Warren Barr Lincoln Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 2732 North Hampden Court, Chicago, Illinois 60614
- CMS Provider Number
- 145875
- Inspections on file
- 28
- Latest survey
- March 14, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Warren Barr Lincoln Park during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, a history of falls, syncope, abnormal gait, and Alzheimer’s disease was identified in assessments and the care plan as needing supervision or touching assistance for toileting and ambulation, frequent monitoring, and use of bed/chair alarms. Despite this, fall risk evaluations later documented the resident as low risk, staff were unsure if the bed alarm was in place, and one CNA reported the alarm was too faint to hear in the hallway. The resident, known to be impulsive and to get up unassisted to toilet, was found on the bathroom floor after an unwitnessed fall without his walker, sustaining a forehead laceration requiring sutures. At surveyor observation, the call light was on the floor out of reach, and staff reported only one nurse with three CNAs caring for 38 residents, which they described as a staffing problem that limited adequate supervision and contributed to the fall.
The facility failed to properly account for and administer narcotic medications, with discrepancies found in narcotic counts and improper documentation by nursing staff. Additionally, a nurse did not follow protocols for administering medications via gastronomy tube, and expired insulin was nearly administered to a resident, causing a delay in treatment. These incidents reflect a lack of adherence to medication administration and accountability policies.
The facility failed to properly label and store medications, including insulins and controlled substances. Insulin vials for several residents were not dated when opened, and some were expired but still in use. A controlled substance was found in an unlocked refrigerator, and a discontinued medication was not destroyed as per guidelines. These issues affected multiple residents.
A CNA allowed another CNA to document resident care under her login credentials, leading to inaccurate medical records for several residents. Despite facility policies against sharing login information, this practice occurred, compromising the integrity of resident documentation.
A facility failed to accurately complete a resident's comprehensive annual assessment, submitting a quarterly MDS instead. The error was linked to the absence of a current MDS Coordinator and was identified on the last day for annual assessment completion. The resident had been admitted to the hospital and returned as a dual Medicaid and Medicare payor, complicating the MDS sequence.
A resident's PASARR screening was not updated after their exemption expired, as required by facility policy. The administrator admitted the oversight and showed a lack of understanding of the DON score ranges necessary for determining the need for further screening.
A resident with diabetes had a high blood sugar level of 333, which required physician notification per orders, but there was no documentation of such notification. The resident's blood sugar later increased to 397, and the resident was pronounced expired by EMS. Interviews revealed a lack of communication and documentation among staff, including the DON and NP, regarding the elevated blood sugar levels and necessary actions.
The facility failed to follow pressure ulcer prevention protocols for two residents on low air loss mattresses. Observations showed improper use of fitted and folded flat sheets, contrary to guidelines that recommend minimal layering to prevent pressure injuries. The Wound Care Manager confirmed the protocol breach, highlighting the deficiency in care.
A resident repeatedly received eggs for breakfast despite expressing a dislike for them, as documented in her food preference form. The Dietary Manager acknowledged the oversight, which was due to the resident's preference not being updated on her dietary meal ticket, contrary to the facility's policy.
The facility failed to ensure proper PPE use for a resident with shingles, as staff entered the room without gowns and gloves, despite contact isolation precautions. Additionally, during a bed bath for another resident, a CNA used the same washcloth for multiple body areas without changing gloves, contrary to infection prevention practices. These actions did not align with the facility's infection control policies, leading to deficiencies in care.
A resident with dementia was physically abused by a CNA in a LTC facility, leading to an Immediate Jeopardy situation. The CNA admitted to hitting the resident, and another CNA witnessed the incident but no immediate action was taken. The facility's policy prohibits abuse, and staff acknowledged the incident as abuse, although the facility's investigation was inconclusive.
The facility failed to secure medication carts, leaving them unlocked and unattended on the 2nd and 3rd floors, contrary to policy. An RN and an LPN acknowledged the carts should have been locked to prevent resident access, but they were left unsecured, posing a potential hazard.
A resident with dementia was roughly handled and hit by a CNA, which was witnessed by another CNA who reported it to the nurse on duty. However, no action was taken until the surveyor's visit. The facility's policy requires immediate reporting of abuse to the administrator and IDPH, which was not followed in this case.
A resident with dementia was physically abused by a CNA, who admitted to hitting the resident but did not report it. Another CNA witnessed the incident and reported it to the nurse on duty, but no investigation was initiated. The facility's policy requires immediate reporting and investigation of abuse, which was not followed.
A resident was administered Potassium chloride on an incorrect day, contrary to the prescribed schedule. The RN failed to document the correct administration time and left medications at the bedside without proper assessment. The facility's policies on medication administration were not adhered to, leading to this deficiency.
The facility failed to label the date and time on enteral feeding bottles for two residents, leading to potential health risks. Both residents had severe cognitive impairment and were on specific enteral feeding regimens. The LPN on duty was unaware of when the feedings were started, which is against the facility's policy.
Failure to Supervise High-Risk Resident and Maintain Effective Fall-Prevention Measures
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise and implement effective fall-prevention measures for a resident with a known history of falls and severe cognitive impairment. The resident had diagnoses including syncope, collapse, falling, transient cerebral ischemic attack, hypertension, abnormal gait and mobility, chronic fatigue, and Alzheimer’s disease. An MDS documented a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment, and showed the resident required supervision or touching assistance for toileting hygiene and walking 10 feet with a walker. The care plan identified the resident as at high risk for falls related to dementia, behavioral and mood disturbances, anxiety, poor awareness, decreased comprehension, impulsivity, and memory deficits, and documented that the resident required assistance with all ADLs, including toileting and walking, and demonstrated movement behaviors such as wandering, pacing, or roaming. Despite these identified risks, the facility did not maintain accurate fall risk assessments or ensure consistent implementation of fall precautions. A fall risk assessment completed on the date of the fall scored the resident as high risk with a score of 13, but subsequent fall risk evaluations in December and January documented a score of 0, categorizing the resident as low risk for falls, which the DON later stated was not accurate. The resident’s orders allowed use of bed and chair alarms, and the care plan included use of a chair/bed alarm related to potential falls and frequent monitoring. However, staff interviews revealed uncertainty about whether the bed alarm was in place at the time of the fall, and one CNA reported that the bed alarm in use had a very faint sound, suggesting low battery, and could not be heard in the hallway. The DON stated that only residents at high risk for falls should have bed alarms and that any resident who has fallen is automatically considered high risk, indicating a discrepancy between policy and the documented low-risk scores. On the day of the incident, the resident was found lying on his back on the bathroom floor with a laceration to the forehead after an unwitnessed fall. The resident reported having walked to the bathroom, used it, and then only remembered waking up on the floor. The resident did not have his walker with him in the bathroom at the time of the fall. Staff reported that the resident was impulsive, would get up by himself when he had the urge to use the bathroom, and required frequent monitoring and supervision when ambulating or going to the bathroom. The LPN and CNA assigned to the resident stated that he should have been supervised for toileting and ambulation and that if he had assistance with toileting, the fall could have been prevented. At the time of surveyor observation, the resident’s call light was found on the floor at the head of the bed, out of reach, despite staff acknowledging that the call light should always be within reach. Staffing on the unit consisted of one nurse and three CNAs for 38 residents, and both the DON and floor staff described this as a staffing problem that affected the ability to provide quality care and adequate supervision, contributing to the failure to prevent the resident’s fall and resulting head laceration requiring sutures.
Medication Administration and Accountability Failures
Penalty
Summary
The facility failed to ensure proper accounting and administration of narcotic medications, as well as adherence to medication administration protocols. During a shift change, a registered nurse (V10) did not sign the narcotic record documents, and discrepancies were found in the count of R23's Pregabalin 75 MG. Similarly, a licensed practical nurse (V11) found discrepancies in the narcotic counts for two residents, with missing tablets of Oxycodone and Morphine Sulfate. Both nurses admitted to forgetting to sign the records, which is a violation of the facility's policy requiring accurate documentation and accountability for controlled substances. Additionally, the facility failed to follow proper procedures for administering medications via gastronomy tube. A licensed practical nurse (V12) prepared multiple medications for R69 without separating them into individual cups, contrary to the policy that requires each medication to be flushed independently with water. V12 also failed to maintain cleanliness by touching high-touch areas and the enteral tube with the same gloves used for medication administration, which could compromise the sterility of the procedure. The facility also did not ensure the availability of insulin as per physician orders, leading to a delay in administration. A licensed practical nurse (V13) attempted to administer expired Humalog insulin to R11, realizing the error only after being questioned. The insulin had been opened beyond its 28-day expiration period, and V13 was unable to find a non-expired insulin vial, resulting in a delay until a one-time dose was authorized by the physician. This incident highlights the facility's failure to adhere to medication labeling and expiration protocols, as outlined in their policy.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store medications, including insulins and controlled substances, as per their policy and professional standards. During an inspection, it was observed that several insulin vials for residents were not dated when opened, and some were found to be expired but still stored in the medication cart. Specifically, insulins for residents were either missing open dates or were past their expiration dates, yet remained in use. Additionally, an eye drop medication was found without a date in the medication cart. Controlled substances were not stored according to the required double-lock protocol. A Lorazepam vial, a controlled substance, was found in an unlocked refrigerator at the nurse station, which was supposed to be secured. Furthermore, this medication had been discontinued but was still present in the storage area. The Director of Nursing confirmed that all narcotics should be double-locked and that discontinued medications should be destroyed per pharmacy guidelines. These lapses in medication management affected six residents reviewed for drug storage.
Improper Documentation Practices by CNAs
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards for eight residents. This deficiency was identified through interviews and record reviews. A Certified Nursing Assistant (CNA), identified as V14, was found to be allowing another CNA, V15, to document resident care under her login credentials. V15, who works through an agency and occasionally at the facility, stated she was unable to log into her account and thus documented care under V14's account. This practice was confirmed by V14, who mentioned that the documentation of care was what mattered, regardless of who logged it. The Assistant Director of Nursing, V3, stated that all agency staff are provided with individual electronic login access to document their work, and another CNA, V32, confirmed that staff are not allowed to share login information. Despite this, the facility's floor assignment records showed that V15 was responsible for several residents, yet documentation for these residents was completed under V14's login. This included tasks related to bowel and bladder management, as well as behavior monitoring and intervention. The facility's policy emphasizes the importance of safeguarding resident information and maintaining accurate medical records, which was not adhered to in this instance.
Inaccurate Completion of Resident's Annual Assessment
Penalty
Summary
The facility failed to accurately complete a comprehensive annual assessment for a resident, identified as R29. The issue arose when the Minimum Data Set (MDS) was incorrectly submitted as a quarterly assessment instead of an annual one. This error was identified during an interview with the MDS Consultant, who noted that the resident's census line contained an error due to the resident's hospital admission and subsequent return to the facility as a dual Medicaid and Medicare payor. The MDS was scheduled in sequence, but the quarterly assessment was mistakenly submitted in place of the required annual assessment. The facility did not have a current MDS Coordinator, and someone from another facility was covering the MDS responsibilities, contributing to the oversight. The error was recognized on the last day to complete the annual assessment, prompting the inactivation of the quarterly assessment and the initiation of the annual assessment process.
Failure to Conduct Timely PASARR Screening
Penalty
Summary
The facility failed to initiate a new Level I PASARR screening for a resident, identified as R70, who was reviewed for Pre-Admission Screening and Record Review (PASARR). R70 was admitted to the facility with an exempted hospital discharge, which allowed for a 30-day length of stay without a new PASARR screening. However, this exemption expired, and the facility did not conduct a new Level I PASARR screening as required. The administrator, V1, acknowledged that the resident's PASARR screening had expired and that a new screening was necessary but had not been completed. The facility's policy mandates that residents with mental disorders or intellectual disabilities receive PASARR screenings within the allowed timeframe. Despite this policy, the facility did not adhere to the requirement for R70, whose exemption status had lapsed. The administrator also demonstrated a lack of understanding regarding the determination of needs (DON) score ranges and their implications, which are crucial for deciding if a resident requires a Level II PASARR screening for severe mental illness. This oversight resulted in a deficiency related to the facility's failure to ensure appropriate PASARR screenings were conducted in a timely manner.
Failure to Address High Blood Sugar in Resident with Diabetes
Penalty
Summary
The facility failed to address a high blood sugar result for a resident with diabetes mellitus, leading to a deficiency in care. The resident, who was receiving Paxlovid for Covid-19, had a physician's order to monitor blood sugar levels and notify the doctor if results were below 60 or above 300. On the day of the incident, the resident's blood sugar was recorded at 333, which required physician notification according to the order. However, there was no documentation indicating that the physician or nurse practitioner was informed of this elevated result. Later, the resident's blood sugar further increased to 397, and the resident was pronounced expired by EMS at 3:15 PM. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's elevated blood sugar levels. The Director of Nursing was not present at the time and was unsure if the physician was notified, while the Restorative Director stated she was not informed of the elevated levels. The Nurse Practitioner acknowledged being informed of the initial high result but was unaware of the subsequent increase to 397. He admitted to not documenting the elevated blood sugar or any actions taken to address it, highlighting a failure in following the physician's order and ensuring proper care for the resident.
Failure to Adhere to Pressure Ulcer Prevention Protocols
Penalty
Summary
The facility failed to ensure proper pressure ulcer preventative measures for two residents, R4 and R62, who were both on low air loss mattresses as per their physician orders. R4's physician order summary indicated the need for a low air loss mattress for pressure reduction, yet observations revealed that R4 was lying on a mattress with a fitted sheet and a flat sheet folded twice, which is against the facility's protocol. Similarly, R62, who required the mattress due to active wounds, was found with a fitted sheet and a folded flat sheet, contrary to the guidelines that specify only a single sheet, a blue pad, and a brief should be used. The Wound Care Manager confirmed that the facility's protocol does not allow for both a fitted and a flat sheet, nor the use of a folded flat sheet as a draw sheet, as this creates excessive layers. The Proactive Medical Products Operation Manual and the Med-Aire 8 Alternating Pressure Mattress Replacement System User Manual both recommend minimal layering to prevent pressure injuries. The facility's failure to adhere to these guidelines resulted in a deficiency in providing appropriate pressure ulcer care and prevention for the residents involved.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to adhere to its policy on accommodating resident food preferences, specifically for one resident, R70, who was part of a sample of 21 residents reviewed. R70's Nutrition Progress Note indicated that her diet should include food preferences and alternatives as needed. Despite this, the facility served eggs to R70 for breakfast on multiple occasions, even though she had explicitly informed the staff, including the Dietary Manager (V8), that she disliked eggs. R70's food preference interview form, which documented her preference against eggs, was not reflected on her dietary meal ticket, leading to repeated servings of eggs. The Dietary Manager, V8, acknowledged awareness of R70's preference against eggs and admitted to completing a food preference interview form for R70. However, the form was initially misplaced and later found in a storage clipboard. The oversight was attributed to the failure to document R70's no-egg preference on her dietary meal ticket, which should have been updated according to the facility's policy. This lapse resulted in R70 refusing her breakfast meal tray when eggs were served, highlighting a breakdown in the communication and implementation of dietary preferences within the facility.
Infection Control Deficiencies in PPE Use and Bed Bath Practices
Penalty
Summary
The facility failed to ensure the appropriate use of personal protective equipment (PPE) by staff caring for a resident with a known infectious disease. A resident diagnosed with shingles was placed on contact isolation precautions, requiring staff to wear gowns and gloves before entering the room. However, observations revealed that staff members, including a CNA Supervisor and a CNA, entered the resident's room without donning the required PPE, despite being aware of the resident's condition and the posted contact precautions. Both staff members acknowledged their failure to adhere to the PPE requirements and recognized the potential risk of cross-contamination and spreading the infection to other residents. Additionally, the facility did not maintain clean technique and infection control practices during a bed bath for another resident. The resident, who required substantial assistance for bathing, reported inadequate cleaning by certain CNAs, particularly in the perineal area. During an observed bed bath, a CNA used the same washcloth for multiple body areas, including the perineal area, without changing gloves or washcloths, contrary to best practices for infection prevention. The CNA acknowledged that the observed procedure was not her usual practice, and the facility lacked a specific bed bath procedure policy. The facility's infection prevention and control policy required the use of gowns and gloves for contact precautions and emphasized maintaining clean techniques during hygienic care. However, the staff's actions during the observed incidents did not align with these policies, leading to deficiencies in infection prevention and control practices for the residents involved.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant (CNA), which was identified as an Immediate Jeopardy situation. The incident involved a resident with dementia who was handled roughly and hit on the arm and back by the CNA while attempting to redirect the resident. The abuse occurred on 06/30/24, but the facility's video recording system did not retain footage from that date, as it only stored recordings for seven days. The resident, who does not speak English and has a history of dementia with agitation, was unable to recall or speak of the abuse incident. The CNA admitted to hitting the resident after the resident allegedly hit her first. Another CNA witnessed the incident and reported it to a nurse on duty, but no action was taken until the surveyor's investigation. The facility's policy clearly states that abuse, including hitting, is not acceptable under any circumstances. Despite the facility's investigation concluding that the allegation of abuse could not be substantiated, multiple staff members, including the Director of Nursing and the Social Services Director, acknowledged that hitting a resident is a form of abuse. The Medical Director suggested that the incident might be considered self-defense but emphasized that staff should de-escalate situations without resorting to aggression. The facility's policy mandates immediate reporting of any abuse allegations to the administrator.
Removal Plan
- V20 suspended.
- R1 is no longer residing at the facility. R1 has been discharged to another Long-Term Care.
- R1 full skin assessment conducted.
- R1 seen by psychotherapist.
- R1 evaluated by Physiatrist.
- R1 screened for abuse/neglect.
- V21 was suspended for not reporting to V1, pending investigation.
- Staff are being educated on Abuse, with quiz to monitor effectiveness.
- Abuse in-service completed.
- Abuse in-service on Handling Aggressive Behaviors with quiz for 5 staff members three times per week for 12 weeks on-going.
- Social Work outside consultation group initiated monthly in-service on de-escalation techniques and handling aggressive residents.
- Staff training on facility code gray for aggressive behavior/violence, initiated and completed.
- QA (Quality Assurance) audit on 3 times weekly times 12 weeks to ensure direct staff care staff (Nurses and CNA's).
- Thirteen residents R1, R7, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22, were reviewed for abuse and aggressive behaviors. List of residents with behaviors provided and posted at the nurse's station inside a closed cupboard.
- V27 (Medical Director) interviewed and was aware of the removal plan with V27's approval.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medication carts were locked and within the visual proximity of licensed nurses when not in use, posing a potential hazard to residents. On the 3rd floor, a treatment cart was observed unlocked and unattended in the hallway. The RN on duty, V16, acknowledged the facility's policy that medications should be locked when not in use but stated that they were not responsible for the cart. The Wound Care Nurse, V18, confirmed that the cart should have been locked to prevent resident access. Similarly, on the 2nd floor, a medication cart was found unlocked and unattended. The LPN, V24, admitted that the cart should have been locked when not in visual proximity, explaining that they had left it to administer medication in the dining room. The facility's policies on hazards and medication storage clearly state that medications must be secured to prevent resident access, yet these protocols were not followed, creating a potential risk for all residents on the affected floors.
Failure to Report Abuse Incident Timely
Penalty
Summary
The facility failed to immediately report an allegation of abuse to the Illinois Department of Public Health (IDPH) within the required time frame. This incident involved a resident with dementia, who was handled roughly and hit on the arm and back by a Certified Nursing Assistant (CNA) in an attempt to redirect the resident. The incident was witnessed by another CNA, who reported that the resident was hit multiple times and handled roughly, which was not appropriate even if the resident was combative. Despite the witness reporting the incident to the nurse on duty, no action was taken until the surveyor's visit. The facility's policy on abuse and neglect, revised in June 2024, mandates that all allegations of abuse must be reported immediately to the administrator, who is the Abuse Coordinator, and to the IDPH. The policy defines abuse as willful infliction of mistreatment, including physical actions such as hitting and grabbing. The failure to report the incident promptly and the lack of immediate action by the staff on duty contributed to the deficiency identified by the surveyors.
Failure to Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to immediately initiate an investigation into an alleged physical abuse incident involving a resident, identified as R1, who was handled roughly and physically hit by a Certified Nursing Assistant (CNA), V20. R1, who has dementia and other medical conditions, was reportedly hit on the arm and back by V20 in an attempt to redirect R1 from sitting on the floor. V20 admitted to hitting R1 after being elbowed by the resident, but did not report the incident to the facility's Abuse Coordinator, V1, as V20 did not initially perceive it as abuse. The incident was captured on a hallway camera, but no action was taken until the surveyor's visit. Another CNA, V21, witnessed the incident and confirmed that V20 hit R1 multiple times and handled the resident roughly. V21 reported the incident to the nurse on duty, V10, but no investigation was initiated. The facility's policy on abuse and neglect mandates immediate reporting and investigation of such incidents, which was not followed in this case. The policy outlines that abuse includes hitting and rough handling, and all staff are required to report any alleged abuse immediately to the Abuse Coordinator.
Medication Administration Error for a Resident
Penalty
Summary
The facility failed to ensure medication was administered as ordered for a resident, identified as R3, who was reviewed for medication administration. R3's Medication Administration Record (MAR) and Physician Order Sheet (POS) indicated an order for Potassium chloride crys ER 20 meq tablet extended release to be given by mouth once a day every Monday, Wednesday, and Friday. However, R3 was administered this medication on a Thursday, which was not in accordance with the prescribed schedule. On the day of the incident, R3 was observed in bed with two plastic medication cups containing pills, including a large whitish pill identified as potassium. R3 expressed stress and confusion about the medication, stating that the nurse had not provided assistance in identifying the pills. The Registered Nurse (RN), identified as V16, was unaware that R3 had not taken the medication and proceeded to administer the potassium despite the error in timing. V16 did not document the administration of potassium at the correct time and signed off the scheduled medication as given at 9:00 am, although it was administered later. The facility's Director of Nursing (DON), identified as V2, confirmed that medications should be administered as ordered and not left at the bedside unless the resident is assessed to self-administer safely. The facility's policies on medication pass and physician orders emphasize adherence to federal and state regulations and following physician orders as written, which were not followed in this instance.
Failure to Label Enteral Feeding Bottles
Penalty
Summary
The facility failed to follow their policy on enteral tube feeding care by not labeling the date and time the feeding was started for two residents. Resident 2 (R2) had severe cognitive impairment and was on a Jevity1.5 enteral feeding at 75ml/hour. During an observation, it was noted that the nutritional supplement bottle was not labeled with the date and time it was started. The LPN on duty was unaware of when the feeding was initiated, which is against the facility's policy. Similarly, Resident 3 (R3), who also had severe cognitive impairment, was on a Jevity1.2 enteral feeding at 60ml/hour. The nutritional supplement bottle for R3 was also found without a date and time label, and the LPN did not know when it was started. Both residents' nutritional supplements were running at the prescribed rates, but the lack of labeling posed a risk for potential gastrointestinal issues and infections due to the possibility of using the supplement beyond the recommended 24-hour period. The Registered Dietitian and the Director of Nursing confirmed that the facility's policy requires the date and time to be labeled on the feeding bottles to ensure they are changed within 24 hours to prevent infections and ensure the residents receive fresh feedings. The failure to label the feeding bottles as per the policy was observed during the survey, and it was acknowledged by the staff that this oversight could lead to significant health risks for the residents, including gastrointestinal issues and potential infections due to compromised health conditions.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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