Warren Barr Buffalo Grove
Inspection history, citations, penalties and survey trends for this long-term care facility in Buffalo Grove, Illinois.
- Location
- 150 North Weiland Road, Buffalo Grove, Illinois 60089
- CMS Provider Number
- 145819
- Inspections on file
- 34
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Warren Barr Buffalo Grove during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia and multiple sclerosis, whose care plan directed that all information be given to her advocate, was started on Losartan for newly diagnosed HTN without prior notification of her health care POA. The POA, who visited frequently and had repeatedly requested to be informed of any changes including medications, only learned of the new antihypertensive from a cardiology NP months later. Documentation showed the new medication was discussed with the resident but contained no evidence that the representative was notified, and staff, including social services and the DON, acknowledged the resident’s confusion and the expectation that the representative should have been contacted before initiating the medication.
A resident with dementia and mobility issues was found in bed with a thick mattress propped upright along one side, held by a chair, while the other side of the bed was against the wall. The setup, confirmed by LPNs and the administrator, restricted the resident's movement and was acknowledged as an inappropriate restraint, contrary to facility policy that prohibits such use except for medical treatment.
A resident's tablet computer was reported missing after being last seen on the nightstand by a CNA and later tracked to a local hotel. An agency CNA, who worked a single night shift and was assigned to the resident, was observed entering the resident's room multiple times during that shift. Attempts to contact the CNA were unsuccessful, and the police confirmed the CNA had checked out of the hotel where the tablet was located. The facility did not prevent the misappropriation of the resident's property.
The facility failed to maintain proper kitchen sanitation and food safety practices, including a dishwasher not reaching the required sanitizing temperature, improper storage of meat products, and unsanitary conditions. A cook was observed handling food without a beard covering, and the kitchen had dust and debris in several areas, potentially affecting all residents.
The facility failed to maintain resident dignity during feeding assistance, as staff members were observed standing over residents while assisting them with meals. This practice contradicts the facility's policy, which requires staff to be seated to ensure resident comfort and dignity. The issue affected five residents who needed assistance during meals, and the DON confirmed the importance of seated feeding assistance.
The facility failed to provide proper restorative care and documentation for residents with contractures and mobility issues. A resident with a hand contracture was observed without a necessary palm protector, and quarterly restorative assessments were not updated for several residents. The Restorative Nurse admitted to performing but not documenting these assessments, contrary to the facility's program requirements.
The facility failed to adhere to infection control protocols, including improper cleaning of shared equipment and inadequate hand hygiene during incontinence care. A CNA did not sanitize equipment after use by a resident on contact isolation, and multiple CNAs failed to change gloves and sanitize hands when moving from dirty to clean tasks. Additionally, a resident with a nephrostomy was not placed on Enhanced Barrier Precautions, as required by the facility's policy.
The facility failed to ensure privacy for two residents during personal care. A resident with antistrophic lateral sclerosis was exposed to the hallway during incontinence care, and another resident with major depressive disorder was exposed to a roommate due to an improperly closed privacy curtain. The facility's policy requires full visual privacy during such care, which was not followed.
The facility did not request Level II PASSAR screenings for two residents who developed psychiatric disorders after admission. Initially, both residents had Level I screenings indicating no need for further assessment, but later MDS assessments showed psychotic disorders. The admissions staff was initially unsure about the need for rescreening, which was later confirmed as necessary. The facility's policy did not address rescreening for new psychiatric diagnoses.
A resident was admitted to the facility without the required PASARR screening, despite having diagnoses of unspecified dementia and schizophrenia. The facility's policy mandates preadmission screenings, including PASARR, for individuals with mental or intellectual disorders. The deficiency was identified when the administrator confirmed the absence of the screening, and the facility was in the process of conducting it during the survey.
Two residents in an LTC facility did not receive adequate ADL assistance. One resident, with cognitive impairment and incontinence, was found with a saturated brief, indicating a lapse in the required two-hourly checks. Another resident, dependent on staff for hygiene, reported not receiving scheduled bed baths due to staffing issues, with documentation confirming missed care. Facility policies for perineal and hygienic care were not followed.
The facility failed to obtain daily weights for a resident with congestive heart failure and did not apply protective arm sleeves for another resident as ordered. The resident with heart failure was not weighed on several days, contrary to physician orders, and the resident with fragile skin was observed without the required protective sleeves. Staff acknowledged these oversights, which were against the facility's policy to follow physician orders.
A facility failed to ensure fall interventions for a resident at high risk for falls. The resident, with a history of Parkinson's disease and unsteadiness, had a wheelchair pressure sensor alarm that did not activate when needed. Observations showed the alarm was not turned on, contrary to the care plan requiring bed and chair alarms to alert staff. The facility's policy mandates assessment and implementation of fall risk interventions.
Two residents in the facility experienced improper positioning of nephrostomy and urinary drainage bags, leading to potential risks of infection. One resident's nephrostomy bag was repeatedly observed on the bed, causing urine to back up into the tubing, while another resident's urinary drainage bag was lifted above bladder level during care. These actions were contrary to the facility's policy and the residents' care plans, which require drainage bags to be positioned below bladder level to prevent backflow.
A resident with a new gastrostomy diagnosis experienced improper care when an LPN administered medications without verifying the tube's placement, contrary to facility policy. The resident reported discomfort during the procedure, and further review showed that the type of tube used required placement verification by aspirating gastric content, which was not performed.
A resident receiving oxygen via nasal cannula had tubing and a bubble humidifier bottle that were not changed as ordered, with the bottle found empty on two consecutive days. The resident reported sinus pain and a dry nose. An LPN confirmed the tubing and bubblers should be changed weekly and the humidifier bottle should not be empty. The facility lacked an oxygen administration policy.
A resident receiving medications through a G-tube experienced a 20% medication error rate due to improper administration. An LPN crushed and mixed multiple medications together, contrary to the facility's policy requiring separate administration with water flushes between each. An RN confirmed the correct procedure, highlighting the deviation from standard practice.
A facility failed to securely store a resident's medication, as a capsule was found on the resident's bedside table. The resident was unsure of the medication, and an LPN later identified it as PhosLo 667 mg, prescribed for end-stage renal disease. The LPN confirmed that medications should not be left at the bedside, as it poses a risk of being forgotten or taken by another resident.
The facility failed to ensure call light accessibility for four residents, including those with cognitive impairments and physical limitations. Residents were unable to reach their call lights due to improper placement, despite care plans and facility policies requiring accessible call systems. This deficiency was observed in residents with severe and moderate cognitive impairments, leading to situations where residents had to call out for assistance.
A resident with severe cognitive impairment and fragile skin, on blood thinners, was found without protective bandages despite being at high risk for bruising. The facility failed to implement physician's orders for protective measures, as confirmed by staff interviews and observations.
A facility failed to notify the doctor and family when a resident's oxygen saturation dropped significantly during a therapy session. Despite the significant change in condition, the doctor was not informed until hours later, and the family was not notified at all. Staff interviews confirmed that the facility's policy on notification procedures was not followed.
A facility failed to ensure accurate medical records for a resident, with discrepancies in admission dates, consent forms, and daily nurse's notes. The resident's daughter raised concerns about the poor charting, and the administrator acknowledged the errors.
Failure to Notify Resident Representative of New Antihypertensive Medication
Penalty
Summary
The facility failed to notify a cognitively impaired resident’s health care power of attorney (POA) prior to initiating a new antihypertensive medication. The resident’s care plan dated 6/6/25 documented cognitive impairment related to dementia and multiple sclerosis, noted that she was very forgetful, and directed that all information be provided directly to her advocate. A POA form dated 9/12/24 identified a family member (V7) as the resident’s POA. Physician progress notes and a physician order dated 8/8/25 showed the resident was started on Losartan 25 mg daily for a new diagnosis of hypertension, and the physician documented that the new medication was discussed with the resident. However, there was no documentation that the POA was notified of the resident’s elevated blood pressures or the initiation of Losartan. On interview, the POA stated she was not informed that the resident had high blood pressure or that Losartan had been started until she spoke with a cardiology nurse practitioner on 12/17/25, despite being in the facility at least twice a week and having repeatedly requested to be notified of any changes, including medications. A cardiology note dated 12/17/25 confirmed that the nurse practitioner contacted the POA, who reported she was unaware the resident was taking Losartan. During observation on 1/5/26, the resident was awake but confused to place and time, unable to state the month, and did not know if she was on a medication for high blood pressure, stating that staff talk to her family member about all her medications. Social services staff described the resident as confused and forgetful with impaired short-term memory and confirmed that the POA was very involved and had requested to be informed of any changes. The DON stated that when a resident is started on a new medication, the resident and/or representative should receive education and consent prior to administration, and acknowledged that the cognitively impaired resident’s representative, who had requested notification of all changes, was not notified prior to starting Losartan.
Resident Restrained in Bed by Improper Use of Fall Mat
Penalty
Summary
A resident with diagnoses including aphasia, restlessness and agitation, dementia, lack of coordination, abnormalities of gait/mobility, and a need for assistance with personal care was found restrained in bed. The resident was observed by his daughter lying in bed with a thick mattress positioned upright along one side of the bed, held in place by a chair, while the other side of the bed was against the wall. The daughter reported this to nursing staff, who confirmed the presence of the fall mattress in an upright position. Interviews with LPNs revealed that fall mats are intended to be placed on the floor next to the bed to prevent injury, not upright along the bed, as this would restrict the resident's movement and effectively trap them in bed. The administrator and staff acknowledged that positioning the fall mat in this manner constituted a restraint, which is not permitted by facility policy except for medical treatment. The facility's restraint policy defines a physical restraint as any device that is attached or adjacent to the resident's body, cannot be easily removed by the individual, and restricts freedom of movement.
Failure to Protect Resident Property from Misappropriation
Penalty
Summary
A resident's tablet computer was reported missing after it was last seen on the resident's nightstand, plugged in, by a CNA at the end of the evening shift. The resident regularly used the tablet, and its absence was first noticed by another CNA the following morning when assisting the resident. The resident's daughter later used a tracking application to locate the tablet at a local hotel. The facility's administrator confirmed that an agency CNA, who worked only one night shift and was assigned to the resident, was seen on camera entering the resident's room multiple times during that shift. Attempts to contact this CNA by both the facility and local police were unsuccessful. The facility's abuse and neglect policy prohibits misappropriation of resident property, including deliberate misplacement or exploitation. Despite this policy, the resident's tablet was not protected from wrongful use or theft. The police were notified and investigated the incident, confirming that the agency CNA in question had checked out of the hotel where the tablet was located. The facility failed to ensure the resident's belongings were safeguarded, resulting in the misappropriation of the resident's property.
Deficiencies in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to ensure proper sanitation and food safety practices in the kitchen, which could potentially affect all residents. The dishwasher did not reach the required temperature of 160 degrees Fahrenheit for sanitizing dishes, as observed during multiple cycles where the final rinse temperature remained at 130 degrees Fahrenheit. Despite being aware of the issue, the Dietary Manager allowed the use of regular silverware and some dishware that had been washed in the malfunctioning dishwasher. Additionally, the facility's dishwashing log showed inconsistencies in the final rinse temperatures, indicating a lack of adherence to the facility's policy. Further deficiencies were observed in the storage and handling of food and kitchen hygiene. Boxes of frozen meat products were found open, unlabeled, and undated in the walk-in freezer, contrary to the facility's policy requiring food to be covered, dated, and labeled. A cook with a thick beard was seen handling food without a facial hair covering, which is required to prevent contamination. The kitchen also had unsanitary conditions, with dust and debris found in the bin holding the ice scooper and on a rack above the meal service assembly. These observations highlight a failure to maintain sanitary conditions in the kitchen.
Failure to Maintain Dignity During Feeding Assistance
Penalty
Summary
The facility failed to assist residents with feeding in a dignified manner, as observed during a dining session. Staff members, including the Activity Director, CNAs, and an LPN, were seen standing over residents while assisting them with their meals, which is contrary to the facility's policy that emphasizes the importance of staff being seated to ensure resident comfort and dignity. This issue was noted for five residents who required varying levels of assistance during meals. The Director of Nursing acknowledged that staff should be seated when feeding residents to maintain their dignity, as per the facility's Privacy and Dignity policy.
Failure to Ensure Proper Restorative Care and Documentation
Penalty
Summary
The facility failed to ensure proper restorative care for residents with contractures and mobility issues. One resident with a left hand contracture was observed without a palm protector, which is necessary to prevent further decline and maintain skin integrity. The resident's care plan required the use of a palm protector post-range of motion exercises, but it was not in place during observations. The Restorative Nurse confirmed that the palm protector should be worn at all times except during hand hygiene and passive range of motion exercises. Additionally, the resident's restorative assessment had not been updated since December 2023, despite the requirement for quarterly assessments. The facility also failed to conduct and document quarterly restorative assessments for other residents requiring restorative services. One resident, who required extensive assistance with activities of daily living and was on a passive range of motion program, had not had an assessment since September 2023. Another resident's last assessment was in December 2023, and the Restorative Nurse admitted to performing but not documenting the quarterly assessments. The facility's Restorative Nursing Program mandates quarterly evaluations, but these were not consistently documented or updated, leading to deficiencies in the care provided to residents.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed, as evidenced by multiple instances of improper handling and cleaning of equipment and personal protective equipment. A certified nursing assistant (CNA) was observed transporting a resident on contact isolation for Norovirus without sanitizing shared equipment such as a dialysis chair, table, and grab bar after use. Additionally, the CNA placed soiled linens on public surfaces without cleaning them afterward, which is against infection control protocols. In several instances, CNAs did not follow proper hand hygiene and glove-changing procedures during incontinence care. For example, a CNA was observed placing soiled linens and incontinence briefs on the floor and then proceeded to touch clean items and the resident without changing gloves or sanitizing hands. This was observed with multiple residents, including those with urinary tract infections and pressure injuries, increasing the risk of cross-contamination and infection spread. Furthermore, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a nephrostomy, as there was no signage indicating isolation precautions. The Infection Control Registered Nurse confirmed that residents with indwelling medical devices should be on EBP, but this was not adhered to, indicating a lapse in following the facility's infection control policies.
Failure to Ensure Privacy During Personal Care
Penalty
Summary
The facility failed to provide privacy during personal care for two residents, leading to a deficiency in maintaining residents' privacy and dignity. Resident R81, who was admitted with diagnoses including antistrophic lateral sclerosis and adult failure to thrive, was observed receiving incontinence care with the door open, exposing the resident's perineal area to the hallway. Similarly, Resident R121, admitted with major depressive disorder and a pressure injury, was exposed when a CNA provided incontinence care without fully closing the privacy curtain, allowing a roommate to see the resident's buttocks. The facility's policy mandates that privacy curtains be drawn fully to ensure visual privacy during such care, which was not adhered to in these instances.
Failure to Rescreen Residents for PASSAR After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to request a Level II Preadmission Screening and Resident Review (PASSAR) for two residents who developed psychiatric/mood disorders after admission. Initially, both residents had Level I PASSAR screenings indicating no need for Level II assessments. However, subsequent Minimum Data Set (MDS) assessments revealed that both residents had developed psychotic disorders. The admissions staff, V19, acknowledged that PASSAR screenings are conducted prior to admission to ensure appropriate services are provided but was initially unsure if a rescreening was necessary when new psychiatric diagnoses are added. It was later confirmed that both residents should have been rescreened, but the facility's policy did not address the need for rescreening when additional psychiatric diagnoses are identified during a resident's stay.
Failure to Conduct PASARR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a resident was screened prior to admission, as required by the PASARR process, for one of the five residents reviewed for preadmission screenings. The deficiency was identified during an observation and interview process. On January 27, 2025, the resident was observed sitting in a reclining chair in his room, sleeping. The following day, the facility's administrator confirmed that no PASARR screening had been conducted for the resident, who had been admitted with diagnoses of unspecified dementia and schizophrenia. The facility's policy, dated August 16, 2024, mandates that no admission from the hospital should occur without a preadmission screening, including PASARR screening for those with mental or intellectual disorders. Despite this policy, the resident was admitted without the required screening, and the facility was in the process of conducting the screening at the time of the survey.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for two residents, R25 and R1, who are dependent on staff for care. R25, who has a history of dysphagia, cognitive impairment, and incontinence, was found with a saturated incontinence brief containing dark urine and soft stool. The care plan for R25 requires checking and changing every two hours, but it was noted that R25 was last changed during the night shift, indicating a lapse in care. The facility's policy mandates perineal care every two hours to prevent infection and skin irritation, which was not adhered to in this instance. R1, diagnosed with dementia and requiring assistance with personal hygiene, reported not receiving a bed bath as scheduled. R1's care plan specifies the need for two showers per week, but documentation showed only three showers in the last 14 days and no bed baths from January 23-28, 2025. A CNA confirmed that R1 was supposed to receive a bed bath but was unsure if it occurred, citing staffing issues. The facility's policy requires regular hygienic care to ensure cleanliness and comfort, which was not provided to R1 as required.
Failure to Follow Physician Orders for Daily Weights and Protective Arm Sleeves
Penalty
Summary
The facility failed to obtain daily weights for a resident with a history of fluid overload, as ordered by the physician. The resident, who has diagnoses including congestive heart failure and chronic kidney disease, was supposed to be weighed daily to monitor for fluid retention. However, records show that weights were not obtained on several days, and the resident confirmed that staff did not always weigh her daily. This oversight occurred despite the facility's policy to obtain weights as ordered by the physician. Additionally, the facility did not ensure that protective arm sleeves were applied as ordered for another resident. This resident, who has a history of fragile skin and is on blood thinners, was observed multiple times without the protective sleeves, which were intended to prevent bruising. The CNA acknowledged that the resident was supposed to wear the sleeves throughout the day but admitted to not applying them as required. The facility's policy mandates adherence to physician orders, which was not followed in this case.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident at high risk for falls. The resident, identified as R39, has a medical history that includes Parkinson's disease with dyskinesia, lack of coordination, unsteadiness of feet, and a history of falling. During an observation, it was noted that R39 had a wheelchair pressure sensor alarm attached to his wheelchair, but the alarm did not sound when the resident lifted his buttocks off the seat multiple times. The alarm's 'In Use' light was not on, indicating it was not activated. Later, a Certified Nursing Assistant (CNA) had the resident stand from the wheelchair, and again the alarm did not sound until the CNA manually turned it on. The resident's care plan specifies the use of bed and chair alarms to alert staff when the resident attempts to get up unassisted. The facility's Fall Occurrence Policy requires that residents are assessed for fall risk and that interventions are implemented and reevaluated as necessary.
Improper Positioning of Nephrostomy and Urinary Drainage Bags
Penalty
Summary
The facility failed to maintain proper positioning of nephrostomy and urinary drainage bags for two residents, R67 and R121, which is crucial to prevent urinary tract infections. For R67, observations on multiple occasions revealed that the nephrostomy drainage bag was placed on the bed, causing urine to pool at the opening of the bag and back up into the tubing. This improper positioning was noted despite the resident's care plan indicating the need for appropriate nephrostomy care due to an acute kidney injury and renal calculi. The Director of Nursing acknowledged that the drainage bag should be positioned to allow urine to flow into the bag, similar to the care required for an indwelling urinary catheter. For R121, the urinary drainage bag was observed to be improperly handled during peri care by a CNA, who lifted the bag above the bladder level and then placed it on the bed. This action contradicted the resident's care plan, which specified that the catheter bag and tubing should be positioned below the bladder level. The facility's Urinary Catheter Care Policy, revised in August 2024, clearly states that the drainage bag must be kept lower than the bladder to prevent backflow of urine, which was not adhered to in these instances.
Failure to Verify Gastrostomy Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure the proper checking of a gastrostomy tube placement before administering medication to a resident, identified as R39, who was readmitted with a new diagnosis of gastrostomy. On the specified date, an LPN administered medications to R39 without verifying the placement of the gastrostomy tube, despite the resident expressing discomfort during the procedure. The facility's policy requires checking the placement by observing the marker at the insertion site or aspirating gastric content if the marker is not visible. However, the LPN did not follow this protocol, leading to a deficiency in care. Further investigation revealed that the type of gastrostomy tube used for R39 did not have a visible line for placement verification, as confirmed by an RN. The RN demonstrated that the placement should be checked by aspirating gastric content, which was not done in this instance. The physician's order and the facility's medication pass policy both emphasize the importance of verifying tube placement before administering any tube feeding or medications, which was not adhered to in this case.
Failure to Change Oxygen Tubing and Maintain Humidifier
Penalty
Summary
The facility failed to provide proper respiratory care for a resident by not changing the oxygen tubing and bubble humidifier bottle as ordered and not keeping the humidifier bottle filled. The resident, who was receiving oxygen via nasal cannula, had tubing and a bubble humidifier bottle labeled with a date over a month old, indicating they had not been changed weekly as required. Additionally, the humidifier bottle was found empty on two consecutive days. The resident reported experiencing sinus pain and a dry nose, which could be related to the deficiency in care. A Licensed Practical Nurse confirmed that the tubing and bubblers should be changed weekly and that the humidifier bottle should not be allowed to run empty. The facility was unable to provide an oxygen administration policy to support their practices.
Medication Administration Error via G-tube
Penalty
Summary
The facility failed to administer medications according to standard practice for a resident receiving medications through a gastrostomy tube, resulting in a 20% medication error rate. The resident, identified as R39, was observed receiving multiple medications, including aspirin, omeprazole, multivitamins, tramadol, vitamin D3, and carbidopa-levodopa, all at once through a G-tube. The Physician's Order Sheet did not document that these medications could be given simultaneously. On a specific date, a Licensed Practical Nurse (LPN) prepared and administered these medications by crushing them together and mixing them with water, contrary to the facility's Medication Pass Policy, which requires medications to be given separately with a water flush between each. A Registered Nurse (RN) confirmed that medications should be crushed and administered individually to prevent interactions, with 10-30 ml of water given between each medication.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the secure storage of a resident's medication, specifically for one resident reviewed for medication storage. During an observation, a blue and white capsule was found in a medication cup on the bedside table of a resident. The resident was unsure of the medication's identity but believed it was something she was supposed to take at breakfast. Later, a Licensed Practical Nurse (LPN) brought the resident her medications and was also unsure of the capsule's identity. Upon verification, the LPN identified the capsule as PhosLo 667 mg, which was prescribed to the resident for end-stage renal disease to be taken with meals on dialysis days. The LPN acknowledged that medications should not be left at the resident's bedside, as the resident might forget to take it or another resident could take it.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that four residents had access to their call lights, which is a critical component for resident safety and communication. Resident 1, who has severe cognitive impairment and a right hand amputation, was found unable to reach or operate his call light, which was wrapped around the right side rail and hanging towards the floor. Despite the resident's care plan emphasizing the need for a reachable call light, the staff did not ensure its accessibility, as confirmed by a Certified Nursing Assistant and the Director of Nursing. Resident 2, with moderate cognitive impairment and a history of falls, was also unable to access her call light, which was similarly wrapped around the side rail and out of reach. Although a sign above her bed instructed staff to place the call light within reach, it was not followed, leaving the resident unable to locate it without assistance. Resident 3, who has moderate cognitive impairment and a history of behavioral issues related to call light use, was found yelling for help because he could not find his call light, which was also positioned out of reach. Resident 7, with moderate cognitive impairment and a history of falls, had her call light placed inside a basin on her bedside table, making it inaccessible. The facility's policy mandates that call lights be within reach of residents capable of using them, but this was not adhered to in these cases. The Director of Nursing acknowledged that call lights should be accessible to prevent residents from attempting to get up on their own, yet the facility did not ensure compliance with this policy, leading to the deficiency.
Failure to Implement Physician's Orders for Resident at Risk of Bruising
Penalty
Summary
The facility failed to implement physician's orders for a resident at risk for bruising, which was identified during a survey. The resident, who has severe cognitive impairment and is dependent on staff for bed mobility, was noted to have a discoloration on the right elbow, indicating a hematoma. The resident is on blood thinners and has fragile skin, increasing the risk of bruising. Despite the nurse practitioner's recommendation to apply a multipurpose bandage or skin protector to provide an additional barrier, there were no physician's orders for these protective measures in the resident's June 2024 orders. Observations and interviews revealed that the resident did not have any bandages or skin protectors on his arms at the time of the survey. A registered nurse stated that the bandages were not applied because they were in the wash, and new ones were eventually cut and applied. The Director of Nursing confirmed that the resident should have had the bandages on at all times due to the high risk of bruising. The facility's policy mandates that all treatments must be in accordance with physician's orders, which was not adhered to in this case.
Failure to Notify Doctor and Family of Change in Condition
Penalty
Summary
The facility failed to notify the doctor and the power of attorney/family when a change in condition occurred for a resident. On the morning of the incident, the resident's oxygen saturation dropped significantly during a therapy session, prompting the therapist to administer oxygen and notify the nurse. Despite this significant change in the resident's condition, the doctor was not notified until several hours later, and the family was not informed at all. The resident's daughter expressed concern that earlier notification might have led to different medical decisions, potentially improving the resident's outcome. Interviews with staff revealed that the nurse on duty did not recognize the need to notify the doctor immediately, as the resident's oxygen saturation was above 90% when she checked. However, other staff members, including the nursing supervisor and nurse practitioner, confirmed that the drop in oxygen saturation and the need for supplemental oxygen constituted a significant change in condition that warranted immediate notification of the doctor and family. The facility's policy on notification procedures for changes in resident condition was not followed in this instance. The resident had multiple medical diagnoses, including type 2 diabetes mellitus, cardiomegaly, peripheral vascular disease, and end-stage renal disease, among others. The failure to promptly notify the doctor and family of the resident's change in condition represents a significant lapse in the facility's adherence to its own policies and procedures, potentially impacting the resident's care and well-being.
Inaccurate Medical Records and Charting
Penalty
Summary
The facility failed to ensure the accuracy of the information available in a resident's chart. The Face Sheet for the resident showed an admission date with multiple medical diagnoses, but the Admission Packet Information was dated prior to the actual admission date. Additionally, several consent forms were signed and dated before the resident was admitted. The Daily Skilled Nurse's Notes contained inaccuracies, such as marking the resident as having an ostomy when she did not and failing to mark dialysis on certain dates, despite the resident being on end-stage renal dialysis. The resident's daughter, who is also the power of attorney, expressed concerns about the poor charting, noting that documents were signed before the actual admission date and that several important medical details were either incorrect or missing from the chart. The facility's administrator acknowledged these discrepancies, stating that staff are expected to chart accurately and that the errors should have been caught. The facility's Electronic Medical Record Policy emphasizes the importance of accurate and authorized entries to maintain the integrity and confidentiality of resident clinical information.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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