The Pearl Of Fox River Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Elgin, Illinois.
- Location
- 1950 Larkin Avenue, Elgin, Illinois 60123
- CMS Provider Number
- 145699
- Inspections on file
- 39
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at The Pearl Of Fox River Valley during CMS and state inspections, most recent first.
Two residents at high risk for pressure ulcers did not receive required heel offloading interventions as specified in their care plans and facility policy. Staff failed to consistently use offloading devices or elevate heels while the residents were in bed, resulting in noncompliance with prescribed pressure ulcer prevention protocols.
The facility failed to provide adequate supervision and implement required safety interventions for four residents with significant cognitive and physical impairments. Two residents with dysphagia and severe cognitive deficits were left unsupervised during meals despite orders for 1:1 supervision, a resident at high risk for falls was transferred without a gait belt, and another resident with a traumatic brain injury was not consistently monitored as required by her care plan. These actions and omissions resulted in deficiencies related to accident hazard prevention and resident safety.
Multiple residents with indwelling catheters did not receive consistent daily peri care or catheter cleaning, and staff were observed placing catheter drainage bags on the floor or above bladder level during transfers and care. These actions were contrary to the facility's infection control policy and care plans, which required daily catheter care and proper positioning of drainage bags to prevent infection.
Eight residents on pureed diets did not receive a pureed dinner roll during a lunch meal as required by their dietary orders and the facility's menu. Dietary staff failed to prepare and serve the pureed bread, and both the Dietary Manager and RD confirmed the omission was due to staff oversight, resulting in the residents not receiving the prescribed carbohydrate portion.
A resident's dignity was not maintained when a housekeeper and a CNA argued in the resident's presence about who was responsible for cleaning up feces in the bathroom, and the housekeeper took unauthorized photographs of the soiled area. The resident, who required significant assistance due to multiple medical conditions, felt embarrassed by the incident, which violated facility policy on privacy and dignity.
A resident with multiple chronic conditions and moderate cognitive impairment was allowed to keep prescription Viagra at the bedside and self-administer the medication without a current assessment, physician order, or care plan as required by facility policy. Nursing staff confirmed the medication was left for the resident to take as needed, and documentation showed no recent evaluation of the resident's ability to self-administer medications.
Two residents with cognitive impairments and multiple chronic conditions did not receive compression stockings as ordered by their physicians. Staff, including CNAs and a wound care nurse, were unaware of the orders, and documentation indicated the stockings were applied when they were not. The facility's policy requires following physician orders, but this was not done for these residents.
A resident with chronic medical conditions was observed splitting and self-administering a prescribed diuretic tablet in two separate doses, rather than taking it as ordered. Staff interviews confirmed that medication administration protocols were not followed, as the nurse did not remain with the resident to ensure the medication was taken as prescribed.
A CNA failed to wear a gown and did not change gloves during high-contact care for a resident on Enhanced Barrier Precautions (EBP) with an indwelling urinary catheter. The CNA touched multiple surfaces with contaminated gloves and only donned a gown after being reminded by another staff member. Facility policy and the DON confirmed that both gown and gloves are required for such care activities to prevent cross-contamination.
A pharmacist's Medication Regimen Review (MRR) failed to identify the omission of a resident's thyroid medication, Levothyroxine, upon readmission to the facility. Despite the presence of hospital documents in the resident's EMR, the omission was not caught during the initial or subsequent monthly MRRs. The resident experienced symptoms related to the missed medication, and her physician had to restart the medication 79 days later.
A resident with hypothyroidism did not receive her prescribed thyroid medication for 79 days due to a transcription error upon readmission to the facility. The omission was discovered after the resident exhibited symptoms of untreated hypothyroidism, and her community physician noted elevated TSH levels. The facility's policies for verifying medication orders upon readmission were not followed.
A resident with Multiple Sclerosis and other conditions was injured when a faulty shower chair abruptly stopped, causing her to fall and fracture her legs. The facility's shower chairs were in poor repair, with issues like locking wheels and difficulty moving over floor strips, which staff had been aware of. Despite warnings in the manufacturer's manual, the chairs continued to be used, leading to the incident.
The facility failed to document and resolve grievances from residents, including concerns about a confused peer wandering into rooms and the poor condition of shower chairs. Despite residents reporting these issues, no concern forms were generated, and the facility's grievance policy was not followed.
The facility failed to obtain weights as ordered for five residents with various medical conditions, including heart failure and diabetes. Despite physician orders for daily or weekly weights, documentation showed significant gaps in weight records. The DON confirmed that staff are expected to follow orders and document refusals, aligning with the facility's policy.
The facility failed to provide properly pureed foods for six residents on pureed diets. A resident was served lumpy pureed beef with visible solid particles, which the Food Service Director confirmed was not fully pureed. The facility's policy requires pureed foods to be smooth, like pudding or mashed potatoes, but the served beef did not meet this standard.
A facility failed to obtain timely treatment orders for a newly admitted resident with multiple pressure ulcers. The resident's medical record showed several pressure ulcers upon admission, but treatment orders were not obtained until days later. Interviews with staff revealed that the admitting nurse did not notify the physician for treatment orders, contrary to facility policy, resulting in a deficiency.
The facility failed to provide proper indwelling catheter care for three residents, resulting in cloudy urine and sediments in the catheter tubing, indicating potential infection risks. Despite care plans requiring regular catheter maintenance, the conditions persisted over several days. Additionally, one resident's catheter was not secured, increasing the risk of trauma. The facility's policies for catheter care and securing devices were not followed, contributing to the deficiency.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement pressure ulcer prevention measures for two residents identified as being at high risk for skin breakdown. One resident with diagnoses including Parkinson's disease, dementia, and hypertension was observed lying in bed with heels resting directly on the mattress, despite care plan interventions specifying that heels should be offloaded. Staff present at the time stated that all necessary care had been completed, and no further interventions were provided to offload the resident's heels. The resident's care plan and risk assessments documented the need for heel offloading due to high risk for pressure ulcers, but this intervention was not followed during the observation period. Another resident with severe cognitive impairment, chronic kidney disease, Alzheimer's disease, and heart failure was also observed lying in bed with heels resting on the mattress, while prescribed offloading boots were not in use and instead placed on a chair in the room. Staff provided inconsistent explanations regarding the use of offloading devices, with one CNA stating the boots were only needed in the afternoon, while another CNA clarified that offloading should occur at all times when the resident is in bed. The facility's policy and care plans required consistent offloading of heels to prevent pressure ulcers, but these measures were not implemented as observed.
Failure to Supervise and Implement Safety Measures for Residents at Risk
Penalty
Summary
The facility failed to provide adequate supervision and implement safety measures for multiple residents, resulting in deficiencies related to accident hazards and prevention. One resident with severe cognitive impairment, metabolic encephalopathy, and dysphagia was observed eating a pureed diet alone in his room without staff supervision, despite orders and speech therapy recommendations for 1:1 supervision at all meals due to swallowing difficulties. Staff interviews confirmed that this resident should not have been left unsupervised while eating, as he required constant reminders and cueing to ensure safe swallowing practices. Another resident with a history of unsteadiness, falls, and maximum assist needs for transfers was transferred from bed to wheelchair by a CNA without the use of a gait belt, contrary to facility policy and care plan instructions. The CNA held the resident under the arms instead, and the resident reported that gait belts were only used during therapy sessions, not in her room. The Director of Rehab confirmed that a gait belt should be used at all times for this resident due to her high fall risk and potential for sudden weakness during transfers. Additionally, a resident with dementia, hemiplegia, and dysphagia was repeatedly observed eating pureed meals alone in her room with the privacy curtain drawn, making her invisible from the hallway. Both the facility dietician and DON stated that this resident required supervision at all meals due to her high risk of choking and aspiration. Another resident with a traumatic brain injury and high fall risk was found alone in her room with the door and blinds closed, contrary to posted safety instructions and care plan interventions. The care plan had not been updated to reflect a recent fall with injury, and required fall precautions were not consistently maintained.
Failure to Provide Proper Catheter Care and Maintain Infection Control
Penalty
Summary
The facility failed to provide appropriate catheter care and maintain proper infection control practices for four out of five residents reviewed for catheters. Observations revealed that one resident's indwelling urinary drainage bag was placed on a hook on her nightstand, and she reported that staff only emptied the drainage bag and did not provide daily peri care or clean the catheter tubing as required. Staff interviews confirmed that peri care and catheter cleaning were inconsistently performed, with some staff indicating that the resident was responsible for her own care, despite her care plan indicating substantial assistance was needed. Another resident was observed with a catheter drainage bag lying on the floor, which staff acknowledged was against infection control protocols. Additional observations showed improper handling of catheter drainage bags during transfers and personal care, including placing the bag above the level of the bladder and on the resident's lap, leading to urine backflow in the tubing. Staff interviews confirmed awareness that the drainage bag should always be kept below the bladder to prevent backflow, but this practice was not consistently followed. Documentation for the residents involved showed significant medical histories, including multiple sclerosis, chronic kidney disease, Parkinson's disease, Alzheimer's disease, and neuromuscular dysfunction of the bladder. Care plans for these residents identified the risk of infection related to indwelling catheters and outlined the need for proper catheter care and infection control measures. The facility's own policy required daily catheter care, keeping drainage bags off the floor, and maintaining the bag below bladder level, but these procedures were not consistently implemented as observed and reported.
Failure to Provide Pureed Dinner Rolls to Residents on Pureed Diets
Penalty
Summary
The facility failed to ensure that residents on pureed diets received a pureed dinner roll during the lunch meal, as required by the menu and residents' dietary orders. During an initial kitchen tour and subsequent meal preparation observation, it was noted that no pureed dinner rolls were provided to any of the eight residents on pureed diets. The Dietary Manager confirmed that the lunch meal was supposed to include herbed turkey, California blend vegetables, mashed potatoes and gravy, cookies, and dinner rolls, but the pureed version of the dinner roll was omitted for those on pureed diets. Interviews with the Dietary Manager and Registered Dietitian revealed that the omission was due to staff forgetting to prepare the pureed dinner rolls. The Registered Dietitian emphasized the importance of serving the pureed bread to meet residents' nutritional needs, specifically carbohydrate intake, and clarified that a larger portion would be necessary if the bread was combined with other items. The facility's menu and policy required all food items, including pureed dinner rolls, to be served as listed, but this was not followed for the lunch meal in question.
Failure to Maintain Resident Dignity During Staff Dispute and Unauthorized Photography
Penalty
Summary
Staff failed to maintain the dignity of a resident when a housekeeper and a CNA engaged in a dispute in front of the resident and his roommate regarding who was responsible for cleaning up feces in the resident's bathroom. The incident was witnessed by both residents, with one reporting feeling embarrassed and down as a result. The housekeeper took multiple photographs of the soiled bathroom to send to her supervisor, further compromising the resident's privacy. The discussion and actions occurred in the presence of the resident, rather than in a private area, and the taking of photographs of the resident's room was not permitted by facility policy. The resident involved had multiple diagnoses, including Parkinson's disease with dyskinesia, unsteadiness, lack of coordination, and was dependent on staff for toilet hygiene and transfers. He was frequently incontinent of urine and occasionally incontinent of bowel, requiring substantial to maximal assistance. The facility's policy required staff to respect residents' privacy and dignity at all times and prohibited sharing health information or taking photographs of residents' rooms without consent. The administrator was unaware of the incident until informed by the surveyor.
Failure to Follow Policy for Self-Administration of Medication
Penalty
Summary
The facility failed to follow its policy regarding self-administration of medications for a resident with multiple diagnoses, including congestive heart failure, hypertension, diabetes mellitus, cardiomyopathy, and stage three kidney disease. The resident, who had moderate cognitive impairment, was observed with a vial of prescription Viagra on his bedside table and reported self-administering the medication for the past two to three months. Nursing staff confirmed that the medication was left at the bedside for the resident to take as needed, despite facility policy requiring a physician's order, a care plan, and an assessment of the resident's ability to self-administer medications safely. Record review revealed that the only assessment of the resident's ability to self-administer medication was over a year old and related to an inhaler, not the current medication in question. There was no current physician order or care plan authorizing self-administration of Viagra or allowing the medication to be kept at the bedside. Facility leadership confirmed that the required assessment, physician order, and care plan were not in place, and that the resident's ability to self-administer had not been evaluated as required by policy.
Failure to Apply Compression Stockings per Physician Orders
Penalty
Summary
The facility failed to apply compression stockings as ordered by physicians for two residents with cognitive impairments and multiple medical diagnoses. For one resident with Parkinson's disease, dementia, and other chronic conditions, physician orders required compression stockings to be applied to both lower extremities. However, during multiple observations, the resident was found without compression stockings, and both the wound care nurse and CNA were unaware of the order. The treatment administration record indicated the stockings were documented as applied, but direct observation contradicted this. The Director of Nursing confirmed that physician orders should be followed at all times and that documentation should reflect actual care provided. Similarly, another resident with severe cognitive impairment and diagnoses including metabolic encephalopathy, chronic kidney disease, Alzheimer's disease, and congestive heart failure had physician orders for daily application and removal of compression stockings. Observations on consecutive days found the resident without compression stockings, and several CNAs, including agency staff, were unsure of the resident's need for them despite signage in the room. The facility's policy requires adherence to physician orders, but staff failed to ensure the prescribed treatment was provided.
Failure to Ensure Proper Administration of Physician-Ordered Medication
Penalty
Summary
The facility failed to ensure that physician-prescribed medications were administered as ordered for a resident with multiple diagnoses, including cellulitis, chronic kidney disease, edema, and paranoid schizophrenia. The resident had a physician's order for Bumetanide (Bumex) 2 mg tablet to be taken by mouth each morning for fluid retention, with the medication scheduled for administration at 6 AM daily. Documentation showed the medication was signed as given at the scheduled time. However, direct observation revealed that the resident kept the medication at his bedside, split the tablet in half, and self-administered it in two separate doses, contrary to the prescribed order. Interviews with staff confirmed that nurses are required to verify medication orders, bring medications directly to the resident, and remain with the resident until the medication is swallowed. The Director of Nurses stated that the resident should not be splitting the dose and that the medication should be taken as ordered. The facility's Medication Pass policy requires staff to sign the MAR after administering medication but did not provide additional policies regarding proper medication administration. The failure to ensure the medication was administered as ordered resulted in a deficiency.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow Enhanced Barrier Precautions (EBP) during catheter care for a resident with multiple diagnoses, including metabolic encephalopathy, chronic kidney disease stage 4, Alzheimer's disease, major depressive disorder, and congestive heart failure. The resident was on EBP due to the presence of an indwelling urinary catheter, as documented in the care plan and indicated by signage at the resident's doorway. The CNA entered the resident's room wearing gloves but did not don a gown while performing high-contact care activities, such as emptying the catheter drainage bag. The CNA also failed to change gloves after providing catheter care and proceeded to touch multiple surfaces, including the shared bathroom door, bed remote, and the resident's clean clothing, without changing gloves. The deficiency was further substantiated by staff interviews and facility policy review. Another CNA reminded the staff member to wear a gown, at which point the gown was applied only for transferring the resident out of bed. The Director of Nursing confirmed that all staff are required to wear both gown and gloves during high-contact care for residents on EBP and to change gloves after catheter care to prevent cross-contamination. The facility's policy, revised on 6/30/25, mandates the use of gown and gloves for high-contact activities involving residents with indwelling medical devices, regardless of colonization status, to reduce the transmission of multi-drug-resistant organisms.
Pharmacist Fails to Identify Omitted Thyroid Medication
Penalty
Summary
The pharmacist's Medication Regimen Review (MRR) failed to identify a transcription omission of a resident's thyroid medication, Levothyroxine, for her hypothyroidism diagnosis at the time of her readmission. The resident was discharged from the facility and readmitted after an emergency room visit, with her hospital documents uploaded to her electronic medical record (EMR). Despite the presence of these documents, the pharmacist did not catch the omission of the thyroid medication during the MRR conducted on the resident's readmission and in subsequent monthly reviews. The resident experienced symptoms such as confusion, fatigue, and ocular issues, which were later attributed to the missed thyroid medication. Her physician noted an elevated thyroid-stimulating hormone (TSH) level and restarted her prior dose of Levothyroxine 79 days after the omission. The pharmacist manager consultant confirmed that the medication was missed during the MRRs and expressed uncertainty about whether the hospital documents were reviewed by the pharmacists. The facility's policy mandates monthly MRRs to ensure medications promote the resident's highest level of function, but this was not achieved in this case.
Failure to Administer Thyroid Medication for 79 Days
Penalty
Summary
The facility failed to transcribe a resident's thyroid medication as ordered, resulting in the medication not being administered for 79 days. The resident, who had an active diagnosis of hypothyroidism, was discharged and readmitted to the facility after an emergency room visit. Upon readmission, the resident's Levothyroxine Sodium, a thyroid hormone medication, was omitted from her medication regimen. This oversight was discovered when the resident's community physician noted elevated thyroid-stimulating hormone (TSH) levels and symptoms consistent with untreated hypothyroidism, such as confusion, fatigue, and ocular issues. The resident's electronic medical record (EMR) and electronic medication administration record (EMAR) showed that the Levothyroxine was last administered before discharge and was not restarted upon readmission. The facility's Director of Nursing acknowledged the error, stating that the medication was omitted and restarted at a lower dose than previously prescribed. The facility's policies required verification of hospital transfer orders with the attending physician upon admission and readmission, which was not adhered to in this case.
Unsafe Transport in Shower Chair Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe transport of a resident, R24, to the shower room, resulting in a fall and serious injuries. R24, a cognitively intact female with Multiple Sclerosis, Chronic Pain, and Polyneuropathy, required substantial assistance for mobility. On the day of the incident, a CNA transported R24 using a PVC shower chair instead of a wheelchair. The chair abruptly stopped at a metal transition strip on the floor, causing R24 to fall and sustain fractures to her right femur and left tibia and fibula. The incident report and interviews revealed that the shower chairs were in poor repair, with issues such as wheels locking unexpectedly and difficulty moving over floor strips. Staff members, including CNAs and the Director of Nursing, acknowledged the problems with the shower chairs, noting that they were hard to push and could tilt when encountering floor strips. Observations confirmed that the chairs were stiff and had a brown substance around the wheels. The manufacturer's manual for the shower chairs advised against using the chairs if they appeared unstable or if the casters were rusted. Despite these warnings, the facility continued to use the faulty chairs, leading to the accident involving R24.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to document and promptly resolve grievances raised by residents, as evidenced by the experiences of five residents. During a resident meeting, several residents expressed that their concerns about a confused peer wandering into their rooms had not been addressed, despite being raised in a previous meeting. The facility's activity director, who attended the meetings and took minutes, did not create a concern form for this issue. The facility administrator acknowledged awareness of the issue but did not ensure that a grievance form was completed as per the facility's policy. Additionally, a resident reported ongoing issues with the condition of shower chairs, which had been a concern for over two years. Despite reporting these issues to multiple CNAs, no concern forms were generated for this resident's complaints. The facility's grievance policy outlines the process for addressing grievances, including documentation and investigation, but these procedures were not followed in these instances, leading to unresolved resident concerns.
Failure to Obtain Resident Weights as Ordered
Penalty
Summary
The facility failed to obtain resident weights in accordance with physician orders for five residents. Resident R21, with multiple diagnoses including heart failure and chronic kidney disease, had a physician order for daily weights starting May 28, 2024. However, weights were only recorded sporadically, with significant gaps between May 29 and July 6, 2024. Similarly, Resident R60, diagnosed with chronic venous hypertension and congestive heart failure, had an order for daily weights from June 13, 2024, but weights were documented only on select days, not daily as required. Resident R14, with conditions such as Parkinson's disease and dementia, had a daily weight order from May 8, 2024, but was not weighed or refused to be weighed on multiple days across May, June, and July. Resident R37, with diagnoses including spinal fracture and COPD, had an order for weekly weights, but was not weighed on three specified weeks in June. Lastly, Resident R61, with a history of stroke and congestive heart failure, had a daily weight order from June 27, 2024, but was not weighed or refused on several days in June and July. The Director of Nursing acknowledged the expectation for staff to follow physician orders and document refusals, as per the facility's policy revised on June 6, 2024.
Failure to Provide Properly Pureed Foods
Penalty
Summary
The facility failed to provide pureed foods to a smooth consistency for six residents on pureed diets. On July 8, 2024, a resident was observed eating a lunch meal that included pureed beef, which appeared lumpy with visible solid particles. The Food Service Director, upon observing and tasting the pureed beef, confirmed that it was not completely pureed and required further processing. The facility's policy, reviewed in June 2024, specifies that pureed foods should reach a smooth consistency similar to pudding or mashed potatoes. However, the pureed beef served did not meet this standard, as it contained small pieces of unpureed beef that required chewing.
Failure to Obtain Timely Treatment Orders for Pressure Ulcers
Penalty
Summary
The facility failed to obtain treatment orders for a newly admitted resident with pressure ulcers, leading to a deficiency in care. The resident, identified as R256, was admitted with multiple diagnoses, including several pressure ulcers. Upon admission, the resident's electronic medical record indicated the presence of two stage three pressure ulcers, two unstageable pressure ulcers, and one deep tissue pressure injury. However, it was found that no treatment orders were obtained for these pressure ulcers until several days after admission. Interviews with facility staff, including the Wound Care Nurse and the Director of Nursing, revealed that the admitting nurse did not notify the physician to obtain treatment orders for the pressure ulcers upon the resident's admission. The facility's policy requires that wound care treatment be initiated upon identification of a wound with a physician's order, but there was no documentation of pressure ulcer treatment for the resident on the first three days following admission. This lack of timely action and documentation led to the deficiency noted in the report.
Inadequate Indwelling Catheter Care Leading to Infection Risk
Penalty
Summary
The facility failed to provide adequate indwelling catheter care for three residents, leading to potential infection risks. Resident 1, with a history of hemiplegia, hemiparesis, and epilepsy, was observed multiple times with cloudy urine and yellow sediments in the catheter tubing, indicating a lack of proper catheter maintenance. Despite having a care plan that required catheter care every shift, the resident's catheter condition remained unchanged over several days. Similarly, Resident 70, diagnosed with Parkinson's disease and urinary retention, was found with cloudy urine and sediments in the catheter tubing on multiple occasions. The registered nurse acknowledged the need for intervention but did not take immediate action to address the issue. Resident 86, with a complex medical history including ventricular tachycardia and chronic kidney disease, was also observed with cloudy urine and sediments in the catheter tubing. Additionally, the resident was seen attempting to pull the catheter tubing, which was not secured, increasing the risk of catheter-related trauma. The facility's policy required catheter irrigation to prevent obstruction and the use of an anchor device to secure the catheter, but these measures were not implemented. The Director of Nursing confirmed the need for catheter irrigation and securing devices, yet these actions were not taken, contributing to the deficiency.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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