Timbercreek Rehab And Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pekin, Illinois.
- Location
- 2220 State Street, Pekin, Illinois 61554
- CMS Provider Number
- 145275
- Inspections on file
- 44
- Latest survey
- March 28, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Timbercreek Rehab And Health Care Center during CMS and state inspections, most recent first.
The facility failed to maintain baseboard heaters safely and to implement an effective system to monitor heater surface temperatures and resident room arrangements, including bed placement, leading to dangerously hot heater surfaces, missing thermostats, and combustible items and beds placed directly against heaters. One cognitively severely impaired, non-verbal hospice resident with multiple comorbidities became entrapped between the bed and a baseboard heater and sustained extensive, painful second-degree burns from the hand to near the shoulder, requiring ED treatment and ongoing wound care. Another moderately cognitively impaired resident’s bed was positioned directly against a hot heater without care plan measures to prevent burns. The Maintenance Director acknowledged the absence of manufacturer operating and preventive maintenance instructions and confirmed there was no established process to monitor or document heater surface temperatures, contributing to the deficiency that placed all residents at risk.
The facility failed to provide QAPI (Quality Assurance and Performance Improvement) training to its staff. Review of the annual in-service schedule and staff in-service and computer-based training records over more than a year showed no QAPI-related education. The census documented 87 residents in the facility, and the Administrator in Training confirmed that staff had not received QAPI training, potentially affecting all residents.
A resident did not consistently receive or have documented pressure ulcer care and daily skin checks as ordered. Multiple dates were missing documentation for wound care and skin checks, and the Infection Preventionist/Treatment Nurse confirmed that unsigned treatments are considered not completed.
A resident did not consistently receive required nephrostomy and urinary catheter care, and staff failed to document urinary output as ordered. Facility records showed that catheter flushes, catheter care, and output monitoring were frequently missed or not performed as scheduled, and care was not always documented or signed out by staff.
Staff did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required by regulation.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
A resident who required pain management did not receive safe and appropriate care as needed, resulting in a deficiency related to pain management services.
A resident with a history of aggression, including schizophrenia and mood disorder, physically struck another resident in the face in a hallway. The incident was witnessed by the DON, and it was documented that the aggressive resident had a known history of both verbal and physical aggression. The facility failed to prevent this physical abuse, as required by policy.
Surveyors found that several resident rooms lacked proper window coverings, had unclean and stained bathrooms, and contained maintenance issues such as a detached heater and missing air conditioning. Staff confirmed that some of these problems had been ongoing and that residents requiring assistance with ADLs were not provided with clean and comfortable environments. The facility's policy requires staff to ensure resident rights, but these deficiencies were observed and verified by staff including an LPN, housekeeper, and the DON.
A resident with severe dementia and a known risk for physical aggression entered another resident's room and struck him multiple times while he was in bed and calling for staff. The incident was witnessed and documented by staff, and the victim reported pain and distress. The facility's abuse prevention policy was not effectively implemented to prevent this resident-to-resident physical abuse.
Staff failed to ensure that several residents consumed their prescribed medications, leaving medication cups unattended at bedsides and tables without verifying ingestion. In one instance, a resident received vitamin gummies without a physician's order. No self-administration assessments were completed, and medications were not administered according to facility policy.
Surveyors found that two residents had inhalers left unsecured at their bedsides, in violation of facility policy requiring medications to be stored in locked compartments. One resident had two unlabeled albuterol inhalers without a current order, while another had a labeled Combivent inhaler at the bedside after administration. An LPN confirmed that these medications should not have been left in the residents' rooms.
A resident sustained fractured ribs after falling from a van during transportation. The incident occurred when the transportation driver mistakenly believed the lift was raised, leading to the resident's wheelchair rolling out of the van. The resident experienced significant pain and was sent to the hospital for evaluation. The driver was terminated for violating safety protocols.
A resident reported not receiving a gift card, leading to an investigation that revealed the Business Office Manager had used the card for personal purchases. The resident had initially consented to the facility opening her mail but later revoked this consent. The Administrator compensated the resident, and the Business Office Manager was dismissed after admitting to the misappropriation.
A resident with a surgical wound on the left stump did not receive daily wound treatments as ordered by the physician. The facility's policy requires daily treatment and documentation, but the Treatment Administration Record showed multiple missed treatments. The resident experienced discomfort and bleeding from the wound, and the Director of Nursing admitted to misreading the order as PRN instead of daily.
A facility failed to follow Enhanced Barrier Precautions and Hand Hygiene policies during wound care for a resident. An LPN entered the resident's room without a gown and did not sanitize hands after removing gloves, despite the resident being under EBP due to an open wound. The Director of Nursing confirmed the need for gowns and hand hygiene in such situations.
A resident with limited mobility and high risk for pressure ulcers developed a new ulcer on the coccyx, which was not promptly assessed or treated by the facility staff. Despite the facility's policy requiring immediate documentation and physician notification, no treatment orders were obtained, and no treatments were recorded for the initial days. The ulcer worsened to an unstageable condition before a wound physician was involved.
The facility failed to implement proper infection control measures for residents with infections and medical devices, as staff did not follow PPE protocols, and necessary signage was missing. This affected residents with conditions like ESBL, MRSA, and those with indwelling catheters and gastrostomy tubes, potentially impacting all 90 residents.
The facility failed to monitor active infections and implement their Antibiotic Stewardship Program, as the DON could not provide necessary logs for the past six months. A change in the DON position contributed to the lack of documentation, potentially affecting all 90 residents.
The facility failed to issue written notifications for hospital transfers upon discharge for several residents. Interviews and record reviews revealed that residents were frequently hospitalized without proper documentation or notification to their representatives. The facility's staff confirmed the absence of a policy and written confirmations for these transfers, indicating a systemic issue in the notification process.
The facility failed to develop comprehensive care plans for several residents, including those with PTSD, heart failure, infections, and those receiving hospice or dialysis services. Care plans were not updated to reflect current diagnoses and needs, such as oxygen therapy and pressure ulcers. The care plan coordinator acknowledged being behind due to heavy admissions, leading to incomplete documentation and potential impacts on resident care.
The facility failed to manage oxygen therapy properly for several residents, lacking physician orders, proper storage of oxygen cylinders, and timely changes of oxygen tubing and humidifier bottles. Observations showed residents using oxygen without documented orders, with cylinders unsecured and tubing undated. Oxygen safety signs were also missing from rooms where oxygen was in use.
The facility failed to accurately complete MDS assessments for two residents. One resident's MDS did not document oxygen use, despite continuous use observed. Another resident's MDS lacked documentation of a wound infection, despite confirmed MRSA and other infections, and the resident being in contact isolation. The MDS Coordinator and resident interviews confirmed these discrepancies.
A facility failed to conduct a PASRR Level II screening for a resident with schizoaffective disorder. The resident's Level I screening incorrectly indicated no mental disorder, despite the diagnosis. The Business Office Manager confirmed the oversight, and the facility lacked a PASRR policy.
A facility failed to include necessary oxygen therapy in a resident's Baseline Care Plan. The resident was observed receiving oxygen via nasal cannula, and the Nurse's Note indicated she arrived with nasal oxygen via concentrator. However, the Baseline Care Plan did not document this need. The Care Plan Coordinator confirmed the omission and noted there was no designated place to mark it, suggesting it should have been manually added.
The facility failed to update care plans for three residents, reflecting changes in their conditions. One resident's care plan did not include changes in gastrostomy feedings or significant weight loss. Another resident's care plan lacked a new diet order, and a third resident's care plan was missing updates for significant weight loss and fall interventions. These deficiencies were confirmed by the MDS and Care Plan Coordinators.
A resident with multiple medical conditions and pressure ulcers did not receive consistent weekly wound assessments or proper hand hygiene during dressing changes. The facility failed to adhere to its policies, resulting in missed wound measurements and improper infection control practices by staff.
A facility failed to investigate a fall and conduct a root cause analysis for a resident identified as high risk for falls. The facility's policy requires an incident report and investigation for all resident accidents, but documentation for the resident's fall was incomplete. The DON confirmed the lack of additional documentation, and the Nurse Manager could not provide further details or evidence of an investigation.
The facility failed to communicate dietician recommendations to the physician and document daily weights for two residents. One resident experienced significant weight loss without the recommended nutritional support being implemented, while another resident with CHF had no daily weights recorded despite a physician order. This lack of documentation and communication compromised the residents' nutritional care.
A facility failed to provide proper gastrostomy tube care and feeding for a resident. The resident's feeding pump was not in use, and the gastrostomy tube dressing was soiled and undated. The LPN admitted to not changing the dressing as required and stated that the resident had not been receiving feedings or flushes since she began eating, pending physician clarification. Documentation inconsistencies were found in the resident's feeding orders and care, with numerous blank entries in the MAR and TAR, and no physician order to discontinue the gastrostomy tube feedings.
A facility failed to comply with its Medication Administration policy by allowing a resident to keep medications at the bedside without a physician's order. The resident had a Stiolto Inhaler and Ipratropium Nasal spray on the overbed table, and a LPN confirmed the practice was based on verbal reports, despite the absence of a documented order.
A resident with known wandering and exit-seeking behaviors left the facility unsupervised and was found three days later on a park bench, requiring hospital evaluation. The facility failed to implement its elopement prevention policy effectively, as there was a lack of documentation and communication regarding the resident's risk. Staff were not adequately informed or trained, and the incident was improperly treated as an unplanned discharge against medical advice.
A facility failed to develop a comprehensive care plan for a resident at high risk for elopement. The resident's care plan lacked documentation of their elopement risk, G-tube, and cervical spine collar care. Despite frequent exit-seeking behaviors, these were not communicated to the care plan nurse, resulting in missing interventions. Staff reported multiple instances of the resident attempting to leave the building, but the care plan was not updated to reflect these needs.
A resident with a history of falls was injured during a transfer when a CNA, who lacked proper training, misjudged the position of a recliner, causing the resident to slide to the floor. The facility failed to ensure adequate supervision and training for staff, leading to the incident and increased pain for the resident.
A resident experienced increased pain and a decline in daily activities due to the facility's failure to provide physician-ordered pain medication and alternative pain management strategies. The resident's pain was exacerbated following a fall, and the facility did not transcribe hospital-recommended pain control measures onto the resident's records.
The facility failed to follow its Abuse Prevention policy by not conducting a background check on a dietary aide with disqualifying criminal offenses. The aide, involved in direct resident care, had convictions for assault and battery, which were not discovered until years after hiring.
Failure to Maintain Safe Baseboard Heaters and Bed Placement Resulting in Severe Resident Burns
Penalty
Summary
The deficiency involves the facility’s failure to maintain baseboard heaters in a safe manner and to implement an effective system to monitor heater surface temperatures and resident room arrangements, including bed placement, to prevent burn hazards and potential fire risks. During a tour, all resident rooms were noted to have six-foot baseboard heaters beneath the windows, with measured surface temperatures as high as 172°F. In one room, a stuffed animal pillow was resting directly on top of the heater and a bag was positioned immediately adjacent to it; in another room, a window curtain was draped over the heater. In multiple rooms, thermostats were missing from the heaters, and one resident’s bed was positioned directly against the heater, with the resident’s hand and arm within reach of the hot surface. The resident, who was hard of hearing, stated that the heater gets very hot. The surveyor found the heater surface too hot to safely touch. The facility’s Maintenance Director confirmed that the facility did not maintain the manufacturer’s operating and preventive maintenance instructions for the baseboard heaters, including the parts list with component descriptions and the air-balance report, and that a complete set of these documents was not available on-site. He also stated that he had not previously monitored or documented the surface temperatures of baseboard heaters or heater covers and was not aware of any established process for doing so. Following a burn incident involving a resident, he reported conducting only a visual inspection of all heaters to identify units needing repair or replacement and measuring the surface temperature of only four heaters, confirming that no formal process for routine temperature monitoring had been implemented. The Administrator-in-Training verified that curtains, personal items, and residents should be kept approximately 12 inches from the heaters to prevent burns and fire hazards and acknowledged that the facility did not have the manufacturer’s operating and preventive maintenance instructions. One resident involved in the incident was an older adult with diagnoses including hemiplegia, convulsions, respiratory failure, type II diabetes mellitus with diabetic hemiplegia, chronic kidney disease stage III, depression, and dementia with anxiety. This resident was cognitively severely impaired and dependent or required extensive assistance for all ADLs, received hospice care, and had no signs or symptoms of pain prior to the burn incident. A CNA reported that around midnight she was unable to turn the resident because the resident’s arm was stuck between the bed and the baseboard heater; when she moved the bed, she observed a large burn up and down the resident’s left arm and immediately notified the nurse. Progress notes and emergency room documentation describe partial-thickness, second-degree burns with blistering extending from the pinky finger up the arm to near the shoulder, requiring emergency treatment and ongoing painful wound care. The coroner stated that the resident was non-verbal and could not have yelled for help when being burned and characterized the situation as neglectful of the facility to have allowed the burns to reach that severity. Another resident whose room was observed during the survey was moderately cognitively impaired, with a care plan that did not include measures to keep the resident at a safe distance from the baseboard heater or to protect from burns. This resident’s bed was positioned directly against a heater with a missing thermostat, and the resident’s right hand and arm were within reach of the heater surface. Across multiple rooms, the combination of high heater surface temperatures, missing thermostats, lack of manufacturer guidance, absence of a monitoring system for heater temperatures, and unsafe placement of beds and combustible items near heaters constituted the actions and inactions that led to the identified deficiency. These failures resulted in a resident becoming entrapped between the bed and a baseboard heater and sustaining painful burns that required emergency room treatment, and had the potential to affect all 87 residents residing in the facility.
Removal Plan
- Positioned all residents and their beds at a safe distance from baseboard heaters.
- Obtained and documented surface temperatures of all baseboard heaters in all resident rooms and verified all were below 140°F.
- Obtained manufacturer guidelines for baseboard heaters to ensure safe operation and compliance with recommended safety standards.
- Educated the Maintenance Director to ensure baseboard heaters do not exceed 140°F and to routinely monitor and document temperatures for ongoing compliance.
- Educated all department heads to ensure resident beds are never lowered or pushed against baseboard heaters when in use; implemented and posted a visual guide showing the appropriate safe distance between beds and heaters.
- Educated all licensed nurses to ensure resident beds are never lowered or pushed against baseboard heaters when in use.
- Educated all CNAs and unlicensed staff to ensure resident beds are never lowered or pushed against baseboard heaters when in use.
- Implemented a process to ensure room assignments are appropriate for the number of residents in each room to allow safe placement away from environmental hazards, including baseboard heaters.
- Conducted a facility-wide audit to identify additional risks related to heater placement and bed positioning; immediately corrected concerns and updated resident care plans accordingly.
- Implemented environmental temperature rounds to ensure baseboard heater temperatures are 140°F or below.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to all employees as required. Record review showed that the Midnight Census Report dated 3/24/26 documented 87 residents residing in the facility. Review of the facility’s Annual In-Service Schedule revealed that it did not include any in-servicing regarding QAPI. Additionally, review of Staff In-Services and Computer Based Training records dated from 3/1/25 through 3/28/26 showed no evidence that QAPI training had been provided. On 3/28/26 at 9:50 AM, the Administrator in Training confirmed that facility staff had not received QAPI training. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency, only that all 87 residents had the potential to be affected.
Failure to Document and Complete Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to perform pressure ulcer care and daily skin checks as ordered for one resident with a pressure injury. According to the facility's policy, wound care and skin checks must be documented in the electronic medical record when completed. Review of the resident's Treatment Administration Record showed multiple dates where the prescribed wound care for the left heel and daily skin checks were not signed out as completed. The resident reported that wound care was performed at least daily, but the documentation was inconsistent. The Infection Preventionist/Treatment Nurse confirmed that if treatments are not signed out, they are considered not completed as ordered, and any refusals should be documented in the progress notes.
Failure to Provide and Document Required Catheter and Nephrostomy Care
Penalty
Summary
The facility failed to provide appropriate nephrostomy and urinary catheter care, as well as to document urinary output as ordered, for one resident reviewed for bowel and bladder care. According to the facility's policy, catheter care and nephrostomy tube care were to be completed every day and night shift, and urinary output was to be recorded every shift. However, documentation showed that catheter flushes, catheter care, nephrostomy care, and output monitoring were frequently missed or only completed once daily instead of twice, and in some instances not done at all on certain days. The resident was unsure if care was being performed as required. The Infection Preventionist/Treatment Nurse confirmed that if care was not signed out, it was not completed as ordered, and that refusals should be documented in the progress notes, which was not consistently done.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements for daily nursing staff coverage and supervision by a licensed nurse on all shifts.
Failure to Provide Safe, Appropriate Pain Management
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate pain management for a resident who required such services. The report indicates that the facility failed to ensure that a resident in need of pain management received care that met professional standards for safety and appropriateness. Specific details about the resident's medical history, the nature of their pain, or the exact actions or omissions by staff are not provided in the report.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with diagnoses including schizophrenia, mood disorder, anxiety, depression, schizoaffective disorder, and mild intellectual disabilities was identified as having the potential to be physically and verbally aggressive, as documented in their care plan. Despite this known risk, the resident was involved in an incident where they struck another resident in the face with a closed fist while in the hallway near the front lobby. The altercation was witnessed by the Director of Nursing, who confirmed the aggressive behavior and noted the resident's history of both verbal and physical aggression toward staff and other residents. The facility's policy requires that all residents be protected from abuse, including abuse by other residents. However, the incident demonstrates a failure to protect one resident from physical abuse by another, as the aggressive resident was able to physically strike another resident. Both residents were separated and debriefed after the incident, and it was documented that neither sustained injuries. The event was recorded as an allegation of abuse, and the relevant parties were notified.
Failure to Maintain Clean, Safe, and Homelike Resident Rooms
Penalty
Summary
Surveyors observed multiple deficiencies related to the maintenance and cleanliness of resident rooms, as well as the provision of a homelike environment. In one room, two residents had a window with no blinds and a curtain that could not be closed, a baseboard heater detached and lying on the floor, and a bathroom floor with a thick brown stain around the baseboards and toilet. Staff confirmed that the window had never had working blinds or curtains and that the bathroom floor had always been stained. Another resident's room was found with two cardboard boxes taped over the window using silver tape, reportedly to block out hot or cold air, as the blinds were ineffective. The Maintenance Director stated that repairs had not been made due to lack of funding. Additionally, a resident's room had a strong urine odor, a full urinal left on the bedside table, no fitted sheet on the bed, and a sticky, dirty floor. This resident had a diagnosis of schizophrenia and required staff assistance with activities of daily living and personal hygiene, as documented in the care plan. Further observations included a resident room without an air conditioning unit, with a recorded temperature of 76 degrees. Staff confirmed that temperature checks were not being conducted and that the room did not have central air conditioning, as the window unit had been removed and not replaced. The resident in this room had a documented preference for a very cold environment and had previously complained about the room being too hot. The facility's Resident Rights policy requires staff to provide services and advocate for resident rights, but these observations indicate failures to maintain clean, safe, and comfortable living conditions for several residents.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with dementia and a history of physical aggression entered the room of another resident who was in bed and began to swat and hit him multiple times on the arm, side of the face, and head. The resident who was attacked had been calling out for staff assistance, as he sometimes does when he forgets to use the call light. The aggressor, who was severely cognitively impaired according to her most recent assessment, left the room after the incident, and staff responded after being alerted by the victim. The incident was documented in multiple records, including incident reports, nursing notes, and interviews with both the residents and staff. The victim reported being upset and in pain from the physical contact, though no visible injuries such as cuts were noted. Staff confirmed that physical contact was made and that the aggressor had a known potential for physical aggression related to her dementia and anxiety diagnoses. The facility's abuse prevention policy prohibits all forms of abuse, including resident-to-resident abuse, and requires staff to protect residents from such incidents. Despite this, the event occurred, indicating a failure to prevent abuse as required by policy. The aggressor's care plan had identified her risk for physical aggression, but the measures in place were insufficient to prevent her from entering another resident's room and causing harm.
Medications Left Unattended and Administered Without Orders
Penalty
Summary
The facility failed to ensure that residents consumed their medications as prescribed and according to facility policy. Multiple residents were observed with medication cups containing their scheduled morning medications left at their bedsides or on tables, with no staff present to verify ingestion. In several cases, residents had not yet taken their medications, were unsure of the contents, or were handling the medications themselves. The facility's policy requires staff to observe residents consuming medications and prohibits leaving medications unattended unless there is a specific physician's order for self-administration, which was not present for any of the residents involved. Additionally, one resident was found with a medication cup containing gummies identified as vitamin/supplement products, for which there was no physician's order documented. The LPN confirmed the nature of the gummies and the absence of a doctor's order. The Director of Nursing acknowledged that none of the residents had been assessed for self-administration of medications, and that medications should not have been left with the residents. These actions and inactions resulted in the facility not following its own medication administration policy and failing to ensure medications were administered and consumed as ordered.
Improper Storage and Labeling of Inhalers
Penalty
Summary
Surveyors observed that two residents had inhalers improperly stored at their bedsides, contrary to facility policy requiring all medications to be kept in locked compartments unless refrigeration is needed. One resident had two albuterol inhalers with over 100 doses each on the bedside table, neither of which was labeled with a name or dispensing date, and there was no current physician order for these inhalers. The LPN confirmed the resident previously had an order for the inhalers but should not have had them in the room at the time of observation. Another resident had a Combivent inhaler at the bedside, which was labeled with the resident's name and pharmacy information, and had been administered earlier that day according to the Medication Administration Record. The LPN also confirmed this inhaler should not have been left in the room.
Resident Injury Due to Transportation Error
Penalty
Summary
The facility failed to ensure the safety of a resident during van transportation, resulting in a fall and injury. The incident involved a resident who was being transported in a handicap van. During the unloading process, the transportation driver mistakenly believed that the lift was raised when it was not, leading to the resident's wheelchair rolling out of the van and the resident falling to the ground. This resulted in the resident sustaining fractured ribs and experiencing significant pain. The resident, who was in a wheelchair, was being transported along with another resident. The transportation scheduler and driver were involved in the unloading process. The scheduler had lowered the lift to unload the first resident and then moved them to a safe location. However, the driver, assuming the lift was raised, proceeded to unhook and roll the second resident, leading to the fall. The driver realized the mistake only when the resident hit the ground, indicating a lack of proper communication and verification between the staff members involved. The resident was sent to the hospital for evaluation, where it was confirmed that they had sustained rib fractures. The transportation driver was later terminated for violating van safety protocols. The facility's Fleet Safety Program outlines the importance of following safety procedures, but in this case, human error and a lack of awareness led to the incident.
Misappropriation of Resident Funds by Facility Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of funds, as evidenced by an incident involving a gift card. A resident reported that she had not received a gift card she was expecting in the mail. Upon inquiry, she discovered that she had previously signed a document allowing the facility to open her mail, which she then revoked. The resident expressed her concerns to the Business Office Manager and subsequently to the Administrator, who apologized and compensated her with cash equivalent to the gift card's value. An investigation was conducted by a business office manager from a sister facility, which revealed that the Business Office Manager had used the resident's gift card for personal purchases. The Business Office Manager admitted to this misappropriation, leading to their dismissal from the facility. This incident highlights a failure in the facility's abuse prevention program, which is designed to protect residents from exploitation and misappropriation of their property.
Failure to Complete Daily Wound Treatments
Penalty
Summary
The facility failed to adhere to physician-ordered wound treatments for a resident with a surgical wound on the left stump. The facility's policy mandates that wound treatments be completed daily and documented on the Treatment Administration Record (TAR). However, the resident's TAR for October and November 2024 showed multiple instances where the daily wound treatments were not completed as ordered. Specifically, the treatments were missed on several dates in October and on November 1st. During an observation on November 4, 2024, the resident's wound was noted to be red, with minimal swelling, and actively bleeding, causing discomfort to the resident. The resident reported that the wound dressing changes were not performed daily, as required. The Director of Nursing acknowledged the oversight, stating that the order was misread as PRN (as needed) instead of daily, leading to the failure in providing the necessary wound care.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) and Hand Hygiene policies during wound care for a resident. The EBP policy requires the use of a gown and gloves during high-contact resident care activities, such as wound care, to prevent the transfer of multidrug-resistant organisms (MDROs). However, an LPN entered the resident's room without wearing a gown, despite the resident being under EBP due to an open wound requiring dressing changes. The LPN performed wound care without following the necessary precautions, including not sanitizing hands or wearing a gown, which are critical steps outlined in the facility's policies. Additionally, the LPN did not follow proper hand hygiene protocols. After removing gloves, the LPN left the room to retrieve supplies and returned without sanitizing or washing hands before donning new gloves. This oversight occurred despite the facility's Hand Hygiene Policy, which mandates handwashing or the use of alcohol-based hand rubs in specific situations, such as after glove removal and before direct resident care. The Director of Nursing later confirmed that staff should wear gowns and gloves in EBP rooms and practice hand hygiene consistently.
Failure to Initiate Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to assess and promptly initiate treatment for a pressure ulcer identified on a resident, leading to the ulcer worsening to an unstageable condition. The facility's Decubitus Care/Pressure Area Policy requires that pressure areas be assessed and documented, with physician notification for treatment orders. However, when a nurse identified a new pressure ulcer on the resident's coccyx, no physician orders for treatment were documented, and no wound treatments were recorded on the Treatment Administration Record for the initial days following the ulcer's identification. The resident, who had a history of cerebral infarction, aphasia, and other conditions, was at high risk for pressure ulcers due to limited mobility and other factors. Despite this, the initial wound assessment and treatment plan were not completed until two days after the ulcer was first noted, by which time the wound had worsened significantly. The wound physician confirmed that the staff did not contact him until the treatment was started, indicating a delay in addressing the resident's condition.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for six residents, potentially affecting all 90 residents. The facility's policies on Contact Precautions and Enhanced Barrier Precautions (EBP) were not followed, as evidenced by the lack of signage and personal protective equipment (PPE) usage. For instance, a resident with an ESBL infection did not have a contact isolation sign on their door, and staff did not wear gowns during catheter care, contrary to the facility's policy. Another resident with a stage 3 pressure ulcer did not have PPE available in their room, and staff did not wear gowns during wound care. Similarly, a resident with an indwelling urinary catheter did not have Enhanced Barrier Precautions signage, and their care plan lacked documentation of catheter care orders. Additionally, a resident with multiple infections, including MRSA, had a contact precautions sign on their door, but staff did not adhere to the required PPE protocols, and there was no soap or hand sanitizer available in their room. Further deficiencies were noted with residents having gastrostomy tubes and urinary catheters, where Enhanced Barrier Precautions were not in place, and staff did not wear gowns or masks during care. The Director of Nursing confirmed the absence of enhanced barrier precautions for any resident in the facility, despite the policy requirements. These failures indicate a systemic issue in adhering to infection control protocols, posing a risk to resident safety.
Failure to Monitor Infections and Implement Antibiotic Stewardship
Penalty
Summary
The facility failed to monitor active infections and implement their Antibiotic Stewardship Program, which is designed to optimize the treatment of infections and reduce adverse events associated with antibiotic use. The facility's policy on Infection Control Surveillance and Monitoring, last reviewed in December 2018, outlines the responsibilities of the Administrator, ICP, and DON in conducting routine surveillance and monitoring to ensure compliance with work practices and the proper use of protective clothing and equipment. However, during the survey, the DON was unable to provide antibiotic stewardship logs or infection control logs for the past six months, indicating a lapse in the facility's infection control practices. Interviews with facility staff revealed that there was a change in the DON position, which may have contributed to the lack of documentation and monitoring. The AIT acknowledged the absence of the previous DON and the challenges faced in tracking infection control and antibiotic stewardship. The failure to maintain proper logs and documentation has the potential to affect all 90 residents currently residing in the facility, as it hinders the facility's ability to effectively manage and monitor infections and antibiotic use.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to provide written notifications of hospital transfers upon discharge for four residents who were hospitalized. This deficiency was identified through interviews and record reviews. For instance, one resident's census list documented multiple hospital unpaid leave dates, yet there was no written notification issued for these hospitalizations. Another resident was admitted to a local hospital and returned to the facility, but there were no nursing progress notes documenting the hospitalization. Additionally, a resident reported frequent hospital visits since admission, but no written notifications were provided for these transfers. The facility's social services worker confirmed that no written notices were given to residents' representatives regarding hospital transfers. The administrator in training also acknowledged the absence of a specific policy for handwritten hospital discharge notifications and the lack of written confirmation for hospital transfers or discharges over the past six months. This indicates a systemic issue in the facility's process for notifying residents and their representatives about hospital transfers and discharges.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for eight residents, as required by their policy. The care plans were not updated to reflect the residents' current diagnoses and needs. For instance, one resident with PTSD did not have their condition or triggers documented in their care plan, despite being cognitively intact and expressing the impact of loud noises on their anxiety. Another resident with heart failure and an order for oxygen therapy did not have their oxygen use documented in their care plan, even though an oxygen concentrator was present in their room. Additionally, the facility did not include necessary care plans for residents with specific medical needs. One resident with a left hip wound infection did not have an infection care plan, and another resident receiving dialysis services lacked a dialysis care plan. Furthermore, a resident receiving hospice services did not have a hospice care plan, and a resident with pressure ulcers did not have a pressure ulcer care plan documented. The facility's care plan policy requires a comprehensive care plan to be developed within seven days of completing the resident assessment. However, one resident only had a baseline care plan, and the care plan coordinator admitted to being behind due to heavy admissions. This lack of timely and accurate documentation in care plans indicates a systemic issue in maintaining up-to-date and comprehensive care plans for residents, potentially impacting their care and well-being.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to ensure proper respiratory care for residents requiring oxygen therapy, as evidenced by the lack of physician orders, improper storage of oxygen cylinders, and failure to change and date oxygen tubing and humidifier bottles. Observations revealed that several residents were using oxygen without documented physician orders, and oxygen cylinders were found free-standing on the floor, not secured in a cart or holder, contrary to the facility's policy. Additionally, oxygen tubing and humidifier bottles were not changed weekly as required, with some dated as far back as July, and others not dated at all. Furthermore, oxygen safety signs were not posted on the doors of rooms where oxygen was in use, which is a requirement according to the facility's policy. Specific instances included residents with undated or outdated oxygen equipment, empty humidifier bottles, and unsecured oxygen cylinders. The Director of Nursing acknowledged these deficiencies, stating that oxygen tubing should be dated when changed and that oxygen cylinders should be stored securely, either in a resident's room in a holder or in a locked storage area.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. For one resident, the MDS assessments dated March and June did not indicate the use of oxygen, despite the resident being observed with oxygen infusing via nasal cannula. The MDS Coordinator confirmed that the resident's MDS should have documented oxygen use if it was continuous or used during the assessment period, but no documentation was provided to prove otherwise. Another resident's MDS assessments from March and June failed to document a wound infection, despite the resident being in contact isolation for MRSA and other infections since admission. The resident's laboratory culture results confirmed a heavy growth of MRSA, and the resident was on antibiotics for the infection. The resident reported that their wounds were checked upon admission, but no re-testing had been conducted to determine if the infection persisted.
Failure to Conduct PASRR Level II Screening for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to ensure a PASRR Level II screening for mental disorder was completed for a resident reviewed for PASRRs. The resident was admitted with a diagnosis of schizoaffective disorder, as documented in the Physician Order Sheet dated 5/8/23. However, the resident's PASRR Level I Screen Outcome, dated 5/1/23, indicated that no Level II was required, citing situational symptoms and low-level behavioral health symptoms. The facility was unable to produce a PASRR policy, and the Business Office Manager confirmed that the resident transferred with a Level I screening that incorrectly stated no mental disorder was present, despite the schizoaffective disorder diagnosis. This oversight led to the failure to conduct a necessary Level II evaluation.
Omission of Oxygen Therapy in Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a resident's Baseline Care Plan included necessary oxygen therapy. The resident was observed in her room with oxygen being administered via nasal cannula. According to the Nurse's Note, the resident arrived at the facility with nasal oxygen via concentrator. However, the Baseline Care Plan did not document the need for oxygen or any related care. The Care Plan Coordinator confirmed that the Baseline Care Plan lacked documentation for oxygen and acknowledged that there was no designated place to mark it on the care plan sheet, indicating it should have been written in manually.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to revise the care plans for three residents, R38, R41, and R43, to reflect their current conditions, as required by their Comprehensive Care Planning policy. For R38, the care plan was not updated to include changes in gastrostomy feedings, pleasure feedings, or significant weight loss, despite a physician's order to decrease gastrostomy feedings and a documented weight loss of 22.86% from June to August 2024. The MDS Coordinator and Care Plan Coordinator confirmed that R38's care plan did not reflect these changes. Similarly, R43's care plan was not revised to include a new physician-ordered mechanical soft diet. Additionally, R48 experienced an 18.37% weight loss and an unwitnessed fall, yet the care plan was not updated to include these significant changes or the fall interventions. The MDS Coordinator and Care Plan Coordinator confirmed that R48's care plan lacked these updates. These deficiencies indicate a failure to maintain accurate and current care plans for residents, as required by the facility's policies.
Deficiencies in Pressure Ulcer Care and Hand Hygiene
Penalty
Summary
The facility failed to properly assess and monitor pressure ulcers weekly and did not adhere to hand hygiene protocols during dressing changes for a resident with multiple medical conditions. The resident, who has a history of Spinal Bifida, Paraplegia, and other chronic conditions, was admitted with pressure ulcers on the right buttock and left lateral hip. Despite physician orders for weekly skin documentation and daily dressing changes, the facility did not consistently document wound assessments or measurements, particularly missing entries for specific weeks. Additionally, the facility's staff did not follow proper hand hygiene procedures during dressing changes. An LPN was observed changing the resident's dressings without performing hand hygiene between glove changes, and used the same soiled gloves to handle community use wound care supplies. This practice was confirmed by the LPN as her usual method for dressing changes, and the DON acknowledged that hand hygiene should be performed between glove changes. The resident expressed concerns about the inconsistency of dressing changes and the lack of retesting for infections in the wounds. The facility's DON and Nurse Manager confirmed the absence of some wound measurements and acknowledged the need for improved wound care management. The facility's policies on pressure ulcer care and hand hygiene were not adhered to, contributing to the deficiencies observed.
Failure to Investigate Resident Fall and Conduct Root Cause Analysis
Penalty
Summary
The facility failed to investigate a resident fall and conduct a root cause analysis for a resident identified as R48, who was reviewed for falls in a sample of 37 residents. According to the facility's Accidents and Incidents policy, all accidents involving a resident require an incident report and an investigation by the interdisciplinary team to determine the root cause and implement appropriate interventions. R48 was assessed as a high risk for falls, with a Fall Risk Assessment score of 21. A Quality Care Reporting Form documented an alleged fall for R48, but it lacked details about the incident. Physician Progress Notes did not include any follow-up information regarding the fall. The Director of Nursing confirmed that there was no additional documentation for R48's fall, and the Nurse Manager was unable to provide further details or evidence of an investigation being completed for the incident.
Failure to Communicate Dietician Recommendations and Document Weights
Penalty
Summary
The facility failed to ensure that the recommendations made by the Registered Dietician (RD) were communicated to the physician and documented appropriately for two residents. For one resident, identified as R48, the facility's records showed a significant weight loss of 18.37% from June to August. The RD recommended a Med Pass Supplement (MPS) to support nutrition and weight gain, but this recommendation was not signed or dated by the resident's Primary Care Physician (PCP) and was not included in the Medication Administration Record (MAR). Additionally, the Physician Orders Sheet (POS) did not reflect any dietary supplement orders, and the physician notes did not address the resident's diet or weight loss. Another resident, identified as R41, had a physician order for daily weights due to Congestive Heart Failure (CHF), but the MAR did not document these daily weights. The resident reported only being weighed at dialysis sessions, not daily as required. The Licensed Practical Nurse (LPN) confirmed that the MAR indicated an order for daily weights, which were not documented. This lack of documentation and communication regarding the residents' nutritional needs and weight monitoring contributed to the facility's failure to maintain adequate nutrition and health for these residents.
Failure to Provide Gastrostomy Tube Care and Feeding
Penalty
Summary
The facility failed to provide gastrostomy feeding per order and appropriate gastrostomy tube care for a resident, identified as R43, who was reviewed for enteral feedings. Observations revealed that the enteral feeding pump was not in use, and the resident's gastrostomy tube dressing was soiled and undated. The resident reported that the feeding pump was no longer used as she could eat food now, and she could not recall when the dressing was last changed. The Licensed Practical Nurse (LPN) admitted to not changing the dressing as required and stated that the resident had not been receiving feedings or flushes since she began eating, pending clarification from the physician. The Registered Dietician's notes indicated that the resident was on tube feeding for nutritional needs, with specific recommendations for feeding and water flushes. However, the Physician Order Sheet (POS) and Medication Administration Record (MAR) showed inconsistencies and omissions in documenting the resident's feeding orders and care. The MAR had numerous blank entries, indicating missed feedings, and there was no documented order to discontinue the gastrostomy tube feedings. Additionally, the Treatment Administration Record (TAR) showed many blank entries for gastrostomy tube care. Despite a dietary note suggesting the discontinuation of the G-tube, there was no physician order confirming this action, leading to a lack of clarity and proper care for the resident's gastrostomy tube needs.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were not left at a resident's bedside, specifically for one resident (R17) out of 19 reviewed for medication storage. The facility's Medication Administration policy, revised on November 18, 2017, clearly states that medications should not be left unattended or at the bedside unless specifically ordered by a physician. On August 4, 2024, it was observed that R17 had a pharmacy-labeled Stiolto Inhaler and Ipratropium Nasal 0.06% spray on the overbed table. R17 stated that they were allowed to self-administer these medications. However, the August 2024 Physician Order Sheet for R17 did not include any order permitting medications to be kept at the bedside. On August 6, 2024, a Licensed Practical Nurse (V25) confirmed that R17 was allowed to keep the nasal spray and inhaler at the bedside based on verbal reports, but acknowledged that there should be a doctor's order for it, which was not found in R17's clinical chart.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent a resident with known wandering and exit-seeking behaviors from leaving the facility without staff supervision. The resident, who had a history of severe mental illness, brain injury, and was dependent on staff for activities of daily living, was last seen by staff in the facility and was found three days later on a park bench, approximately two and a half miles from the facility. The resident required transportation to a local hospital for evaluation and treatment after being exposed to high temperatures. The facility's elopement prevention policy was not effectively implemented, as evidenced by the lack of a resident information sheet and photograph for the resident in the elopement risk binder. Additionally, the facility's missing resident policy was not adequately followed, as there was a delay in notifying law enforcement and the resident's family, and the facility did not conduct a thorough search or investigation into the resident's disappearance. Staff members were not adequately informed of the resident's exit-seeking behaviors, and there was a lack of documentation regarding the resident's elopement risk and the events surrounding the incident. The facility's failure to maintain accurate and complete records, including nursing notes and behavior tracking sheets, contributed to the deficiency. The resident's care plan did not reflect their exit-seeking behaviors, and staff were not adequately trained or informed about the resident's risk for elopement. The facility's response to the incident was inadequate, as they treated the resident's disappearance as an unplanned discharge against medical advice, rather than an elopement, and did not report the incident to public health authorities.
Removal Plan
- R1's, R2's, R3's and R4's Elopement Assessment and Care Plans were reviewed and updated accordingly.
- All Resident's Elopement Assessments were reviewed and updated, and Residents at Risk Plan of Cares were reviewed and updated.
- All Staff were in-serviced on Elopement Policy and Abatement Plan. (Door Alarm Policy and Elopement Prevention Policy)
- Weekly Door Alarm Testing was initiated.
- Quarterly QA Meeting reviewed.
- Notification of the Allegation of Immediate Jeopardy to the Medical Director was completed.
- The Elopement Binder was reviewed. Elopement Prevention Policy, Missing Resident Policy, Door Alarm Policy, Investigate Report of Missing Resident Form and Emergency Codes were reviewed.
- Continue to monitor R2, R3 and R4 and other high-risk for elopement residents.
- Monitor Residents with potential to be affected by the alleged deficient practice: All residents who have the ability to exit a door without assistance have the potential to be affected by this alleged deficient practice.
- The Facility (V15//Social Services and V16/Care Plan/Minimum Data Set/MDS) will review immediate actions and changes to Facility systems and review/update all elopement assessments on all residents.
- V2 (DON) and V16 (Care Plan/MDS) will review and update all Care Plans for elopement related to supervision and monitoring.
- V3 (Maintenance Director) will check door alarm functionality and review all doors and alarms and ongoing weekly by V3.
- V15 (Social Service Director) will review/update the Facility elopement books.
- V2 (DON) to complete training/educate staff with Staff on the Elopement Policy, monitor the door alarms, and identify Residents at risk for elopement. All staff will complete in-service prior to working the floor to work.
Failure to Develop Comprehensive Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident identified as high risk for elopement. The facility's policies require that the interdisciplinary team initiate a care plan for residents at high risk for elopement, including specific measures to minimize risk factors. However, the resident's care plan did not document the resident's elopement risk, enteral Gastrostomy Tube (G-tube), perineum medicated ointment application, or cervical spine collar care. Despite the resident's frequent attempts to exit the building and setting off door alarms, these behaviors were not communicated to the care plan nurse, resulting in the absence of necessary interventions in the care plan. Interviews with facility staff revealed that the resident had a history of exit-seeking behaviors and had previously eloped from the facility. Staff members, including a CNA and the housekeeping supervisor, reported multiple instances of the resident attempting to leave the building and requiring redirection. The care plan nurse admitted to not being informed of the resident's exit-seeking behaviors and acknowledged that the care plan was not updated to reflect the resident's needs. The lack of communication and failure to update the care plan contributed to the deficiency in providing adequate care for the resident.
Failure to Prevent Falls and Provide Adequate Supervision
Penalty
Summary
The facility failed to prevent accidents and falls with injury for a resident (R1), resulting in the resident requiring hospital evaluation and treatment for injuries. The facility's fall prevention policy and mechanical lift policy were not adequately followed. Specifically, the resident, who had a history of falls and required assistance with transfers, was being transferred by a single CNA using a sit-to-stand lift. The CNA misjudged the position of the recliner, causing the resident to slide to the floor, resulting in pain and injury. The resident's care plan required two staff members for transfers, but this was not adhered to during the incident. The incident was witnessed by the resident's roommate and corroborated by the resident's daughter and the CNA involved. The CNA did not receive proper in-service training on the facility's mechanical lifts, and the facility relied on staffing agencies to provide such training. The facility's Director of Nursing (DON) admitted that the CNA should not have been performing the transfer alone and acknowledged that the incident was not thoroughly investigated as a fall. The resident experienced increased pain following the incident and had to use a full mechanical lift for transfers, which did not fit into the bathroom, necessitating the use of a bedpan. The facility's failure to provide adequate supervision and training for staff, particularly agency staff, contributed to the incident. The resident's complaints about pain and the lack of timely assistance were documented, but no corrective actions were taken. The facility's reliance on agency staff without ensuring they were properly trained on the facility's equipment and procedures led to the deficiency, resulting in harm to the resident.
Failure to Provide Pain Management
Penalty
Summary
The facility failed to provide physician-ordered pain medication and manage pain for a resident (R1), resulting in increased pain and a decline in the resident's activities of daily living. The facility's policy on pain prevention and treatment was not followed, as evidenced by the lack of administration of the prescribed pain medication Norco on multiple occasions. Additionally, the facility did not implement alternative pain management strategies such as ice or heat application, as recommended by the hospital after R1's fall and subsequent visit to the emergency department. R1's medical history includes a history of falls, hypertension, congestive heart failure, neuropathy, osteoarthritis, hyperlipidemia, diabetes, left hip pain, and dependent edema. After a fall incident involving a sit-to-stand lift, R1 experienced increased pain in the back and legs. Despite the hospital's recommendation for pain control measures, the facility did not transcribe these orders onto R1's medication or treatment administration records. This oversight led to R1 experiencing significant pain without appropriate intervention. Interviews with R1, R1's daughters, and R1's roommate revealed that R1 was in excruciating pain following the fall and that the facility ran out of the prescribed pain medication, leaving R1 without pain relief for an entire day. The facility staff, including the Director of Nursing and a Licensed Practical Nurse, acknowledged the failure to provide the necessary pain management and the lack of communication with the physician to seek alternative pain relief options.
Failure to Conduct Background Checks on Dietary Aide
Penalty
Summary
The facility failed to follow their Abuse Prevention policy by not performing a health care worker background check and not obtaining a fingerprint-based criminal history check for an unlicensed dietary aide, who had two disqualifying criminal offenses. The dietary aide, hired in 2018, had convictions for assault and battery, which were not discovered until a background check was finally conducted in 2024. The facility's policies clearly state that no staff with disqualifying criminal offenses should be employed unless a waiver is granted, which was not the case here. The Administrator-In-Training admitted to not running the necessary background checks, which would have revealed the disqualifying convictions. The dietary aide was involved in direct resident care activities, such as recording food intake and responding to residents' requests, which could have put residents at risk. The Dietary Manager was unaware of the aide's criminal history, highlighting a significant lapse in the facility's hiring and monitoring processes.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
