Alton Memorial Rehab & Therapy
Inspection history, citations, penalties and survey trends for this long-term care facility in Alton, Illinois.
- Location
- 1251 College Avenue, Alton, Illinois 62002
- CMS Provider Number
- 145121
- Inspections on file
- 26
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Alton Memorial Rehab & Therapy during CMS and state inspections, most recent first.
A resident on apixaban with known fall risk was being transferred from a shower chair to a wheelchair when a CNA and an RN assisted her without using a gait belt, despite noted weakness and buckling knees. The resident’s knees gave way, and staff lowered her to the floor; her face contacted a handrail, resulting in broken dentures, mouth bleeding, and later-identified bruising. The RN did not consider this a fall, did not notify the provider, did not obtain vitals or neuro checks, and did not complete any post-fall documentation, despite facility policies requiring a post-fall evaluation and neuro checks when the head is struck. About 12 hours later, an LPN assessed the resident’s mouth pain and dried blood, notified the NP, and the resident was sent to the ER, where facial contusion and other findings were documented after EKG, labs, head CT, and chest x-ray.
A resident with a documented fall risk and on Apixaban experienced a fall in the shower when their knees buckled, causing their face to strike a handrail, breaking dentures and resulting in bleeding and significant mouth pain. The nurse on duty at the time did not notify the provider or document the incident in the electronic record in a timely manner. The oncoming LPN the next morning learned of the fall in report, assessed the resident, and noted dried blood and pain, after which the NP was notified and the resident was sent to the ED. The NP later documented that the fall and suspected head/mouth injury had not been reported when it occurred, despite the resident’s anticoagulant use and a facility policy requiring immediate physician notification of serious incidents such as head injuries using SBAR and documenting provider notification in the chart.
The facility failed to adequately staff the dietary department, resulting in late meal service, particularly during dinner. A resident reported receiving dinner as late as 6:30 PM, despite the scheduled time being 5:30-6:00 PM. Staff confirmed that meal service is slower in the evenings, especially when only one person is working in the kitchen. The issue was previously discussed in a Resident Council Meeting, and the facility's dietary schedule showed understaffing during several dinner services.
A facility failed to report and investigate an alleged abuse incident involving a resident and a CNA. The resident felt abused after being handled roughly and left on a wet bed. Despite a family member's report and written statement, the facility administrator did not initiate an investigation or report the incident to authorities, allowing the CNA to continue working on the resident's floor.
A facility failed to investigate an abuse allegation involving a resident who reported being handled roughly by a CNA, resulting in spilled water and a wet bed. Despite the resident's and family's concerns, the facility's administrator did not initiate an investigation or implement protective measures. The facility's policy requires immediate investigation and reporting of abuse allegations, but this protocol was not followed, leading to a significant deficiency.
The facility failed to provide timely and complete incontinent care for several residents, leading to discomfort and embarrassment. One resident reported being left in a urine-soaked state all night, while others confirmed inadequate care and staffing issues during a Resident Council meeting. Observations revealed incomplete cleaning during care, contrary to the facility's perineal care policy.
A resident experienced a significant medication error when a six-day delay in starting an antibiotic for a UTI occurred due to miscommunication between nursing staff and a Physician Assistant. This delay led to increased confusion, pain, and missed therapy sessions, impacting the resident's recovery and therapy participation.
The facility failed to properly store and discard expired medications, potentially affecting all 45 residents. Expired medications, including Dulcolax and Acetaminophen suppositories, were found in the East Wing Medication Storage Room. LPNs confirmed these were stock medications for all residents, but expired medications should be destroyed. Staff interviews revealed inconsistencies in checking and discarding expired medications, despite procedures requiring their separation and destruction.
A resident was left in a soiled state overnight, compromising their dignity and comfort. The resident, who requires assistance for toileting, was found with soaked clothing and bedding, and not all areas were cleansed by the CNA. The resident expressed feelings of embarrassment and discomfort, and staff confirmed the resident's account of inadequate care and insufficient staffing.
The facility failed to submit MDS assessments for three residents within the required 14-day period. The assessments were submitted late, as confirmed by the Corporate Director of Reimbursement. The facility's protocol requires timely electronic transmission of assessments, which was not followed in these cases.
A resident was left in a soiled state overnight due to inadequate staffing, impacting their dignity and well-being. The resident, who requires assistance with daily living activities, reported feeling dirty and embarrassed after being left wet all night without being changed. This issue was corroborated by multiple residents during a Resident Council meeting, highlighting a systemic problem with staffing and care timeliness in the facility.
A resident sustained a significant injury during a transfer when a CNA failed to use a gait belt, as required by facility policy. The resident's fragile skin condition and low body weight contributed to the severity of the injury, which resulted in a large abrasion and laceration on her right calf. Multiple staff members documented the incident, confirming that the improper transfer technique led to the injury.
Failure to Follow Fall Policy, Use Gait Belt, and Perform Post-Fall Assessment After Shower Transfer Incident
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management and gait belt policies for a cognitively impaired resident identified as being at risk for falls and receiving apixaban for atrial fibrillation. The resident’s care plan required assistance with transfers and ambulation and specified maintaining appropriate bed height and call light access, but did not document whether a gait belt should be used, the number of staff required, or the mode of transfer. On the evening in question, a CNA requested assistance from an RN to transfer the resident from a shower chair to a wheelchair because the resident’s knees were buckling and she was weak. During the transfer, the CNA stood the resident up to hold the grab bar, moved the shower chair away, and the resident’s knees buckled; the CNA and RN then lowered the resident to the floor without a gait belt in use, despite the RN later acknowledging that a gait belt probably should have been used due to the resident’s weakness. Following this event, the RN observed a small amount of blood on the resident’s mouth and noted that the resident’s dentures were broken, but reported she did not see or hear the resident hit her mouth or head on the rail and therefore did not consider the incident a fall. The CNA later told the RN, about an hour afterward, that the resident’s face had hit the handrail, but the RN still did not notify the provider, did not complete a post-fall assessment, did not obtain vital signs, and did not perform neurological checks, despite facility policy requiring a post-fall evaluation and neuro checks for any fall in which the head was struck. There was no documentation in the electronic medical record on the date of the shower incident regarding a fall, being lowered to the floor, or the resident’s injuries, and no SBAR or post-fall assessment was completed at that time. Approximately 12 hours after the incident, an LPN coming on day shift received report that the resident had fallen in the shower, assessed the resident, and noted dried blood on the lip and complaints of significant mouth pain. The LPN immediately notified the nurse practitioner, who ordered transfer to the ER for evaluation and treatment. Emergency department records documented that the resident presented for evaluation of a fall the previous day with head and facial impact, jaw tenderness and pain on movement, lip abrasion, and bruising to the right upper extremity, and underwent EKG, blood work, head CT, and chest x-ray. The administrator and nurse practitioner both stated there was no documentation of the shower fall or post-fall assessments in the medical record, that the resident was not promptly sent to the ER despite being on a blood thinner, and that staff were expected to follow the facility’s fall and gait belt policies, including treating being lowered to the floor as a fall and using gait belts during transfers.
Failure to Notify Provider of Fall With Head/Mouth Injury for Anticoagulated Resident
Penalty
Summary
The deficiency involves the facility’s failure to notify the provider immediately after a resident experienced a fall with injury. The resident’s care plan dated 11/26/2025 documented that the resident was at risk for falls and required assistance with transfers and ambulation, with interventions including maintaining the bed at an appropriate height and ensuring the call light was within reach. According to an SBAR dated 12/22/2025 at 8:05 AM, an LPN documented that approximately 12 hours earlier the resident’s knees buckled in the shower room, causing the resident’s face to come into contact with a handrail and resulting in broken dentures, bleeding, and mouth pain rated 8/10. The resident was prescribed Apixaban (Eliquis), an anticoagulant, 5 mg BID. The LPN who worked the following day stated she received report that the resident had fallen in the shower, then assessed the resident and noted dried blood on the lip and complaints of mouth pain. She stated it was her understanding that the nurse on the prior shift had not notified the provider when the resident fell and hit her head. The nurse practitioner’s progress note dated 12/23/2025 documented that the fall was not reported to the provider until the oncoming nurse received report the following morning, and that the incident was not documented in the electronic medical record in a timely manner, with no nursing notes available for review. The NP noted that the resident was on Eliquis and that any reported or suspected head strike while on anticoagulation warrants immediate transfer to the emergency department and at minimum a STAT head CT. The NP stated she was not notified of the fall and head/mouth injury when it occurred and that she would have expected staff to notify her because of the resident’s anticoagulant use and need for physician assessment. The facility’s Reporting of Injuries Policy, revised 12/2025, states that serious incidents such as head injuries are to be reported to the physician at the time of occurrence, using SBAR to convey assessment findings and pertinent medication information, and that all charting should include notification of the doctor. These policy requirements were not followed for this resident’s fall with head/mouth injury.
Inadequate Dietary Staffing Leads to Late Meal Service
Penalty
Summary
The facility failed to adequately staff the dietary department, resulting in meals being served late, particularly during dinner service. This deficiency was observed in the case of a resident who reported receiving dinner as late as 6:30 PM and 6:35 PM, despite the scheduled dinner time being from 5:30 to 6:00 PM. The resident, who was cognitively intact and independent with eating, had a care plan goal to improve nutritional status and was on a carbohydrate-controlled diet. Interviews with staff, including a CNA, a dietary aid, and the dietary manager, confirmed that meal service tends to run slower in the evenings, especially when only one staff member is working in the kitchen. The issue of late meal service was previously discussed in a Resident Council Meeting, and the facility's dietary schedule showed that only one staff member was working during several dinner services. The facility administrator was unaware of the late meal service and stated that there was no policy regarding acceptable meal time frames, although meal times were posted. The deficiency was further supported by the facility's Resident Council Meeting Minutes, which documented the need for food to be served on time.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to report and investigate an alleged abuse incident involving a resident, identified as R2, in accordance with state law and facility policy. The incident involved a certified nursing assistant (CNA), V7, who allegedly handled R2 roughly, resulting in R2 feeling abused and frightened. R2 reported the incident to her family member, V5, who then informed the facility's licensed practical nurse (LPN), V6. Despite the family member's written statement and verbal communication of the incident, the facility administrator, V1, did not initiate an investigation or report the incident to the appropriate authorities. The report details that R2 was left on a wet bed after V7 allegedly mishandled her, causing distress and fear. R2's family member, V5, arrived at the facility to find R2 upset and the bed soaked with water. V5 cleaned the water and reported the incident to V6, who instructed V5 to write a statement and assured that V7 would not provide further care to R2. However, V7 continued to work on R2's floor the following day, indicating a lack of immediate action to protect R2 from further contact with V7. The facility's policy mandates immediate investigation and reporting of any abuse allegations, but V1 did not follow these procedures. V1 claimed not to have received any statements or allegations of abuse, despite V6's report and the statement placed under V1's door. The facility's failure to document and investigate the incident, as well as to report it to the state agency, constitutes a deficiency in ensuring resident safety and compliance with abuse reporting regulations.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to ensure that all abuse allegations were thoroughly investigated for one of the residents reviewed. The incident involved a resident, R2, who reported feeling abused by a male CNA, V7. R2 described an incident where V7 allegedly handled her roughly, causing water to spill on her and leaving her in a wet bed. R2 expressed fear and discomfort due to V7's actions, which she reported to her family member, V5. V5 corroborated R2's account, stating that upon arrival at the facility, they found R2 upset and the bed soaked with water. Despite V5's report to the LPN, V6, and the assurance that V7 would not provide further care to R2, V7 continued to work on R2's floor the following day. The facility's administrator, V1, did not initiate an investigation into the alleged abuse, nor were any protective measures put in place for R2. V1 claimed to be unaware of any abuse allegations, despite V6 stating that they had informed V1 and V2, the DON, about the family's concerns. The facility's policy mandates immediate investigation and reporting of any abuse allegations, but this protocol was not followed in R2's case. No documentation of the incident or any investigation was found in R2's medical records. The facility's failure to investigate the abuse allegation and implement protective measures for R2 represents a significant deficiency in adhering to their abuse prevention policy. The lack of communication and action from the facility's management, including the administrator and DON, contributed to the oversight. This deficiency highlights a breakdown in the facility's procedures for handling and investigating abuse allegations, leaving residents vulnerable to potential harm.
Inadequate Incontinent Care and Staffing Issues
Penalty
Summary
The facility failed to provide timely and complete incontinent care for five residents, resulting in significant discomfort and embarrassment for the residents involved. One resident, who is alert and oriented, reported being left in a urine-soaked state all night, leading to feelings of dirtiness, anger, and embarrassment. The resident expressed that there was insufficient staff to provide necessary care, and that only one CNA consistently provided proper cleaning. The resident's care plan required frequent toileting and peri care after each incontinent episode, but this was not adhered to, as evidenced by the resident's condition and statements. Another resident, who is moderately cognitively impaired and requires extensive assistance with ADLs, was observed receiving incomplete incontinent care. The staff failed to clean all wet areas, which is contrary to the facility's perineal care policy. The policy mandates cleaning from the cleanest to the dirtiest area to prevent infection and promote hygiene, but this was not followed during the observed care. Additional residents also reported inadequate care during a Resident Council meeting, citing insufficient staffing and delayed responses to call lights. One resident, who is cognitively intact and requires substantial assistance, stated that they often remained in soiled conditions due to staff not responding promptly. Another resident, who is also cognitively intact, confirmed assisting a roommate with toileting needs due to staff unavailability. These accounts highlight a systemic issue with staffing and care provision during night shifts, leading to unmet care needs and compromised resident dignity.
Medication Error Leads to Delay in Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of antibiotics for a urinary tract infection (UTI). The resident, who was admitted with multiple diagnoses including a displaced intertrochanteric fracture, Parkinson's disease, and rheumatoid arthritis, was ordered a course of ciprofloxacin by a Physician Assistant on 9/27/24. However, due to a miscommunication between the nurse and the Physician Assistant, the antibiotic was not administered until 10/2/24, resulting in a six-day delay. During this period, the resident experienced increased confusion, abdominal pain, and leg pain, which affected their ability to participate in therapy sessions. The resident's therapy progress notes indicated a decline in performance, with increased assistance required for tasks and decreased mobility. The resident's wife expressed concerns about the delay in treatment and its impact on the resident's therapy and overall condition. The facility's Director of Nursing acknowledged the medication error and attributed it to miscommunication. The incident was documented in a medication error report, and the delay in starting the antibiotic was noted. The resident's wife also reported that the resident was administered oxycodone for pain during the delay, which contributed to the resident being 'zoned out' and unable to participate in therapy effectively.
Improper Storage and Handling of Expired Medications
Penalty
Summary
The facility failed to properly store medications and ensure expired medications were discarded appropriately, which could potentially affect all 45 residents. During an inspection of the East Wing Medication Storage Room, surveyors found expired medications, including a Dulcolax suppository with an expiration date of January 2023, two Acetaminophen 650mg suppositories with an expiration date of April 2024, and a large bottle of stool softener with an expiration date of March 2022. Licensed Practical Nurses (LPNs) confirmed that these medications were stock medications intended for use by all residents, provided there was an order and no allergies. They also acknowledged that expired medications should not be used and must be destroyed. Interviews with staff revealed inconsistencies in the process of checking and discarding expired medications. The Nurse Supervisor and Central Supply person were unsure why expired medications were present, despite procedures stating that expired medications should be separated and destroyed. The facility's Pharmacy Services and Procedure Manual outlines that medications with expired dates should be stored separately until destroyed or returned. However, the staff's statements indicated a lack of clarity and adherence to these procedures, as expired medications were found in the storage room, and there was confusion about the responsibility for checking and removing them.
Resident's Dignity Compromised Due to Inadequate Incontinent Care
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and had their needs met in a timely manner. The resident, identified as R23, was observed to be incontinent of urine and required assistance from staff for toileting. On the morning of October 7, 2024, a CNA, identified as V5, was observed providing incontinent care to R23. The resident's gown, incontinent brief, pad, and sheets were soaked with urine, indicating that the resident had been left in a soiled state for an extended period. V5 did not cleanse all areas of incontinence, leaving R23's inner thighs and back uncleaned. R23 expressed feelings of embarrassment, anger, and discomfort due to being left wet all night and not being properly cleaned by the staff. Interviews with the resident and staff confirmed the resident's account of the events. R23 stated that she had been wet all night and that there was insufficient staff to attend to her needs. The resident reported feeling dirty, angry, and embarrassed, and mentioned that she had to rely on her roommate for assistance at times. Staff members, including a Nurse Supervisor and an LPN, corroborated the resident's statements, acknowledging that R23 was alert and oriented and that her account of the situation was accurate. The facility's Resident Handbook emphasizes the right of residents to be treated with dignity and respect, which was not upheld in this instance.
Late Submission of MDS Assessments
Penalty
Summary
The facility failed to complete and transmit the comprehensive Minimum Data Set (MDS) assessments within the required time frame for three residents. The assessments for these residents were not submitted within the 14-day period following the MDS completion date, as required by the facility's protocol. Specifically, the assessments for residents R28, R23, and R16 were all submitted late, with submission and processing dates recorded as October 8, 2024, which is more than 14 days after the respective completion dates. The MDS Coordinator, V29, was unsure why the assessments were overdue, while the Corporate Director of Reimbursement, V30, acknowledged that the assessments were submitted late. The facility's protocol mandates that comprehensive assessments be transmitted electronically within 14 days of the Care Plan Completion Date, and all other MDS assessments within 14 days of the MDS Completion Date. The failure to adhere to these timelines resulted in the deficiency noted in the report.
Inadequate Staffing Leads to Resident Neglect
Penalty
Summary
The facility failed to ensure sufficient nursing staff to provide necessary care for residents, impacting their physical, mental, and psychosocial well-being. This deficiency was observed through the experience of a resident, R23, who was left in a soiled state overnight due to inadequate staffing. R23, who is occasionally incontinent of urine and requires assistance with activities of daily living, reported feeling dirty, angry, and embarrassed after being left wet all night without being changed. The resident's care plan required frequent toileting and peri care, which was not adhered to, leading to discomfort and a loss of dignity. During an observation, a CNA, V5, was seen providing care to R23, who was found heavily soiled with urine. The CNA did not fully cleanse all areas of incontinence, leaving R23's inner thighs and back uncleaned. R23 expressed dissatisfaction with the care received, stating that only one CNA consistently provided proper care, while others failed to clean her adequately. The resident also mentioned that her roommate had to assist her with toileting needs due to the lack of staff response to call lights. The issue of insufficient staffing was further corroborated during a Resident Council meeting, where multiple residents, including R23, R24, R31, and R33, voiced concerns about the lack of staff and the timeliness of incontinent care. These residents reported similar experiences of being left in soiled conditions for extended periods due to staff not answering call lights or failing to return after promising assistance. The facility's policy on staffing was not effectively implemented, as evidenced by the residents' complaints and the observations made by the surveyors.
Failure to Ensure Safe Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure a safe transfer for one resident, resulting in a significant injury. The resident, who had a history of abnormal weight loss, severe protein-calorie malnutrition, and other health issues, sustained a large abrasion and laceration on her right calf during a transfer. The incident occurred when a CNA attempted to transfer the resident from a wheelchair to a bed without using a gait belt, as required by the facility's policy. The resident began to slide out of the wheelchair, and in the process of preventing her from falling, the CNA caused the resident's leg to hit the footboard, resulting in a severe skin tear and bleeding. The resident's fragile skin condition and low body weight contributed to the severity of the injury. The incident was documented by multiple staff members, including the DON and a nurse practitioner, who confirmed that the resident's injury was due to the improper transfer technique. The facility's policy mandates the use of gait belts for all transfers unless there is a medical contraindication, which was not the case for this resident. The CNA admitted to not using a gait belt during the transfer, which directly led to the resident's injury. The facility's Director of Nursing stated that she expected staff to follow the policy and use gait belts for all transfers to ensure resident safety. The failure to adhere to this policy resulted in the resident sustaining a significant wound that required ongoing wound care.
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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