Thryve Of South Holland
Inspection history, citations, penalties and survey trends for this long-term care facility in South Holland, Illinois.
- Location
- 2145 East 170th Street, South Holland, Illinois 60473
- CMS Provider Number
- 145608
- Inspections on file
- 41
- Latest survey
- January 4, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Thryve Of South Holland during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, gait abnormalities, and a documented high fall-risk score required partial/moderate assistance for transfers and a wheelchair for mobility, with a care plan calling for adaptive equipment, appropriate footwear, and staff assistance with ambulation. Surveyors observed the resident multiple times in the day room without any mobility device nearby and without proper footwear, including wearing only regular socks and at one point having one bare foot. Staff interviews showed inconsistent recognition of the resident’s high fall risk and assistance needs, with some CNAs and an RN stating the resident was not a fall risk and walked independently without devices, despite documentation to the contrary. On the day of the fall, the resident followed a CNA into her room while the CNA was in the bathroom with the roommate; the resident was later found on the floor after apparently attempting to sit on a bed that had been left unlocked and shifted away, and she was initially assessed as having no pain. Later that day, an LPN documented that the resident complained of leg pain, was unable to stand during transfer attempts, and was sent to the hospital, where she was diagnosed with a right femoral neck fracture requiring ORIF. The facility’s fall management policy requires individualized interventions based on identified risks, but observations and interviews showed that environmental safety (locked bed), supervision, assistive device availability, and appropriate footwear were not consistently provided for this high-risk resident.
A resident at high risk for skin breakdown developed a facility-acquired stage 3 pressure wound on the ear due to staff not providing required turning and repositioning, and improper use of bedding materials. Additionally, two residents at risk for pressure ulcers had air mattress pumps set incorrectly for their weights, with no policy in place to guide staff on proper settings. These failures contributed to the development and risk of pressure ulcers.
Surveyors found that medications, including insulin pens and eye drops, were not consistently labeled with open or expiration dates, and some medications were stored in unlabelled containers or left expired in medication carts. Staff interviews confirmed that required labeling and removal procedures were not followed, affecting multiple residents and potentially all who use house stock medications.
The facility did not effectively eliminate strong, ongoing odors in hallways and a care unit, as confirmed by staff and the ombudsman. Despite contracting a cleaning company, odors remained due to spills and resident accidents on carpets, and the facility's carpet extractor was broken and not in use, contrary to facility policy requiring a clean, odor-free environment.
A resident with an intellectual disability experienced a significant delay in transfer to another facility because the required PASARR Level II screening was not completed. The delay was caused by the facility entering incorrect address information into the PASARR system and failing to provide timely follow-up, which prevented the necessary external assessment from being initiated.
A resident with neurogenic bladder and an indwelling urinary catheter was observed with the catheter tubing improperly positioned and the statlock device dirty, undated, and not secured to the leg. A nurse confirmed the catheter was not secured and the statlock was unclean, contrary to facility policy requiring catheters to be stabilized with a clean statlock attached to the leg.
The facility failed to accurately complete MDS assessments for several residents, resulting in discrepancies such as missing or incorrect documentation of psychiatric diagnoses, hospice status, and serious mental illness. Staff interviews and record reviews revealed that some residents' MDS forms did not match their medical records or care plans, and staff acknowledged errors or lack of awareness regarding required information.
A resident who was totally dependent on staff for transfers and required two-person assistance was transferred from a shower table to bed by a single CNA, contrary to the care plan and facility policy. The resident fell during the transfer, resulting in bruising and acute lower back pain, and expressed anxiety about future falls. Staff interviews and documentation confirmed that the required supervision and assistance were not provided.
Two residents experienced falls due to staff failing to follow fall care plans and safe transfer protocols. One resident, dependent on staff for all ADLs, fell from a mechanical lift when staff used malfunctioning equipment and did not secure the straps properly. Another resident with severe cognitive impairment fell out of a wheelchair while being moved, as staff did not follow care plan interventions for safe transfers and failed to report the incident accurately. Both incidents resulted from not adhering to established safety procedures.
Two residents experienced avoidable falls—one during a wheelchair transfer and another from a mechanical lift—resulting in pain, bruising, and hospital evaluation, but the facility did not report these incidents to the state agency as required. Staff interviews revealed confusion about reporting requirements, and the facility lacked a policy for reportable events.
Multiple dependent residents did not receive adequate assistance with ADLs, including hygiene, grooming, and incontinence care, as evidenced by stained clothing, infrequent changing, and reports of prolonged waits for help. Observations also revealed unclean resident rooms with dead ants and residue, despite facility policies requiring cleanliness and comprehensive care.
Two residents with significant cognitive and mobility impairments experienced repeated unwitnessed falls due to inadequate supervision and ineffective fall interventions. Despite care plans outlining various strategies, both residents continued to fall while attempting to perform activities independently, and staff interviews confirmed that one-on-one monitoring and fall alarms were not used. The facility's approach relied on periodic checks and verbal reminders, which did not prevent ongoing incidents.
Surveyors found that multiple residents with significant ADL deficits were living in rooms with trash, food particles, soiled linens, sticky floors, and cluttered surfaces. Staff interviews confirmed that nursing and housekeeping were responsible for maintaining cleanliness, but these standards were not upheld, resulting in unsanitary and uncomfortable living conditions.
Three residents with significant physical and cognitive impairments did not receive the required assistance or supervision with eating, despite care plans and physician orders indicating the need for such support. Observations showed residents left alone during meals, struggling to eat, or unable to locate food items, with documentation and staff interviews confirming that appropriate assistance was not consistently provided.
Two residents with indwelling catheters were observed with catheter tubing and drainage bags improperly positioned, including tubing and bags on the floor and tubing being sat on or dragged, contrary to facility policy. Both residents had care plans addressing catheter care, but staff did not ensure proper placement or cleanliness of catheter equipment.
The facility did not notify IDPH that the sprinkler system was non-functional in all four units, as required by its fire watch policy. Despite ongoing fire watch procedures and fire department notification, the administrator could not confirm that IDPH was informed about the full extent and duration of the outage, affecting all 117 residents.
A resident with COPD and other conditions did not receive the correct dosage of Prednisone due to transcription errors in the physician's order. The order was incorrectly noted as 1 mg instead of 60 mg, and there was no documentation of the correct dosage being dispensed. Additionally, an order for Norco was incomplete, lacking proper processing and documentation.
The facility failed to provide adequate ADL care, including incontinence care and bathing, for several residents. One resident was found soiled in urine, and others did not receive scheduled showers or bed baths. The ADON confirmed that staff should check and change residents every two hours, but documentation of refusals and interventions was lacking. Facility policies on shower/tub baths and refusal of care were not followed, leading to deficiencies in resident care.
A resident requiring supervision during smoking breaks was left unsupervised, resulting in burn holes in clothing and over 200 cigarette butts discarded on the ground. The facility failed to provide an ashtray, and a melted flowerpot was used for extinguishing cigarettes, which was not reported to the appropriate staff.
A resident was subjected to verbal abuse by a housekeeper who moved the resident's personal items without consent, leading to a verbal altercation. Despite the resident's request to stop, the housekeeper used profanity, and the situation escalated in the presence of the Social Service Director. The facility's investigation confirmed the verbal abuse, highlighting a failure to adhere to its Abuse Prevention Policy.
A resident with hemiplegia and hemiparesis was found in bed with the call light placed out of reach, contrary to the facility's policy and care plan interventions. The resident, who is alert and able to communicate, reported that a CNA had transferred him back to bed earlier. The RN acknowledged the oversight and adjusted the call light to be within reach. The resident's care plan highlights a high risk for falls and specifies that the call light should always be accessible.
The facility failed to post accessible information about the State LTC Ombudsman Program, affecting a resident whose family was unaware of advocacy resources. The information was initially posted inside the nursing station, not visible to residents or families, contrary to facility policy. The issue was acknowledged by the Social Service Director and Administrator.
A resident admitted for rehabilitation following a stroke did not receive a comprehensive care plan for ADLs and activities, as required by facility policy. The resident was only given a shower once since admission, despite being scheduled for twice-weekly showers, and was observed in a disheveled state. The facility failed to document scheduled showers and did not post the monthly activity schedule, leading to a deficiency in care planning.
The facility failed to follow its pressure ulcer prevention policy, affecting two residents. One resident was found with a deflated low air loss mattress and without heel protectors, while another was observed without heel protectors in bed. Both residents were at high risk for pressure ulcers, and the facility's policy required the use of functioning LAL mattresses and heel protectors.
A diabetic resident in a LTC facility was found with long, dirty fingernails and toenails, indicating a failure in providing necessary foot care. Despite the facility's policy that toenails should be trimmed by qualified personnel, the resident had not been seen by a podiatrist within a month of admission. The resident, who is dependent on assistance for most ADLs, had not received the required foot care, although the facility's guidelines emphasize routine cleaning and trimming to prevent complications.
A resident with peripheral vascular disease and an arterial ulcer did not receive appropriate pain management during wound care. Despite having prescriptions for hydrocodone-acetaminophen and acetaminophen, the resident reported a pain level of 6 and had not received pain medication from August 1 to August 13, 2024. The facility's policy requires pain assessment and management, which was not followed, as confirmed by the DON.
The facility failed to monitor and document refrigerator temperatures in resident rooms, affecting two residents. Observations showed incomplete temperature logs and unlabeled food items, contrary to facility policy. The DON stated that certified nurse aides are responsible for these tasks, but the procedures were not followed, resulting in the deficiency.
Two residents in the facility did not receive necessary personal hygiene and grooming care. One resident, dependent on assistance for ADLs, was only given a shower once since admission, despite being scheduled for showers twice a week. Another diabetic resident had long, dirty fingernails and toenails, indicating a lack of proper nail care. The facility's policies on ADLs and nail care were not followed, leading to these deficiencies.
The facility failed to maintain a clean and odor-free environment in the memory care unit, affecting all 21 residents. Observations revealed strong urine odors near the entrance and specific rooms. The Assistant Director of Nursing acknowledged the issue but was unsure if the Environmental Manager had addressed it. The facility's housekeeping policy requires maintaining a clean and odor-free environment, which was not upheld in this instance.
The facility failed to notify family members of significant health changes and medication adjustments for three residents, despite having policies in place to ensure such communication. This deficiency involved abnormal lab results and new treatment orders, with no documentation of family notifications.
A resident with a history of lower back pain and muscle weakness was not provided with authorized physical therapy sessions despite having insurance approval and physician orders. The resident expressed a desire to resume therapy to achieve her goal of returning home, but the facility failed to communicate effectively and did not provide the necessary services. Interviews with staff revealed a lack of coordination and communication regarding the resident's therapy status.
Failure to Control Environmental Hazards and Provide Required Supervision and Assistive Devices for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards, provide adequate supervision, and ensure the availability and use of required assistive devices for a resident at high risk for falls. The resident is an elderly female with diagnoses including unspecified dementia with behavioral disturbance, peripheral vascular disease, hypertension, gait and mobility abnormalities, anxiety disorder, bilateral hip osteoarthritis, and vitamin deficiencies. Her MDS shows a BIMS score of 3, indicating severe cognitive impairment, and section GG indicates she requires partial/moderate assistance for sit-to-stand and bed-to-chair transfers and uses a manual wheelchair for mobility. A fall risk assessment score of 13 identifies her as high risk for falls, and her care plan calls for a restorative walking program with adaptive equipment as needed (e.g., wheelchair, walker, gait belt, cane), appropriate footwear, staff assistance with ambulation at the level required, and reminders not to ambulate without assistance. On multiple observations by the surveyor, the resident was seen in the day room watching TV without any mobility device in her immediate vicinity and without appropriate footwear. On one occasion she was wearing regular socks and no shoes; on another, she had a regular sock on one foot and the other foot was bare. Her bed was observed in the low and locked position with a fall mat on one side, but no mobility devices were present in her room. The resident reported remembering that she fell and hurt herself but was unable to provide details due to disorientation and forgetfulness. Staff interviews revealed inconsistent understanding of her fall risk and required level of assistance. One CNA stated the resident was able to walk independently without assistive devices, freely walked around the unit, and was not a fall risk resident, despite also reporting that the resident required total assistance with ADLs and sometimes two-person assist when agitated, and that she would try to get out of bed unassisted. The fall event occurred when the resident was following a CNA into her room while the CNA was assisting the roommate in the bathroom with the door closed. The CNA heard the resident say “Ouch,” then found her sitting on the floor with her back against the roommate’s bed, which had shifted because it was not locked. The CNA reported that she did not know who left the bed unlocked. An RN responded, assessed the resident, and documented that vital signs, neurological assessment, and pain assessment were within normal limits, and the resident initially denied pain. The resident was assisted to a wheelchair and placed in the day room. Later that day, another nurse noted the resident refused dinner and complained of pain in both legs; on further attempts to transfer her to bed, the resident was unable to stand, was in significant pain, and required pain medication and hospice assessment. The resident was subsequently sent to the hospital, where imaging showed a subcapital fracture of the right femoral neck with slight impaction, and she underwent right hip ORIF. The attending physician stated the fracture appeared to be fall-related and that the resident was considered a high fall risk, and also indicated that if a bed was unlocked it should have been locked and the resident should have been wearing non-slip footwear. Staff interviews further demonstrated conflicting assessments of the resident’s fall risk and supervision needs. One RN described the resident as a fall risk but was unsure if she was high risk, and stated the resident was safe to walk around without assistance, while also acknowledging that the resident did not listen to staff, stood up whenever she wanted, and did not want to wear shoes. Another nurse stated the resident was not a fall risk before the fall but was afterward, and that the resident walked fine and did not use assistive devices. The DON/fall coordinator stated the resident was found on the floor after attempting to sit on a bed that was not locked and that the bed moved away from her, leading to the fall. The facility’s written policy on managing falls and fall risk requires staff to identify interventions related to specific risks and causes to prevent falls and minimize complications, but the interviews and observations showed that the resident’s high fall risk status, need for assistive devices, and need for appropriate footwear and supervision were not consistently implemented or adhered to at the time of the incident and subsequent observations.
Failure to Prevent Pressure Ulcers and Ensure Proper Air Mattress Settings
Penalty
Summary
The facility failed to prevent an avoidable pressure wound in a resident identified as high risk for skin breakdown and dependent on staff for turning and repositioning. The resident's Braden scale assessment indicated a high risk for pressure sores, with very limited mobility and a need for moderate to maximum assistance. Despite this, the resident developed a facility-acquired stage 3 pressure wound on the left ear, which was observed by nursing staff and confirmed by the wound physician. Staff interviews and observations revealed that the resident was not turned and repositioned as required, and the wound was attributed to prolonged pressure from lying on a pillow with a plastic covering that created folds, as well as possible contact with a call light cord. The Director of Nursing confirmed that the wound resulted from staff not turning and repositioning the resident as needed. Additionally, the facility failed to ensure that air mattress pumps were set according to manufacturer recommendations based on residents' weights. Observations showed that two residents at risk for pressure ulcers had their air mattress pumps set significantly higher than their actual weights. For example, one resident weighing 117 pounds had the mattress set at 200 pounds, and another weighing 63.6 pounds had the mattress set at 280 pounds. The wound nurse acknowledged that incorrect mattress settings would not provide the intended benefit for pressure ulcer prevention. Maintenance staff reported that there was no policy in place for setting air mattress pumps, and that they relied on verbal instructions from nursing staff. The lack of proper mattress settings and failure to turn and reposition high-risk residents contributed to the development and risk of pressure ulcers among the affected residents.
Failure to Properly Label and Store Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and storage of medications and biologicals in accordance with professional standards and facility policy. Multiple instances were identified where medications, including insulin pens and eye drops, lacked required open and expiration dates. Some medications were found in unlabelled containers, such as thirteen tan pills in a clear medicine cup that could not be identified by the Director of Nursing. Additionally, expired medications, such as house stock acidophilus capsules and Bisacodyl tablets, were found in medication carts, and some medications were not stored in their original labeled packaging. The deficiencies affected all six residents reviewed and had the potential to impact all residents using house stock medications. Staff interviews confirmed that medications in use did not have appropriate expiration or open dates, and that some medications, such as inhalers and insulin pens, were not labeled with the required information. Facility policy requires that medications be labeled with open and expiration dates, and that expired or improperly labeled medications be removed and destroyed, but these procedures were not consistently followed.
Failure to Eliminate Persistent Odors Due to Ineffective Cleaning Practices
Penalty
Summary
The facility failed to maintain an effective policy and practice for eliminating odors, resulting in strong, persistent odors in the hallways and on care unit three hundred. During the survey, both staff and the facility ombudsman confirmed that odors have been an ongoing issue. The Director of Nursing stated that a company was contracted to clean the carpets, but the odor problem persisted. The maintenance supervisor reported that the odors originated from the carpets due to spills and resident accidents, and noted that the facility's carpet extractor, which is used between professional cleanings, was broken and had been out of service for some time. Facility policy requires maintaining a clean, odor-free, and comfortable environment, but observations and interviews indicated this standard was not met.
Failure to Complete PASARR Level II Screening Due to Incorrect Information
Penalty
Summary
The facility failed to obtain a required PASARR (Preadmission Screening and Resident Review) Level II screening for a resident with a diagnosis of intellectual disability. Despite the resident's family waiting for over two months for the screening to be completed in order to facilitate a transfer to another facility, the process was delayed due to incorrect information being entered into the PASARR system. Specifically, the facility listed its own address instead of the resident's prior community address, which prevented the external assessment from being initiated. The PASARR Help Desk confirmed that the screening could not proceed without the correct address information. Documentation shows that the most recent PASARR was completed in late May, indicating a referral for Level II screening. Progress notes reveal ongoing communication attempts with the PASARR assessment company and the state, but there were significant gaps between follow-ups, with over 30 days passing between contacts. The resident, who has an intellectual disability, was observed to have limited verbal communication during the survey. The deficiency resulted from the facility's failure to provide accurate information and timely follow-up, leading to a prolonged delay in the required screening process.
Failure to Secure Indwelling Catheter According to Policy
Penalty
Summary
A resident with a diagnosis of neurogenic bladder had a physician order for an indwelling urinary catheter. During observation, the resident was found lying in bed with the catheter tubing positioned between the posterior legs toward the buttock, and the statlock device, intended to secure the catheter, was folded, dirty, undated, and not attached to the resident's leg. A nurse confirmed that the catheter was not secured and that the statlock was unclean, stating it should have been clean and properly attached. The Director of Nursing stated that facility policy requires indwelling catheters to be secured to the resident's leg with a statlock for stabilization. The facility's urinary catheter care policy specifies that the catheter should be secured with a leg strap to reduce friction and movement at the insertion site, but this was not followed in this instance.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for five residents, resulting in multiple discrepancies between documented diagnoses, care plans, and MDS coding. For one resident, the MDS did not reflect the psychiatric diagnoses of generalized anxiety disorder and major depressive disorder, despite these being documented in psychotherapy notes. Another resident with a diagnosis of schizophrenia and a Level II PASRR indicating a serious mental health condition was incorrectly coded on the MDS as not having a serious mental illness, due to the Social Service Director's lack of awareness of the Level II screening. Additionally, a resident receiving hospice care was not identified as such on the MDS, even though hospice certification and care plans were present, and the MDS nurse acknowledged the error after reviewing the documentation. Further, another resident on hospice was not marked as such on the MDS, despite confirmation from staff, care plans, and census records, with the MDS nurse attributing the omission to an error. Lastly, a resident's MDS indicated a diagnosis of bipolar disorder, but there was no supporting documentation or ICD code on the face sheet, and both the LPN and DON confirmed the resident did not have this diagnosis. These inaccuracies in MDS assessments were identified through interviews, record reviews, and staff admissions of errors or lack of awareness.
Failure to Provide Required Two-Person Assistance During Transfer Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's fall prevention policy by not providing the required two-person assistance during a transfer for a resident who was totally dependent on staff for transfers. The resident, an older male with a history of rhabdomyolysis, polyneuropathy, left artificial knee joint, prior falls, and generalized arthritis, was being transferred from a shower table to his bed by a single certified nursing assistant (CNA). The care plan for this resident specifically required the use of a mechanical lift and two-person assistance for all transfers due to his high risk for falls and previous injuries. During the incident, the CNA attempted the transfer alone after being unable to find another aide and forgetting to ask the LPN for help, despite being instructed to do so. As a result, the resident slid off the shower table and fell to the floor, sustaining bruising and acute lower back pain, which was confirmed by hospital evaluation. The resident expressed anxiety and fear of future falls, stating he had previously requested not to be transferred in that manner. Documentation and staff interviews confirmed that the facility's fall prevention policy and the resident's care plan were not followed at the time of the incident.
Failure to Follow Fall Care Plans and Safe Transfer Practices Resulting in Resident Falls
Penalty
Summary
The facility failed to follow fall care plans and ensure safe transfer practices for two residents, resulting in both residents experiencing falls. One resident with quadriplegia and intact cognition was dependent on staff for all activities of daily living and was assessed as a low fall risk. This resident fell from a mechanical lift during a two-person transfer when the lift's strap was not properly secured, and the equipment used was reported by staff to be malfunctioning, with loose or swinging arms and missing safety clips. Staff used the lift despite being aware of its issues, and alternative lifts were unavailable due to dead batteries. The resident experienced pain and bruising on the left side and was later sent to the hospital for evaluation after reporting persistent pain. Another resident with severe cognitive impairment and a high fall risk was involved in an incident where a CNA attempted to move the resident in a wheelchair. The resident was being pushed backwards and grabbed onto a door frame, resulting in a fall to the floor. The CNA did not immediately report the incident as a fall, and initial documentation described it as an "almost fall" with the resident being assisted to the floor. However, further investigation revealed that the resident had actually fallen out of the wheelchair while being moved, contrary to the care plan interventions that required close monitoring and ensuring the resident did not grab stationary objects during transfers. Both incidents demonstrate failures to adhere to established care plans and safe transfer protocols. In the first case, staff used malfunctioning equipment and did not ensure proper mechanical lift operation, while in the second case, the staff did not follow the care plan's guidance for safe wheelchair transfers and failed to report the incident accurately and promptly. These actions and inactions directly led to avoidable falls and injuries for both residents.
Failure to Report Resident Falls and Injuries to State Agency
Penalty
Summary
The facility failed to report two unusual occurrences involving two residents to the state agency, as required. In the first case, a resident with severe cognitive impairment and high fall risk was involved in an incident where a CNA assisted the resident to the floor after the resident missed the wheelchair while attempting to sit. The resident later stated that a staff member pulled the wheelchair from underneath him, resulting in a fall, although he did not recall if it was accidental or intentional. Staff interviews confirmed the incident, and the Director of Nursing acknowledged that such an occurrence should have been reported as it was out of the ordinary. In the second case, a resident with quadriplegia and intact cognition fell from a mechanical lift during a two-person transfer. The resident reported pain in the elbow, hip, and head, and was sent to the hospital several days later for evaluation due to persistent pain. Hospital records confirmed the resident presented with post-traumatic pain and bruising. Staff interviews indicated that the mechanical lift incident was witnessed, and the resident was assessed and offered hospital transfer at the time, which was initially declined. Despite these incidents, the facility did not report either event to the state agency as required. The facility was unable to provide a policy for reportable events and relied solely on state guidelines. Staff interviews revealed uncertainty about what constituted a reportable event, and documentation confirmed that both incidents were not reported, despite resulting in avoidable falls and, in one case, hospital evaluation for injuries.
Failure to Provide Adequate ADL Assistance and Maintain Cleanliness
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for five residents who were dependent on staff for care. Observations and interviews revealed that residents with significant medical conditions, such as Alzheimer's disease, severe malnutrition, quadriplegia, partial paralysis, and morbid obesity, were not consistently receiving necessary hygiene, grooming, and incontinence care. For example, one resident was found in a stained gown that had not been changed since the previous day and reported going all day without incontinence care, resulting in soreness. Another resident reported sitting in feces for extended periods due to delayed call light responses, and both residents and their rooms were observed to have poor cleanliness, including sticky floors and buildup of residue and particles. Multiple residents and their care plans indicated total dependence on staff for ADLs, yet documentation and direct statements from residents described frequent delays or omissions in care, such as infrequent changing, lack of bathing, and insufficient grooming. Grievance forms over several months documented repeated concerns about long call light response times, lack of incontinence care, missed showers, and unclean linens. One resident developed a facility-acquired moisture-associated incontinence wound, with the DON confirming the need for more frequent incontinence checks and acknowledging that the resident had not refused care. Environmental observations further highlighted deficiencies in housekeeping, with dead ants and unclean conditions persisting in resident rooms after pest treatments. The facility's own policies require maintaining a clean, comfortable, and sanitary environment and providing comprehensive ADL support, but these standards were not met as evidenced by the observed and reported conditions.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement effective fall interventions for two residents with a history of falls and significant cognitive and physical impairments. One male resident with vascular dementia, poor safety awareness, and impaired mobility experienced multiple unwitnessed falls in various locations, including his room, lounge, dining room, and hallway. Despite a care plan with numerous interventions such as keeping the bed in the lowest position, frequent observation, and positioning near the nursing station, the resident continued to fall while attempting to transfer or retrieve items independently. Observations revealed that his call light was not accessible, and he was often left unsupervised, leading to repeated incidents. A female resident with epilepsy, stroke, gait abnormalities, and a history of falls also experienced several unwitnessed falls in her room. Her care plan included interventions like ensuring the call light was within reach, encouraging the use of appropriate footwear, and providing prompt assistance. However, she was observed alone, attempting to dress herself and ambulate without assistance, despite being known to resist care and having cognitive deficits. The resident repeatedly fell while trying to perform activities of daily living independently, such as dressing or reaching for items, and often refused to use the call light or accept help from staff. Interviews with facility staff, including the restorative nurse and DON, confirmed that the facility does not provide one-on-one monitoring, does not use restraints or fall alarms, and relies on staff to check on residents periodically. Staff acknowledged the residents' impulsivity, confusion, and lack of safety awareness but indicated that falls "just happen" and that interventions are modified as needed. Despite multiple falls with similar causes, effective supervision and interventions to prevent recurrence were not consistently implemented, resulting in ongoing unwitnessed falls for both residents.
Failure to Maintain Clean and Homelike Resident Environments
Penalty
Summary
Surveyors identified a failure by the facility to maintain a clean, safe, and homelike environment for four residents with significant physical and cognitive impairments. Observations revealed that resident rooms contained trash, food particles, soiled linens, dust, and sticky substances on floors and furniture. Specific findings included food particles and red stains on a resident's bed, sticky floors, and clutter such as gowns and briefs left out in rooms. Another resident's room had stained blankets, latex gloves, and various personal items scattered on surfaces and chairs, as well as a rolled mattress and foot splint obstructing access to the closet. Additional observations included a resident with food in her hair, on her gown, and on her bed, a sticky floor, and a noticeable urine odor in the room. Items such as clean briefs, house shoes, and hair covers were left out on nightstands and chairs. Another resident's room had trash on the floor, non-skid socks strewn about, unfolded clothes on a nightstand, and a dead fly and dust on the window sill. These conditions were present despite the residents' documented deficits in activities of daily living (ADLs), which required staff assistance for maintaining cleanliness and order in their living spaces. Interviews with staff confirmed that nursing and housekeeping personnel were responsible for ensuring rooms were clean and free of clutter, and that linens and personal items should be properly stored. Staff acknowledged that rooms should not have trash on the floor, cluttered surfaces, or clean briefs left out, especially for residents dependent on staff for room maintenance. Facility policies also required maintaining a sanitary, odor-free, and comfortable environment, but these standards were not met as evidenced by the survey findings.
Failure to Provide Required Assistance with Eating and Activities of Daily Living
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically with eating, for three residents who were assessed as needing such support. One male resident with multiple diagnoses including dementia, Parkinson's disease, traumatic brain injury, and visual impairment was observed eating alone in his room without staff supervision or assistance. He was unable to locate a food item on his tray due to his blindness until verbally guided by the surveyor. Documentation showed that he often ate independently or with only setup or cleanup assistance, despite care plans indicating he required supervision while eating. A female resident with a history of partial paralysis following a stroke, dysphagia, and significant recent weight loss was observed with her meal barely touched and no staff present to assist her. Food particles were noted in her hair, on her gown, and on her bed. Staff interviews confirmed that she would eat if fed, and her care plan and physician orders required one-on-one feeding assistance due to her nutritional risk. However, records indicated she mostly received only setup or cleanup help during meals. Another female resident with dementia, partial paralysis, and a history of failure to thrive was observed struggling to eat independently, with trembling hands and difficulty grasping food items. She was left alone with her meal, which was barely touched, and stated she sometimes received help but not consistently. Her care plan required supervision and cueing during meals, but documentation showed she often ate independently or with minimal assistance. Staff confirmed that supervision and encouragement were needed, but these were not consistently provided.
Failure to Maintain Proper Catheter Positioning and Hygiene
Penalty
Summary
The facility failed to follow its policy and procedures for catheter care by not ensuring that residents' catheters were positioned properly to prevent contamination. For one resident with a history of dementia, Parkinson's disease, traumatic brain injury, chronic kidney disease, urine retention, urinary tract infections, and other conditions, observations showed that the resident was sitting on his catheter tubing, with the tubing and bag placed directly on the floor and the catheter bag lacking a privacy cover. These observations were made on two separate occasions, and the resident's care plan required checking the tubing for kinks each shift. Another resident with a history of dementia, partial paralysis due to stroke, and urinary tract infection was observed in a wheelchair with his catheter tubing and bag dragging and rubbing directly across the floor, with part of the catheter bag exposed from the privacy bag. The resident reported recent groin pain related to the catheter, which resolved after adjustment. The facility's urinary catheter care policy requires that residents not lie on the catheter and that catheter tubing and drainage bags be kept off the floor, but these procedures were not followed for the two residents reviewed.
Failure to Report Facility-Wide Sprinkler System Outage to IDPH
Penalty
Summary
The facility failed to follow its fire watch policy by not reporting to the Illinois Department of Public Health (IDPH) that the sprinkler system was non-functional in all four units of the building. The facility's fire watch policy requires notification of the fire department and other authorities having jurisdiction when the fire protection system is impaired. Although the fire department was notified and fire watch procedures were implemented, the facility did not ensure that IDPH was informed about the full extent and duration of the sprinkler system impairment affecting all units. Multiple incident reports document a series of sprinkler system failures, beginning with a broken pipe that initially affected a vacant unit, followed by additional pipe failures impacting units with residents. The maintenance director confirmed that after a series of leaks and repairs, the entire sprinkler system, including all resident-occupied units, was drained and left non-operational while awaiting parts. Throughout this period, the facility remained on fire watch, with staff conducting building rounds every 30 minutes and logging their activities. The administrator acknowledged responsibility for reporting such incidents to IDPH but could not recall if the most recent report included the critical detail that all four units were without a working sprinkler system or the duration of the outage. The failure to provide this information to IDPH represents a deficiency in following the facility's own fire safety and reporting policies, potentially affecting all 117 residents present at the time.
Medication Order Transcription Errors
Penalty
Summary
The facility failed to properly transcribe a physician's order for Prednisone 60 mg for a resident with multiple diagnoses, including COPD exacerbation. The Director of Nursing (V2) acknowledged that the nurse should have clarified the order with the physician and transcribed it correctly. Instead, the order was incorrectly transcribed as 1 mg on the medication administration record and physician order sheet. Additionally, there was no documentation to support that the pharmacy dispensed the correct dosage of 10 mg and 50 mg tablets to achieve the prescribed 60 mg dose. This lack of documentation and incorrect transcription led to the failure to ensure the resident received the correct dosage of Prednisone. Furthermore, the facility did not complete an order for Norco 7.5mg-325mg for the same resident. The physician order sheet indicated that Norco was to be given as needed for pain, but there was no evidence that the prescription was properly processed and dispensed by the pharmacy. The facility's policy requires that all verbal or telephone orders be read back to ensure accuracy and completeness, including the drug's name, strength, dosage, frequency, and duration. The failure to adhere to this policy resulted in incomplete and potentially inaccurate medication orders for the resident.
Deficiencies in ADL Care and Bathing Documentation
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care to residents, specifically incontinence care and bathing, as observed in four residents. One resident, R6, was found soiled in urine and reported not being changed for several hours, contrary to the care plan that required checking for incontinence every two hours. The Assistant Director of Nursing (ADON) confirmed that staff should be checking and changing residents every two hours and applying skin barrier cream as needed. The facility also failed to ensure residents received showers or bed baths according to their scheduled days. Several residents, including R1, R3, and R4, did not receive the required number of showers or bed baths, and there was a lack of documentation for refusals or interventions. The ADON acknowledged that showers should be documented and that residents should not go more than 1-2 days past their scheduled shower day without some form of bathing. However, there was no documentation of follow-up on shower refusals, and the CNAs often forgot to fill out shower sheets. The facility's policies on shower/tub baths and refusal of care were not followed, as there was insufficient documentation of refusals and interventions. The policies required that refusals be documented in the nurse's progress notes and care plans, but this was not done for the residents reviewed. The lack of adherence to these policies resulted in residents not receiving the necessary care and services to maintain their hygiene and comfort.
Inadequate Supervision During Smoking Breaks
Penalty
Summary
The facility failed to provide adequate supervision during smoking breaks for a resident identified as requiring supervision. On the observed date, three residents were seen smoking outside on the patio without staff supervision, as the activity aide responsible for monitoring them was inside the facility. One resident was noted to have burn holes in his clothing, which he attributed to cigarette ash. Additionally, there was no ashtray available for the residents to use, leading to over 200 cigarette butts being discarded on the ground. A melted flowerpot, used by residents to extinguish cigarettes, was also observed, but this was not reported to the appropriate personnel. The resident in question had a smoking assessment indicating cognitive loss and required supervised smoking times. The facility's policy mandates that residents are supervised during smoking for safety reasons, and staff should monitor for signs of unsafe smoking practices, such as burn holes in clothing. However, the activity director and social services director were not informed of the unsafe conditions, including the melted flowerpot and the large number of cigarette butts on the ground. The lack of communication and supervision led to the deficiency in ensuring a safe environment for residents during smoking breaks.
Resident Subjected to Verbal Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident, identified as R111, from verbal abuse by a staff member, specifically a housekeeper referred to as V27. The incident occurred on June 6, 2024, when V27 entered R111's room to clean and began moving the resident's personal items without consent. Despite R111's request for V27 not to touch his belongings, V27 continued to do so, which led to a verbal altercation. V27 became upset and used profanity towards R111, who responded in kind. The situation escalated when V27 left the room to seek assistance and returned with V6, the Social Service Director, who witnessed V27's continued verbal aggression towards R111. The facility's investigation, completed on June 12, 2024, substantiated the allegations of verbal abuse. The facility's Abuse Prevention Policy, dated February 2017, defines verbal abuse as the use of oral, written, or gestured language that includes disparaging and derogatory terms towards residents. The policy emphasizes the residents' right to be free from abuse and the facility's commitment to preventing such occurrences. Despite these policies, the incident involving R111 and V27 highlights a failure in adhering to these standards, resulting in a substantiated case of verbal abuse.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, affecting one resident out of a sample of 26 reviewed for accommodation of needs and resident safety. On August 13, 2024, at 12:15 PM, a resident, identified as R44, was observed lying in bed with the call light placed on top of his bedside tray table, out of his reach. The resident, who is alert and oriented and able to verbalize needs, reported that a CNA had transferred him back to bed after therapy that morning. He expressed that if he cannot reach his call light, he would yell for help until someone responds. The RN, identified as V24, acknowledged the observation and moved the tray table to place the call light within the resident's reach. The resident, R44, was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, abnormal posture, and lack of coordination. His comprehensive care plan indicates a high risk for falls related to incontinence, paralysis, and unawareness of safety needs, with an intervention to ensure the call light is within reach. The facility's policy on call lights, revised in August 2008, states that when a resident is in bed or confined to a chair, the call light must be within easy reach.
Failure to Post State Ombudsman Program Information
Penalty
Summary
The facility failed to post information, including names, addresses, and telephone numbers of the State Long Term Care (LTC) Ombudsman Program, in a form and manner that is accessible and understandable to residents and their representatives. This deficiency was identified during an observation on August 13, 2024, when a family member of a resident expressed concerns about the care received and was unaware of the State Agency and advocacy groups available for assistance. During rounds with the Social Service Director and the family member, it was observed that there was no posting of the State LTC Ombudsman Program contact information in the front lobby or the Medicare unit where the resident resided. The information was found posted inside the nursing station, which was not visible or accessible to residents and family members. The facility's policy on Resident Rights indicates that all residents have the right to communication with and access to persons and services inside and outside the facility. This includes the posting of names, addresses, and telephone numbers of pertinent State client advocacy groups, such as the State survey and certification agency, the State licensee office, the State ombudsman program, the protection and advocacy network, and the Medicare fraud control unit. The Social Service Director acknowledged that the information should be posted in a visible and accessible location, and a staff member subsequently moved the poster to a more appropriate location beside the meal menu bulletin board. The Administrator was informed of the concern and agreed that the information should be posted visibly and accessibly.
Deficiency in Comprehensive Care Planning for Resident's ADLs and Activities
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R116, affecting their Activities of Daily Living (ADL) and choice of activities. The deficiency was identified through observation, interview, and record review. R116, who was admitted for rehabilitation following a stroke, was only given a shower once since admission, despite being scheduled for showers twice a week. The resident's family member expressed concerns about the lack of motivation for R116 to participate in activities, as he often remained in bed after therapy sessions. During the survey, R116 was observed in a disheveled state, with unkempt hair and beard, indicating a lack of personal hygiene care. The Minimum Data Set (MDS) assessment indicated that R116 was dependent on assistance for most ADLs, yet no care plan was developed to address these needs. The facility's policy requires a comprehensive care plan to be developed within seven days of the MDS assessment, but this was not done for R116. Interviews with facility staff revealed that the scheduled showers for R116 were not documented as required, and the monthly activity schedule was not posted. The Activity Aide completed the resident's assessment but did not develop a care plan, as this was the responsibility of the Activity Director. The facility's policies on care planning and activities were not followed, leading to the deficiency in providing necessary care and services to R116.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement its policy on the prevention of pressure ulcers by not ensuring that a low air loss (LAL) mattress was functioning properly and by not applying bilateral heel protectors as ordered by a physician. This deficiency affected two residents. One resident was observed lying in bed with a deflated LAL mattress, causing him to sink into it. The CNA acknowledged that the mattress was not working properly and should have been checked during rounds. Additionally, the resident was not wearing his bilateral heel protectors as required, with the CNA stating they were removed to give the resident a rest. Another resident was found lying in bed without his bilateral heel protectors, which were instead placed on his wheelchair. The RN confirmed that the heel protectors should be applied when the resident is in bed to prevent pressure ulcers. Both residents were at high risk for pressure ulcers, as indicated by their Braden Scale assessments, and had active physician orders for pressure ulcer prevention interventions, including the use of LAL mattresses and heel protectors. The facility's policy on pressure wound prevention and support surface guidelines were not followed, leading to these deficiencies.
Failure to Provide Diabetic Foot Care
Penalty
Summary
The facility failed to provide adequate foot care and preventive treatment to a diabetic resident, leading to a deficiency in diabetic foot care services. During an observation, a resident was found with long, dirty fingernails and toenails. The resident, who is diabetic, was able to communicate his needs to the staff. A registered nurse acknowledged the condition of the resident's toenails and mentioned that a podiatrist should trim them. However, it was noted that the resident had not been seen by a podiatrist despite being admitted over a month ago with a diagnosis of Type 2 Diabetes Mellitus, among other conditions. The facility's policy on nursing care for residents with diabetes mellitus states that toenails should be trimmed by qualified personnel, which does not necessarily have to be a podiatrist. Additionally, the facility's nail care guidelines emphasize the importance of routine cleaning and trimming to prevent skin problems. Despite these policies, the resident had not received the necessary foot care, as the podiatrist visits the facility twice a month, and the resident had not been scheduled for a visit within a month of admission.
Failure in Pain Management During Wound Care
Penalty
Summary
The facility failed to ensure proper pain management for a resident during wound care procedures. On August 13, 2024, a resident with a dressing on her left foot reported that she had not been given any pain medication before her wound care, despite having a prescription for hydrocodone-acetaminophen and acetaminophen. The resident expressed that her pain level was a 6, indicating significant discomfort. The wound-care nurse stated that the resident did not report pain when asked, but the resident's medication records showed that neither acetaminophen nor hydrocodone-acetaminophen had been administered from August 1 to August 13, 2024, until pain medication was given on August 13, 2024, with a reported pain level of 3. The facility's policy on pain management, revised in August 2008, requires staff to assess and recognize pain in residents, including during wound care. The policy also mandates regular reassessment of pain and its consequences. However, the facility did not adhere to this policy, as evidenced by the lack of pain assessment and medication administration for the resident with a diagnosis of peripheral vascular disease and an arterial/ischemic ulcer. The Director of Nursing confirmed that wound care nurses are expected to inquire about pain before and during wound care, which was not consistently done in this case.
Failure to Monitor Refrigerator Temperatures and Label Food
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of refrigerator temperatures in resident rooms, affecting two residents. Observations revealed that the temperature logs for the refrigerators in the rooms of two residents were not completed on the day of the survey, with the last entries being several days prior. Additionally, food items stored in these refrigerators were not labeled or dated, which is against the facility's policy. The Registered Nurse (RN) was unaware of why the logs were incomplete and acknowledged that food should be labeled to determine when it should be discarded. The Director of Nursing (DON) indicated that certified nurse aides are responsible for monitoring and recording refrigerator temperatures daily. The facility's policy mandates that any food or beverage must be dated and labeled with the resident's name, and any perishable food not consumed after three days should be discarded. However, the observations showed that these procedures were not followed, leading to the deficiency noted in the report.
Deficiency in Personal Hygiene and Grooming Care
Penalty
Summary
The facility failed to ensure that residents received necessary services to maintain good grooming and personal hygiene, affecting two residents. One resident, who was admitted for rehabilitation following a stroke, was only given a shower once since admission, despite being dependent on assistance for most activities of daily living (ADLs). The resident's hair was observed to be disheveled and oily, and he was unshaven with a scraggly beard. The facility's documentation showed that the resident was scheduled for showers twice a week, but records indicated that he only received one shower in August. The Director of Nursing acknowledged that all care and services provided must be documented, and a care plan for the resident's ADL needs was not developed. Another resident was observed with long, dirty fingernails and toenails. This resident, who is diabetic and requires extensive assistance with ADLs, had not received proper nail care. The Registered Nurse confirmed that the resident's fingernails should be trimmed by a nurse, and toenails by a podiatrist. The facility's policy on ADLs and nail care emphasizes the importance of routine cleaning and trimming to prevent skin problems and injuries. However, the facility failed to adhere to these guidelines, resulting in inadequate personal hygiene care for the resident.
Failure to Maintain Clean and Odor-Free Environment in Memory Care Unit
Penalty
Summary
The facility failed to maintain a clean and odor-free environment in the memory care unit, affecting all 21 residents residing there. Observations made on June 14, 2024, revealed strong odors, including urine, near the entrance of the unit and specifically near the rooms of two residents. These observations were corroborated by the Assistant Director of Nursing (V2), who acknowledged the presence of strong odors upon entering the unit and expressed uncertainty about whether the Environmental Manager (V9) had been notified or had taken action to address the issue. The facility's housekeeping policy, reviewed on June 17, 2024, mandates maintaining a clean, odor-free, and comfortable environment in all healthcare and public areas. The policy emphasizes the importance of using accepted practices to keep the facility free from offensive odors, aligning with the residents' rights to a safe and homelike environment. Despite this policy, the facility did not ensure the memory care unit was free of unpleasant odors, as expected by the Assistant Director of Nursing, who noted the importance of a clean environment for both residents and visitors.
Failure to Notify Family of Health Changes
Penalty
Summary
The facility failed to adhere to its policy and procedures for notifying family members of changes in residents' health status and medications. This deficiency was identified through interviews and record reviews, affecting three residents. Resident R4, who had abnormal thyroid hormone levels and a new medication order for hypothyroidism, did not have her emergency contact, V21, notified of these changes. Despite R4's request for her sister to be informed of any health changes, there was no documentation of such notifications in her medical records. Resident R5, who had a history of schizoaffective disorder and other health issues, was found to have a lump in her armpit and abnormal lab results. Orders for a mammogram and new lab tests were made, but her emergency contacts, V22 and V23, were not informed of these significant health changes. R5 expressed a need for physical therapy due to pain, yet there was no record of her family being notified about her condition or the new treatment orders. Resident R7, diagnosed with Alzheimer's disease and other conditions, experienced increased pain and abnormal thyroid lab results, leading to changes in her medication. Her emergency contact, V3, was not informed of these developments, including the increased pain and medication adjustments. The Assistant Director of Nursing confirmed that family members should have been notified of these changes, as per the facility's policy, but acknowledged the lack of documentation and communication with the residents' families.
Failure to Provide Authorized Physical Therapy Services
Penalty
Summary
The facility failed to ensure that a resident received the necessary physical therapy services as assessed and care planned, despite having physician orders in place. The resident, a female with a history of lower back pain, spinal stenosis, generalized muscle weakness, and difficulty in walking, was admitted to the facility for short-term rehabilitation with the goal of returning home. She was discharged from physical therapy in October 2023 due to exhausted benefits, but her insurance later approved 15 additional therapy sessions, which she did not receive because she was not informed of the approval until four days before the sessions expired. The resident expressed her desire to resume physical therapy and reported experiencing significant anxiety over the issue, which discouraged her hope of leaving the facility. She also mentioned discomfort with a male therapist and requested a female therapist, which she felt led to a change in the therapy staff's attitude towards her. Despite her motivation and efforts to work on her rehabilitation independently, the facility did not communicate effectively with her regarding her therapy status, and she was not provided with the approved therapy sessions. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's therapy services. The Assistant Director of Nursing acknowledged that the resident should have received more physical therapy if authorized by her insurance. The Director of Rehab and Physical Therapy Director confirmed the insurance authorization for additional sessions but stated that a reevaluation was required before resuming therapy. The facility could not provide a policy for therapy services, and the Administrator could not explain why the resident was discharged from therapy without waiting for insurance authorization. This lack of communication and failure to provide the necessary therapy services led to the deficiency identified in the report.
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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