealed that residents consistently received meals that were cold, unappetizing, and often late. For instance, one resident was observed struggling to cut through a burnt and cold breaded fish filet, while another resident, who is the Resident Council President, reported multiple complaints about the quality of food, including cold meat, room temperature drinks, and meals that were typically an hour late. The soup served was described as unseasoned milk with a few pieces of carrot and hard uncooked navy beans, which residents found inedible and unappetizing. Further interviews with other residents echoed similar complaints about the food quality, with descriptions of cold meals, unseasoned and improperly cooked food, and consistent delays in meal service. A Certified Nurse Aide confirmed that the soup served on a particular evening looked like white milk with carrots and beans, and was an hour late. The facility administrator acknowledged that the kitchen staff were all new employees and admitted that meals should be palatable and served at the proper temperature, recognizing the residents' dissatisfaction with the food quality and service timing.
Failure to Provide Properly Pureed Food
Penalty
Summary
The facility failed to prepare pureed food in a safe texture for three residents who had physician orders for pureed diets. On 4/26/24, the cook prepared coleslaw that was lumpy and not in a pureed texture, which was then served to three residents (R6, R7, R8). The cook acknowledged that coleslaw does not puree well and that the prepared coleslaw did not meet the required consistency of pureed food, which should be like pudding. R8 was observed eating the lumpy coleslaw and began coughing while swallowing it. R7, who was also served the lumpy coleslaw, expressed difficulty in eating it. R6, despite recognizing that the food might not be appropriate, consumed the coleslaw because it was given to them by the staff. The facility's policy on therapeutic and mechanically altered diets states that such diets should be ordered by the physician and planned by the dietician to manage health conditions and facilitate oral intake, which was not adhered to in this instance.
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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