Avenues At Royal Oak
Inspection history, citations, penalties and survey trends for this long-term care facility in Kewanee, Illinois.
- Location
- 605 East Church Street, Kewanee, Illinois 61443
- CMS Provider Number
- 145418
- Inspections on file
- 46
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Avenues At Royal Oak during CMS and state inspections, most recent first.
Two residents engaged in a physical altercation when a cognitively impaired male resident wandered into a roommate’s room from a shared bathroom and the cognitively intact roommate reacted by placing an arm around his neck while both were on the floor, with shouting and hair-pulling observed by staff. In a separate event, a cognitively intact male resident with multiple psychiatric and medical diagnoses repeatedly directed racial slurs at a dietary staff member, who responded by yelling profanities back, moving toward the resident as if to strike, and verbally challenging him, requiring other staff to intervene to separate and de-escalate the situation.
A bariatric resident with diabetes and bipolar disorder, weighing 426 lbs and requiring specialized equipment, was discharged to another nursing home without proper verification, documentation, or discharge instructions. Social services did not clearly document or confirm the receiving facility, and the administrator of the intended facility reported the resident was never admitted there. Upon arrival, the intended facility lacked a bariatric bed and wheelchair, leading to the resident being sent to the ER, where a different nursing home was found. The discharging LPN provided only medications without written discharge papers, contrary to the DON’s expectations and facility policy requiring documented communication of necessary information and DME needs to the receiving institution.
The facility failed to follow its abuse prevention and reporting policy when a CNA reported finding a transportation aide alone in a resident’s room with the door closed, the resident’s shirt pulled up exposing her bra, and the aide behind the door repeatedly saying, “don’t say anything.” The aide later stated he was delivering a sandwich related to a football bet and denied inappropriate behavior, and the resident gave the same account. The Administrator, who is the aide’s sibling, was informed of these details by the DON and CNA but concluded the CNA was making trouble, did not treat the event as potential abuse, and did not report the incident to the state agency or local law enforcement.
The facility failed to report a potential allegation of sexual abuse involving a resident and a transportation aide to the state agency and local law enforcement, despite a policy requiring immediate reporting of any abuse allegations. A CNA reported finding the aide behind the door in the resident’s room with the door closed, while the resident had her shirt up covering her face and her bra exposed, and the aide allegedly provided the resident a sandwich over a football bet. The Administrator, who acknowledged awareness of the incident and that the aide is her brother, stated she was informed by the DON and CNA, but after consulting corporate staff, decided the CNA was making trouble and did not consider the situation potential abuse, resulting in no report being made to authorities.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. The report does not specify further details about the individuals involved or the exact nature of the hazards.
A resident with severe cognitive impairment and a history of hip surgery experienced a fall resulting in a hip fracture. Despite repeated complaints and signs of pain observed by staff, there was inadequate pain assessment, lack of documentation of pain complaints, and no recorded administration of ordered pain medication. The facility did not follow its pain management policy, leading to unrelieved pain for the resident while awaiting further evaluation and treatment.
Two residents experienced physical abuse from peers when staff were not present to supervise or intervene. In one case, a resident with a history of aggression struck another after a hallway altercation, and in another, a resident swatted at a peer's hand during a dining room incident. Both events involved individuals with behavioral health histories, and neither aggressor had documented aggression screening, highlighting lapses in supervision and risk assessment.
A resident with a history of chronic health conditions and major depressive disorder struck another resident with a crutch, causing a laceration. The incident occurred due to agitation over noises made by the victim, who has paranoid schizophrenia. The facility failed to prevent this abuse, despite having a policy on abuse prevention.
A facility failed to update a PASARR screen for a resident after a new diagnosis of severe recurrent major depression with psychotic features. Despite the resident's significant behavioral changes and the facility's policy requiring a PASARR Level 1 screen with any significant change of status, no updated screen was performed.
A high-risk resident with multiple mental health conditions was involved in a physical altercation with another resident, both having traumatic brain injuries. The incident occurred in the dining room, where one resident punched the other in the face. Despite immediate separation and no injuries reported, discrepancies in staff accounts and the facility's investigation raised concerns about the adequacy of supervision and preventive measures.
The facility failed to monitor and document food temperatures, leading to meals being served at inadequate temperatures. Residents expressed dissatisfaction with cold meals, and the Dietary Manager acknowledged issues with staff not documenting temperatures and delays in serving trays. This affected all 132 residents receiving meal trays.
The facility failed to provide residents access to their personal funds following a change in ownership, affecting 100 residents. The previous company took all funds, leaving the new management without sufficient resources. Residents reported being unable to access their money, with some receiving as little as four dollars a week, and banking hours were reduced. The administration acknowledged the issue, attributing it to the transition and insufficient funds from the new company.
A resident reported being inappropriately touched by an LPN during a search for missing hand sanitizer. Despite the facility's policy requiring immediate reporting of abuse allegations, the incident was not reported to the State Agency or Law Enforcement until three days later. The DON and Interim Administrator were informed of the incident but did not act on it as a reportable abuse incident until prompted by a State Surveyor.
A resident reported being inappropriately touched by an LPN during a search for missing hand sanitizer. Despite the facility's policy to protect residents by removing accused staff, the LPN returned to work the next day due to a scheduling error. The incident was reported to the Ombudsman and the State, highlighting a deficiency in the facility's response to the allegation.
A resident with multiple diagnoses, including bipolar disorder and obesity, reported verbal abuse by a night shift CNA, who made derogatory remarks about her weight and menstrual condition. Other CNAs confirmed the resident's complaints, but the facility failed to address the issue, despite having a policy against such abuse.
A resident with multiple diagnoses, including bipolar disorder, reported verbal abuse by a night shift CNA, who allegedly made derogatory comments and refused assistance. Despite the resident's complaints, staff failed to report these allegations to the CNA supervisor or administrator, violating the facility's policy on immediate reporting of abuse.
A resident with multiple health conditions was injured during a transfer using a mechanical lift due to a CNA attempting the procedure alone, contrary to the care plan requiring two to three staff members. The incident led to a hospital visit for a back contusion and ongoing fear of transfers. The facility's failure to ensure proper staffing and equipment maintenance contributed to the incident.
A resident did not receive prescribed medications for several days due to a failure in transcribing hospital orders to the Medication Administration Record. The LPN used paper prescriptions instead of the hospital transfer sheet, leading to a lapse in medication administration, as confirmed by the Assistant Director of Nurses.
The facility failed to implement Enhanced Barrier Precautions and Contact Precautions, as staff were observed performing catheter and wound care without proper PPE. The Infection Preventionist confirmed that precautions were not implemented for several residents with wounds or medical devices, risking MDRO transmission.
The facility failed to implement its Antibiotic Stewardship Program, lacking protocols to review clinical signs and symptoms before administering antibiotics. The Assistant Director of Nursing/Infection Preventionist admitted that the facility does not use assessment tools or management algorithms, affecting all 132 residents by potentially exposing them to unnecessary antibiotic use.
The facility's Infection Preventionist, also the Assistant DON, failed to implement necessary infection control measures, including Enhanced Barrier Precautions and Contact Isolation Precautions, due to insufficient time and guidance. Additionally, the facility lacked protocols for antibiotic use, relying on doctor orders without assessment tools, affecting all 132 residents.
The facility failed to respond to resident call lights in a timely manner, affecting multiple residents. Residents reported excessive wait times, particularly during the third shift, with some waiting over an hour for assistance. The call light system lacks an audible alert, contributing to delays. A staff member was terminated for sleeping on the job, which was expected to improve response times.
The facility failed to ensure that the electronic medical records and care plans of two residents matched their POLST regarding CPR code status. One resident's records indicated a Full Code status, while the POLST indicated DNAR. Another resident's records showed a Full Code status, but the POLST indicated DNR with comfort-focused treatment. These discrepancies were confirmed by facility staff.
A facility failed to implement a baseline care plan for a newly admitted resident with complex mental health diagnoses, including Borderline Personality Disorder and PTSD. Despite the facility's policy requiring a care plan within 48 hours of admission, the Care Plan Coordinator confirmed that no such plan was developed for the resident, who has a history of self-harming behaviors and substance use.
A resident with MRSA in a right ankle wound did not receive proper wound care due to a failure in hand hygiene by an LPN. The LPN did not wash hands after glove removal and before donning new gloves, and placed contaminated scissors on a bedside table. The resident was on Contact Precautions, but the LPN did not adhere to the facility's infection control policies, risking cross-contamination.
A facility failed to implement ROM exercises for a resident with limited mobility due to a stroke. The resident, non-ambulatory and dependent on caregivers, had a Passive ROM Program order incorrectly entered as PRN instead of every day, every shift. This error was confirmed by the administrator, leading to a deficiency in providing necessary restorative care.
A facility failed to provide proper care for a resident with an indwelling urinary catheter. The catheter tubing and drainage bag were found on the floor without a privacy cover, and during a transfer, a CNA improperly raised the catheter bag above the resident's bladder. Staff acknowledged these errors.
A facility failed to coordinate care and communicate with a dialysis center for a resident with End Stage Renal Disease. The care plan lacked essential elements like dialysis schedule, medication changes, and emergency protocols. Staff did not send required communication forms with the resident to the dialysis center, as confirmed by the DON. This led to a deficiency in providing appropriate dialysis care.
A facility failed to provide necessary psychosocial therapies and psychiatric support to a resident with Adjustment Disorder and Major Depressive Disorder, leading to repeated ER visits for suicidal ideations. Despite the care plan and PASRR recommendations, the resident did not receive required psychiatric counseling or therapy services, with only one telehealth session documented. The facility lacked documentation of any refusals by the resident for these services.
Two residents in a LTC facility were involved in a physical altercation, resulting in one resident receiving a black eye. The incident, which was not witnessed by staff, occurred during an argument over a boyfriend. Both residents have mental health disorders, and the facility's failure to prevent the altercation indicates a deficiency in their Abuse Prevention Program.
The facility failed to follow physician orders and have Speech Therapy services assess the swallowing needs of two residents after choking incidents. One resident choked on a biscuit and was sent to the emergency room, while another choked on lettuce and was also hospitalized. Despite physician orders for Speech Therapy evaluations, neither resident received the mandated assessments, constituting a deficiency in the provision of specialized rehabilitative services.
Failure to Protect Residents From Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical and verbal abuse. In one incident, a male resident with dementia, anxiety, chronic pain, and moderate cognitive impairment wandered from a shared bathroom into his roommate’s room during the night. The cognitively intact roommate, who was new to the facility, reacted by placing his arm loosely around the first resident’s neck while both ended up on the floor. Staff heard shouting and found the two residents on the floor, with one resident’s arm around the other’s neck in a choke hold and the other resident pulling hair and yelling to be released. Staff separated and assessed the residents, and the administrator later confirmed that the physical altercation was substantiated and that the cognitively impaired resident had wandered into the roommate’s room. In a separate incident, the facility failed to prevent verbal abuse and threatening behavior between a cognitively intact male resident and a dietary staff member. The resident, who had diagnoses including edema, type 2 diabetes, antisocial personality disorder, bipolar disorder, and major depression, admitted to calling the dietary staff member racial slurs. Multiple staff witnesses reported that the resident was screaming racial slurs at the staff member, who responded by shouting back, using profanity, and moving toward the resident as if to strike him, while verbally challenging the resident and stating that nobody talks to him like that. Another staff member intervened by stepping between them with hands raised to keep them separated and de-escalate the situation. The facility’s abuse policy affirms residents’ rights to be free from abuse, including physical and verbal abuse, but the described events show that residents were subjected to both physical and verbal mistreatment.
Failure to Safely Coordinate and Document Bariatric Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to safely discharge a resident with significant medical and equipment needs. The resident had diagnoses including diabetes and bipolar disorder, no documented cognitive impairment, and a recorded weight of 426 lbs, requiring bariatric equipment. The face sheet listed the discharge destination only as an unknown nursing home, and the facility assessment and records did not clearly document the receiving facility. The social services staff member reported that the resident was transferred approximately 145 miles away to a nursing home that accepted bariatric residents, but she did not verify the resident’s status after transfer, could not recall whom she spoke with at the receiving facility, and did not document this communication in the medical record. The administrator of the intended receiving nursing home stated that the resident was never admitted there. The resident and a family member reported that upon arrival at the intended nursing home, the facility did not have a bariatric bed or bariatric wheelchair available, and the resident became anxious with palpitations and was sent to the ER. The hospital then arranged placement at a different nursing home that had the needed equipment. The LPN who discharged the resident stated she sent only the resident’s discharge medications and did not provide any additional discharge papers because she was not instructed to do so. The DON stated that discharge to another nursing home should include written discharge instructions such as a medication list, equipment needs, and a copy retained in the medical record to ensure continuity of care and safety. The facility’s own policy on notice of transfer and discharge required documentation of the transfer in the medical record, communication of appropriate information to the receiving institution, and review of necessary items including DME, prescriptions, appointments, and treatments, which was not followed in this case.
Failure to Recognize and Report Potential Sexual Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to implement its Abuse Prevention and Reporting policy when presented with a situation that met criteria for a potential sexual abuse allegation. The facility’s policy, effective 12/2025, states that residents have the right to be free from abuse, neglect, exploitation, and misappropriation of property, and that staff will be oriented and trained on what constitutes abuse and how to recognize and report incidents or allegations. A Resident Grievance form dated 12/8/25 documented that a CNA reported finding a transportation driver in a resident’s room with the door closed; when the CNA partially entered, the resident had her shirt pulled up, covering her face, and her bra exposed. Once the CNA was able to fully enter the room, the transportation driver was found behind the door, facing the resident, and he repeatedly stated, “don’t say anything.” The grievance also documented the driver’s explanation that he was delivering a sub sandwich to the resident over a football bet and that he denied any inappropriate behavior, and that the resident gave the same account when questioned. During an interview, the Administrator confirmed awareness of the situation between the resident and the transportation aide and stated she had been called at home by the DON, with the CNA present, and informed of what the CNA had witnessed. The Administrator acknowledged that the CNA had reported seeing the resident with her shirt up and bra exposed, and the transportation aide behind the door, and that the aide had repeatedly told the CNA not to say anything. The Administrator stated she consulted with corporate staff and they concluded that the CNA was making trouble because she knew the aide was the Administrator’s brother and wanted to get him in trouble. The Administrator stated she did not consider the situation to be potential abuse, did not report it to the state agency, and did not notify local law enforcement, despite the facility’s policy requiring recognition and reporting of occurrences and allegations of abuse. This failure to recognize and report a potential sexual abuse allegation for one of four residents reviewed for abuse led to the cited deficiency.
Failure to Report Allegation of Potential Sexual Abuse to Authorities
Penalty
Summary
The facility failed to report a potential allegation of sexual abuse to the state agency or local law enforcement as required by its Abuse Prevention and Reporting policy. The policy, effective 12/2025, states that any allegation of abuse will be reported to the state agency immediately and that local law enforcement will be contacted in situations involving sexual abuse of a resident by a staff member. A Resident Grievance form dated 12/8/25, signed by the Assistant Administrator, documents that a CNA reported attempting to enter a resident’s room and finding the transportation driver behind the door while the resident had her shirt up and bra exposed, with the driver allegedly giving the resident a sub sandwich over a football bet. During an interview on 01/10/2026, the Administrator stated she was aware of the situation between the resident and the transportation aide, who is her brother. She reported being called at home by the DON, with the CNA present, and was informed that the CNA had witnessed the transportation aide in the resident’s room with the door closed, the resident with her shirt up covering her face and exposing her bra, and the aide behind the door facing the resident. The Administrator stated that when the CNA entered the room, the aide raised his arms and repeatedly said, “don’t say anything.” The Administrator further stated that after conferring with corporate staff, it was decided that the CNA was making trouble because she knew the aide was the Administrator’s brother, and the Administrator concluded the situation was not potential abuse. Based on this conclusion, she did not report the situation to the state agency and did not notify local law enforcement, contrary to facility policy.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions by staff or details about the residents involved are not provided in the report. No further information about the circumstances or individuals involved is included.
Failure to Assess, Document, and Manage Pain Following Resident Fall
Penalty
Summary
The facility failed to follow its pain management policy and procedure by not adequately assessing, documenting, or treating a resident's pain following a fall that resulted in a significant injury. The resident, who had a history of dementia, neurocognitive disorder, and a right artificial hip joint, experienced a fall and subsequently showed signs of pain, including vocalizations and physical resistance during care. Despite these indications, there was a lack of consistent pain assessments, documentation of pain complaints, and administration of pain medication as ordered. Multiple staff interviews revealed that the resident expressed pain throughout the night after the fall, particularly when being moved or touched, and staff observed bruising and other signs of injury. However, the medical record did not reflect these complaints or the interventions taken, such as administration of acetaminophen or use of non-pharmacological measures like ice packs. The medication administration record showed no documented administration of pain medication during the relevant period, despite orders for as-needed acetaminophen and documented pain scores. The facility's pain management policy required documentation of pain assessment and monitoring, but this was not followed. The Director of Nursing confirmed that there were no new pain management orders post-fall and that documentation of pain complaints and medication administration was expected. The lack of timely and thorough pain assessment, documentation, and intervention resulted in the resident experiencing unrelieved pain while awaiting further evaluation and treatment for a hip fracture.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two vulnerable residents from resident-to-resident physical abuse. In the first incident, one resident in a wheelchair attempted to move past another resident in a hallway, making physical contact. The standing resident, who had a history of bipolar II disorder, anxiety, PTSD, and prior verbal/physical aggression, responded by hitting the resident in the wheelchair on the head. Both residents were assessed as having no cognitive impairment, and both had documented histories of behavioral issues and high risk for abuse/neglect. No staff were present to witness or intervene during the altercation, and there was no documented aggression screening for the resident who initiated the physical contact. Staff were supposed to monitor the area but were not present at the time of the incident. In the second incident, a resident with severe cognitive impairment reached for another resident's drink at the dining table. The other resident, who had no cognitive impairment but a history of major depressive disorder and prior peer conflict, reacted by swatting the first resident's hand. This incident was witnessed by the Assistant Director of Nursing, who observed that no other staff were nearby, as aides were occupied picking up trays in the vicinity. The resident who initiated the physical contact had no documented aggression screening in their medical record, despite a history of behavioral issues. Both incidents involved residents with documented behavioral and psychiatric histories, and in both cases, staff were either not present or not actively monitoring the areas where the altercations occurred. The lack of staff supervision and absence of aggression screening for residents with known behavioral risks contributed to the facility's failure to prevent resident-to-resident physical abuse.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. The incident involved two residents, one of whom struck the other with a crutch, resulting in a 2 cm laceration to the left forearm of the victim. The altercation occurred because the aggressor was agitated by noises made by the victim. The facility's policy on abuse prevention and reporting was not effectively implemented to prevent this incident. The aggressor, who has a history of chronic health conditions and major depressive disorder, admitted to hitting the victim due to being disturbed by the victim's noises. The victim, who has paranoid schizophrenia and other mental health issues, was injured during the altercation. The facility's investigation revealed that there were no witnesses to the incident, and the residents were in their room when the altercation occurred. The facility's response included separating the residents and notifying relevant parties, but the deficiency lies in the failure to prevent the abuse from occurring in the first place.
Failure to Update PASARR Screen After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to perform a PASARR rescreen for a resident after the emergence of a newly diagnosed severe mental illness. The facility's policy requires a PASARR Level 1 screen to be completed annually and with any significant change of status. This includes reporting any changes to the state mental health authority or the state intellectual disability authority promptly. However, the facility did not adhere to this policy for one resident who was diagnosed with severe recurrent major depression with psychotic features. The resident, who was admitted with diagnoses including right above the knee amputation, chronic diastolic heart failure, chronic obstructive pulmonary disease, and alcohol abuse, exhibited significant behavioral changes. These changes included responding to internal stimuli, verbal outbursts, and an attempt to attack another resident. Despite these developments and the psychiatric note indicating a serious mental illness, the facility did not update the PASARR screen as required. The administrator confirmed that no updated PASARR screen had been performed following the documented diagnosis.
Failure to Protect High-Risk Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a high-risk resident from physical abuse, as evidenced by an incident involving two residents with traumatic brain injuries. Resident 1, who has a history of bipolar disorder, anxiety, depression, and other conditions, was identified as high risk for abuse. Despite this, an altercation occurred in the dining room where Resident 2, who also has a traumatic brain injury and other mental health issues, approached Resident 1 and made physical contact with their face. The incident was initially described as a slap, but later accounts from staff indicated that Resident 2 punched Resident 1 with a closed fist. Both residents were separated immediately, and no injuries were reported. The facility's investigation concluded that the incident did not constitute abuse, as there was no intent to harm. However, discrepancies in staff accounts of the event suggest a lack of clarity in the facility's response and documentation. The facility's policy requires that resident-to-resident altercations be reviewed as potential abuse situations, yet the investigation did not substantiate abuse. The report highlights the impulsive behavior of both residents due to their medical conditions, but it does not address the adequacy of supervision or preventive measures in place to protect high-risk residents from such incidents.
Failure to Monitor and Document Food Temperatures
Penalty
Summary
The facility failed to monitor and document food temperatures to ensure meals were served at a palatable temperature, affecting all residents. The facility's policy, last revised in September 2023, mandates that food temperatures be taken and documented before serving to prevent foodborne illness and ensure palatability. However, food temperature logs were incomplete for several weeks, with no documentation for the evening meals from December 4 to December 28, 2024, and missing records for B and C Halls between November 13 and December 18, 2024. This lack of documentation and monitoring led to residents receiving meals at inadequate temperatures. Residents expressed dissatisfaction with the temperature of their meals during Resident Council Meetings, noting that food was often served cold. On December 17, 2024, a resident reported that their food was cold and staff refused to reheat it. Another resident's meal was found to be at a low temperature, with mashed potatoes at 108 degrees Fahrenheit and carrots at 110 degrees Fahrenheit. The Dietary Manager acknowledged issues with staff obtaining but not documenting temperatures and noted that delays in serving trays, especially on weekends, contributed to the problem. The facility roster indicated that all 132 residents received meal trays, highlighting the widespread impact of this deficiency.
Facility Fails to Provide Residents Access to Personal Funds
Penalty
Summary
The facility failed to ensure that residents had access to their personal funds, affecting 100 out of 100 residents reviewed for personal funds management. The facility's policy stated that residents should have access to petty cash and be able to arrange for access to larger funds, with specific timelines for accessing different amounts. However, since the facility changed ownership on November 1st, 2024, residents have been unable to access their funds as needed. The previous company took all the resident funds from the cash box, leaving the new management without sufficient funds to meet residents' requests. Residents reported being unable to access their money, with some only receiving as little as four dollars in a week. The facility's banking hours were reduced from twice a week to once a week, and residents were limited to withdrawing ten dollars at a time. This situation left residents unable to purchase personal items or gifts, particularly during the holiday season. The Business Office Manager and Social Service Director confirmed the lack of funds and the inability to fulfill residents' requests, attributing the issue to the transition in ownership and the insufficient funds provided by the new company. The facility's administration acknowledged the problem, stating that the new company did not account for the number of residents and their financial needs. The facility was still in the process of resolving the issue, but in the meantime, residents continued to experience restricted access to their personal funds, causing frustration and dissatisfaction among them.
Failure to Report Alleged Sexual Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of employee-to-resident sexual abuse to the State Agency and Law Enforcement in a timely manner. The incident involved a resident who reported that an LPN entered his bathroom and inappropriately touched his groin area during a search for missing hand sanitizer. The resident reported the incident to the Ombudsman and the State, and it was noted that all the nurses were aware of the situation. Despite the resident's report, the facility did not notify the State Agency or Law Enforcement immediately as required by their policy. The facility's policy mandates that any allegation of abuse must be reported to the State Agency immediately, but not more than two hours after the allegation. However, the report to the State Regional Office was not made until three days after the incident. The facility's Director of Nursing (DON) was informed of the incident on the night it occurred but focused on the medical aspect of the resident potentially ingesting hand sanitizer rather than the abuse allegation. The Interim Administrator was also informed of the nature of the allegation on the day it occurred but did not act on it as a reportable abuse incident until prompted by a State Surveyor. The report indicates that the facility's failure to report the incident promptly was due to a misinterpretation of the situation as a behavioral issue rather than a serious allegation of sexual abuse. Written statements from staff were obtained, but the facility did not provide evidence that Law Enforcement was notified. The delay in reporting the incident to the appropriate authorities constitutes a deficiency in the facility's abuse prevention and reporting procedures.
Failure to Protect Resident After Allegation of Sexual Abuse
Penalty
Summary
The facility failed to protect a resident after an allegation of sexual abuse by an employee was reported. The incident involved a Licensed Practical Nurse (LPN) who allegedly entered a resident's bathroom while the resident was on the toilet and inappropriately touched the resident's groin area during a search for missing hand sanitizer. The resident reported the incident to the Ombudsman and the State, and it was noted that the LPN was initially removed from the facility but returned the following day and was assigned to the same resident. The facility's policy on abuse prevention and reporting requires immediate protection of residents involved in such allegations, including removing the accused employee from resident contact until the investigation is complete. However, the LPN returned to work the next day due to a scheduling mistake, which was acknowledged by the Director of Nursing (DON). The incident was reported to the Interim Administrator, and the LPN was eventually removed from the facility, but the initial failure to prevent the LPN's return to work constituted a deficiency in protecting the resident.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R9, from verbal abuse by a night shift CNA, V15. R9, who has multiple diagnoses including bipolar disorder and obesity, reported feeling insecure and degraded by V15's comments. R9 stated that V15 made derogatory remarks about her weight and menstrual condition, which made her feel humiliated. Other CNAs, V11 and V12, confirmed that R9 had complained about V15's behavior, including ignoring her call light and making derogatory comments. However, these complaints were not addressed by the CNA supervisor, V10, who claimed not to have received any reports of verbal abuse. The facility's policy on abuse prevention and reporting emphasizes the residents' right to be free from abuse, including mental and verbal abuse. Despite this policy, the facility did not take appropriate action to investigate or address the allegations made by R9. The administrator, V1, acknowledged that such behavior would be considered abuse, yet there was no evidence of any follow-up or corrective measures taken to address the situation. Attempts to contact V15 for her account of the events were unsuccessful, leaving the issue unresolved.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure that allegations of abuse were immediately reported to the administrator for a resident who was cognitively intact and had multiple diagnoses, including bipolar disorder and borderline personality disorder. The resident expressed concerns about a night shift CNA, who allegedly made derogatory comments about her weight and refused to assist her properly during her menstrual period. The resident felt insecure and reported that some staff ignored her call light and grievances, leading to a lack of response to her complaints. Interviews with other CNAs revealed that the resident had complained about verbal abuse involving the same CNA, but these complaints were not reported to the CNA supervisor or the administrator. The CNA supervisor and the administrator both stated they had not received any reports of verbal abuse towards the resident. The facility's policy requires employees to report any incidents or suspicions of abuse immediately to the administrator, but this protocol was not followed, resulting in the deficiency.
Failure to Ensure Safe Transfer with Mechanical Lift
Penalty
Summary
The facility failed to ensure the safe transfer of a resident using a full mechanical lift, resulting in the resident being sent to the hospital with a back contusion. The resident, identified as R84, has multiple diagnoses including Bipolar Disorder, Deep Vein Thrombosis, Neurogenic Bladder, Diabetes Mellitus, Anxiety Disorder, Depression, and Obesity. The care plan for R84 indicated the need for a mechanical lift and two to three staff members for transfers due to limited mobility and morbid obesity. However, on the day of the incident, the resident was transferred by a single Certified Nurse Aide (CNA), V15, which led to the resident slipping out of the sling and sustaining an injury. The incident occurred when R84 requested to use the restroom and was hooked up to the mechanical lift by V15. Despite the care plan's requirement for multiple staff members, V15 attempted the transfer alone due to a lack of available staff. The CNA's personnel file indicated a lack of documented completion of mechanical lift training, and although V15 had received training in the past, the incident report noted that the fall was due to the improper use of the lift without the assistance of additional staff. The manufacturer's guidelines also recommended two assistants for safe operation, although it allowed for one assistant based on professional evaluation. Following the incident, the resident expressed fear of being transferred with the mechanical lift, citing concerns about the equipment's condition, including issues with the lift's legs and the availability of appropriately sized slings. The facility's failure to adhere to the care plan and ensure proper staffing and equipment maintenance contributed to the resident's injury and ongoing psychosocial distress.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to administer medications as prescribed for a resident, identified as R232, who was reviewed for medication administration. The facility's Medication Administration policy requires that medications be administered according to physician orders and documented accordingly. However, from September 18, 2024, to September 24, 2024, there was no documentation that R232 received their prescribed medications, including Albuterol, Amlodipine, Emtricitabine/Tenofovir, Fluticasone Propionate, and Folic Acid. This lapse occurred because the medications were not transcribed from the hospital transfer sheet to the Medication Administration Record, as confirmed by the Assistant Director of Nurses. The deficiency was identified during an interview with a Licensed Practical Nurse (LPN), who admitted the resident on September 18, 2024. The LPN stated that they used paper prescriptions and pill bottles to create the medication sign-out sheet, rather than following the facility's process of using the hospital transfer sheet. This deviation from protocol resulted in the resident not receiving their prescribed medications for several days, as confirmed by the Assistant Director of Nurses.
Failure to Implement Infection Control Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and Contact Precautions to prevent the spread of multi-drug resistant organisms (MDROs) among its 132 residents. The facility's EBP policy, dated July 13, 2023, outlines the use of gowns and gloves during high-contact resident care activities, particularly for residents with open wounds, indwelling medical devices, or those colonized with MDROs. However, during a facility tour on September 22, 2024, no residents were observed to be in isolation or have EBP signage on their doors. Additionally, on September 23, 2024, staff members were observed performing catheter and wound care on residents without wearing gowns or other personal protective equipment (PPE), despite wearing gloves. The Infection Preventionist confirmed that EBP had not been implemented for several residents with wounds or indwelling medical devices. Furthermore, procedures related to Contact Isolation Precautions were not implemented for a specific resident. The facility's failure to adhere to its own policies and procedures for infection prevention and control was confirmed by the Infection Preventionist, highlighting a significant lapse in protecting residents from potential MDRO transmission.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program, which is designed to improve antibiotic use and reduce antibiotic resistance. The program's policy outlines several core elements, including leadership commitment, accountability, drug expertise, action, tracking, reporting, and education. However, the facility did not adhere to these elements, as evidenced by the lack of protocols to review clinical signs, symptoms, and laboratory reports before administering antibiotics. The Assistant Director of Nursing/Infection Preventionist admitted that the facility does not use assessment tools or management algorithms to determine the necessity of antibiotics, relying instead on obtaining a doctor's order based on belief rather than documented criteria. The deficiency was identified during an interview and record review, revealing that the facility's staff did not complete forms detailing McGeer's protocol, which is intended to guide antibiotic use. This oversight affects all 132 residents in the facility, as there is no systematic approach to ensure antibiotics are used appropriately. The facility's failure to implement the Antibiotic Stewardship Program as per its policy potentially exposes residents to unnecessary antibiotic use and the associated risks of antibiotic resistance.
Inadequate Implementation of Infection Control Measures
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) was adequately implementing and performing the duties required for the position, potentially affecting all 132 residents. The IP, who also serves as the Assistant Director of Nursing, confirmed that Enhanced Barrier Precautions were not implemented for residents with wounds or indwelling medical devices. Additionally, procedures related to Contact Isolation Precautions were not followed for a specific resident. The IP had recently received her training certificate but lacked proper guidance and was learning on the job. She reported being unable to dedicate sufficient time to the Infection Prevention Control Program due to other responsibilities, including staff scheduling, working on the floor, and attending meetings. The facility also failed to implement protocols for reviewing clinical signs and symptoms or laboratory reports before administering antibiotics. The IP admitted that the facility does not use assessment tools or management algorithms to determine the necessity of antibiotics, relying instead on calling the doctor for orders. The IP acknowledged that the antibiotic stewardship program was not yet operational. The facility's application for Medicare and Medicaid confirmed the presence of 132 residents, underscoring the potential widespread impact of these deficiencies.
Delayed Call Light Response Times
Penalty
Summary
The facility failed to ensure that resident call lights were responded to in a timely manner, affecting eight residents. During a group meeting with residents who attend Monthly Resident Council Meetings, several residents expressed concerns about excessive call light response times, particularly after meals and during the third shift. One resident reported waiting over an hour for assistance, while another mentioned being left on the toilet for over 20 minutes. The residents described the third shift staff as lazy, and one resident was so distressed by the wait times that it brought her to tears. Another resident reported having accidents and falls due to the long wait times for assistance. Observations confirmed these concerns, as one resident's call light was on for at least 20 minutes before a CNA responded. The CNAs acknowledged the issue, noting that the call lights do not make any noise, requiring staff to constantly look for lights that are on. This lack of an audible alert system contributed to delays in response times, especially during busy periods like after meals. The facility's Administrator in Training acknowledged the problem and mentioned that a staff member on the third shift had been terminated for sleeping on the job, which was expected to improve the situation.
Discrepancy in POLST and Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that the electronic medical records and care plans of two residents matched their Physician's Order for Life-Sustaining Treatment (POLST) regarding their CPR code status. For one resident, the Physician Orders sheet and the current care plan indicated a Full Code status, while the POLST form, signed by both the resident and the physician, indicated a Do Not Attempt Resuscitation (DNAR) status. This discrepancy was confirmed by the Social Services Director, who stated that the electronic chart should match the Physician's Order and the Care Plan, and both should align with the POLST. Similarly, another resident's care plan and Physician Order Sheet documented a Full Code status, whereas the POLST form, signed by the resident, Social Services, and the Medical Director, indicated a Do Not Resuscitate (DNR) status with comfort-focused treatment only. This inconsistency was verified by the Care Plan Coordinator and Social Services, who acknowledged that the care plans and Physician Orders did not match the POLST forms for these residents.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to complete and implement a baseline care plan for a newly admitted resident, identified as R232, within the required 48-hour timeframe. According to the facility's policy on Baseline Care Planning, a care plan should be promptly developed to provide effective person-centered care based on the resident's initial assessment. R232 was admitted with diagnoses including Adjustment Disorder with Depressed Mood, Borderline Personality Disorder, Post-Traumatic Stress Disorder, and Transsexualism. The resident's hospital history indicated a history of mental health issues, self-harming behaviors, and substance use. Despite these complexities, the Care Plan Coordinator confirmed that no baseline care plan was present in R232's medical record, stating that they had not yet addressed it.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for a resident with pressure ulcers, specifically for a resident identified as R84. The facility's policies on Preventative Skin Care and Dressing Care require handwashing at specific steps during wound care procedures. However, during an observation, a Licensed Practical Nurse (LPN) did not perform hand hygiene after removing gloves and before donning new ones while treating R84's sacral and right ankle wounds. Additionally, the LPN placed contaminated scissors on the bedside table and used a tube of antibiotic ointment without conducting hand hygiene, further compromising the infection control protocols. R84 had a physician's order for Contact Precautions due to a Methicillin-resistant Staphylococcus aureus (MRSA) infection in the right lower leg wound. Despite this, the LPN failed to adhere to the facility's Contact Precautions policy, which mandates handwashing and disinfection of equipment after glove removal. The LPN also handled personal items, such as a marker, without performing hand hygiene, increasing the risk of cross-contamination. The Assisting Director of Nursing and Infection Preventionist confirmed the breach in protocol, acknowledging that hand hygiene should have been conducted before and after glove changes and that equipment should have been disinfected.
Failure to Implement ROM Exercises for Resident with Limited Mobility
Penalty
Summary
The facility failed to implement and follow through with Range of Motion (ROM) exercises for a resident with functional limited range of motion. The resident, who is non-ambulatory and has difficulty with bed mobility and balance due to a musculoskeletal and neurological disorder, was observed in a wheelchair unable to move his legs or arms, with hands tightly balled up. The resident's care plan indicated a dependency on caregivers for activities of daily living due to a history of stroke, and the Minimum Data Set documented functional limitations in both upper and lower extremities. Despite having an order for a Passive ROM Program due to poor motivation for exercise and a sedentary lifestyle, the program was incorrectly entered into the system as PRN (as needed) instead of being scheduled for every day, every shift. This error was confirmed by the facility administrator, who acknowledged the incorrect entry in the Point Click Care system, leading to the deficiency in providing the necessary restorative care to maintain or improve the resident's range of motion.
Improper Indwelling Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter. The resident, identified as R92, had a physician's order for an indwelling catheter. During an observation, the catheter tubing and drainage bag were found lying on the floor, and the catheter bag was not covered with a privacy bag. Additionally, during a mechanical lift transfer, a CNA held the catheter bag above the resident's bladder, which is against proper procedure. These actions were verified by the staff involved, including a Licensed Practical Nurse and Certified Nursing Assistants, who acknowledged that the catheter should not have been on the floor and should have been covered, and that the catheter bag should not have been raised above the bladder during the transfer.
Failure in Dialysis Care Coordination and Communication
Penalty
Summary
The facility failed to provide ongoing communication with the dialysis center and did not develop a comprehensive care plan for a resident receiving dialysis services. The facility's policy requires coordination of care with the dialysis provider, including a predetermined schedule, medication changes, meal or snack provisions, fluid restrictions, and emergency protocols. However, the care plan for the resident did not address these elements, such as specific dialysis days, medication schedule changes, or emergency protocols. Additionally, the facility did not send a dialysis communication form with the resident to the dialysis center, which is a requirement according to the facility's policy. The resident, who was admitted with diagnoses including Type 1 Diabetes Mellitus, End Stage Renal Disease, and Kidney Transplant Rejection, attended dialysis three times a week. Despite this, the facility staff, including a Registered Nurse and a Licensed Practical Nurse, confirmed that they did not send a communication form with the resident to the dialysis center. The Director of Nurses verified that the resident's electronic medical record lacked any Dialysis Communication Tools and that the care plan did not include the necessary interventions. This lack of communication and incomplete care planning led to the deficiency identified by the surveyors.
Failure to Provide Adequate Psychiatric Support Services
Penalty
Summary
The facility failed to provide adequate psychosocial therapies and psychiatric support services to a resident diagnosed with Adjustment Disorder and Major Depressive Disorder, who had repeated emergency room visits for suicidal ideations and depression. The facility's assessment indicated that they would provide mental health and behavior support, including individual and group therapies, and psychiatric management. However, the resident, identified as R102, did not receive the necessary psychiatric counseling or therapy services as outlined in their care plan and PASRR recommendations. Observations and interviews revealed that R102 expressed unhappiness and had a history of suicidal ideations, which led to multiple hospital visits. Despite these incidents, there was a lack of documentation showing that R102 received the required psychiatric counseling or therapy services. The facility's records did not reflect any in-person psychiatry visits or group therapies since the resident's admission, except for a telehealth session with a psychiatrist in August. Additionally, there was no documentation of any refusals by the resident for the offered services. The facility's Social Service Director and Administrator in Training confirmed the absence of professional psychiatry notes and the lack of documentation regarding the resident's refusal of community mental health treatment. This deficiency highlights the facility's failure to adhere to its own policies and care plans, resulting in inadequate support for a resident with significant mental health needs.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to prevent physical abuse between two residents, R1 and R2, who were involved in an altercation resulting in R2 receiving a black eye. The incident occurred in the residents' shared room, and no staff witnessed the event. R1 admitted to hitting R2 in the face during an argument, which R2 confirmed, stating that the altercation was over a boyfriend. Both residents have a history of mental health disorders, with R1 diagnosed with Schizoaffective Disorder, Bipolar Disorder, and Paranoid Personality Disorder, among others, and R2 diagnosed with Schizophrenia, Paranoid Schizophrenia, and Dementia with Behavioral Disturbance. The facility's records indicate that the altercation was reported to the Administrator and the local police department, who interviewed both residents. The facility's Abuse Prevention Program, dated 11/28/2016, outlines the commitment to protecting residents from abuse by anyone, including other residents. However, the altercation between R1 and R2 suggests a failure in implementing this program effectively, as the root cause was determined to be related to R1's paranoid personality disorder. The incident reports and interviews reveal that both residents were aware of the altercation, with R1 stating that she would retaliate if hit. Despite the facility's efforts to educate the residents on appropriate behaviors and conflict resolution, the initial failure to prevent the altercation highlights a deficiency in the facility's ability to protect residents from abuse, as outlined in their Abuse Prevention Program.
Failure to Provide Speech Therapy Evaluations After Choking Incidents
Penalty
Summary
The facility failed to follow physician orders and have Speech Therapy services assess the swallowing needs of two residents after choking incidents. One resident, who had a history of poor-fitting dentures and difficulty chewing, choked on a biscuit and was sent to the emergency room. Despite a physician's order to downgrade the resident's diet and a subsequent refusal to attend a dental appointment, there was no documentation of a speech therapy evaluation before or after the choking incident. The facility's Director of Nursing confirmed that the resident had not been evaluated by Speech Therapy, and the Administrator acknowledged the absence of Speech Therapy services for the resident since the incident. Another resident, who had a diagnosis of COPD and was a former smoker, choked on lettuce and was also sent to the emergency room. The resident's diet was downgraded to mechanical soft texture, and a physician's order was issued for a Speech Therapy evaluation. However, there was no documentation of a speech therapy evaluation in the resident's medical record. The Director of Nursing was unsure about the availability of Speech Therapy services due to a new therapy company, and the Administrator confirmed that the resident had not been seen by Speech Therapy since the choking incident. Both residents experienced significant choking incidents that required emergency intervention, yet neither received the mandated Speech Therapy evaluations to assess their swallowing needs. The facility's failure to provide these evaluations, despite clear physician orders and the residents' documented needs, constitutes a deficiency in the provision of specialized rehabilitative services. The lack of Speech Therapy assessments potentially compromised the residents' safety and well-being, as their dietary needs were not adequately addressed following the choking episodes.
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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