Axiom Healthcare Of Harrisburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Harrisburg, Illinois.
- Location
- 1000 West Sloan Street, Harrisburg, Illinois 62946
- CMS Provider Number
- 145978
- Inspections on file
- 27
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Axiom Healthcare Of Harrisburg during CMS and state inspections, most recent first.
The facility failed to protect multiple residents from abuse by not adequately managing a resident with known aggressive behaviors and not updating his care plan after repeated incidents. A resident with severe dementia and a documented risk for aggression physically grabbed and held his roommate’s legs during the night, leading to a physical struggle. Later, the same resident became combative in the dining room, swung fists and a board, struck a CNA, and hit another resident on the head with facility signage. In a separate dining room incident, this resident rammed his wheelchair into another resident’s wheelchair, hit the resident in the back, yelled at him, and pulled his blanket, as reported by the resident and his family member. Staff interviews described this resident as commonly aggressive with frequent conflicts, yet the care plan interventions remained unchanged from their original initiation date, and the administrator delayed reporting one of the incidents despite receiving a detailed email from the family member describing the assault.
The facility failed to timely report an allegation of resident-to-resident abuse to the state agency as required by its abuse policy. A cognitively intact resident with COPD and other conditions reported that another cognitively impaired resident in a wheelchair rammed his wheelchair, hit him in the back, yelled at him, and pulled his blanket in the dining room, an event witnessed by the resident’s family member and another resident. The family member immediately informed an LPN, who assisted the alleged aggressor away and, according to the family member, instructed her to email the Administrator with a full account, which she did that evening. Despite this written report and later direct discussion with the family member, the Administrator did not notify the Department of Public Health within the required 24-hour timeframe and instead delayed reporting for several weeks, only submitting an Initial & Final report after receiving a subsequent complaint letter, resulting in a deficiency for untimely reporting of suspected abuse.
The facility failed to timely and thoroughly investigate an alleged resident-to-resident abuse incident. A cognitively intact resident reported that another resident with dementia rammed his wheelchair, hit him in the back, yelled at him, and pulled his blanket in the dining room, an event also described in detail by the resident’s family/POA in an email to the Administrator and later in a formal letter. Staff had previously observed the alleged aggressor being physically and verbally aggressive toward multiple residents. Despite this, the Administrator did not initiate an investigation when first informed of the allegation weeks after the event, and later submitted an initial and final report to the state on the same day without having interviewed all involved staff or the alleged victim, while still documenting that residents and staff had no concerns. These actions did not follow the facility’s abuse policy requiring immediate reporting, prompt investigation, and comprehensive interviews and documentation of all abuse allegations.
The facility did not ensure 8 consecutive hours of RN coverage each day, with gaps in coverage on multiple days when the DON was on medical leave and only one full-time RN was available. The Assistant DON confirmed that RN coverage was not always provided on weekends, and the facility lacked a formal staffing policy.
The facility did not ensure 8 hours of daily RN coverage on multiple occasions, as confirmed by review of nursing schedules and staff interviews. This affected all 35 residents and was acknowledged by the DON, a regional specialist, and the administrator, who also noted the absence of a staffing policy.
A resident with multiple pressure ulcers did not receive proper care and treatment as per physician orders, resulting in a Stage 4 ulcer not being treated for nine days. The facility failed to assess and document the resident's condition regularly, and staff were unaware of updated treatment orders. The Director of Nurses admitted to being behind on documentation, leading to inadequate care.
The facility failed to provide RN coverage for 8 consecutive hours daily, 7 days a week, as required. The schedule for February and March 2025 showed multiple days without RN coverage. The DON confirmed the lack of coverage on specific dates, and a resident expressed concerns about insufficient staffing. The facility's current census is 26 residents.
A resident with severe cognitive impairment and a history of falls did not have fall mats in place as per their care plan, despite multiple previous falls. The facility's failure to consistently apply fall prevention interventions was confirmed by an LPN, indicating a deficiency in adherence to the facility's Fall Prevention Program policy.
The facility failed to meet the required minimum living space of 80 square feet per resident in multiple occupancy rooms for eight residents. During a survey, ten rooms certified for four beds each were found to be below the required space per bed, with measurements ranging from 72.3 to 78.9 square feet per bed. Despite the deficiency, residents did not express concerns about the space, and some rooms were not fully utilized as four-bed rooms.
A resident with multiple health conditions did not receive doctor-ordered wound care twice daily as required. Despite the resident's cognitive awareness and communication with staff, the treatment was often administered only once per day. Staff interviews confirmed the inconsistency, and the facility administrator acknowledged the issue, suspecting undocumented refusals, although none were found in the records.
Failure to Protect Residents From Repeated Aggression by an Identified Assaultive Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not adequately managing and responding to a resident with known aggressive behaviors. One resident (R2) had documented diagnoses of anxiety disorder, depression, and dementia, with a BIMS score of 6 indicating severe cognitive impairment. R2’s care plan identified a focus area of potential for aggressive behavior related to dementia, with interventions such as encouraging activities, monitoring labs, observing location and aggression level, and removing the resident from areas when aggression increased. These interventions were all initiated on the same date with no further additions or revisions despite multiple subsequent aggressive incidents involving other residents. The first substantiated incident occurred in R2’s room during the night, when staff heard yelling and found R2 on the floor holding onto the legs/foot of a roommate (R3), while R3 was hitting R2 in the head. R3 reported that R2 had come over and started “attacking” him by grabbing his foot and not letting go, and R3 stated he no longer wanted to room with R2. Both residents had dementia diagnoses, with R3’s BIMS score of 11 indicating moderate cognitive impairment. The facility’s investigation and report to the state agency characterized this as a resident‑to‑resident physical altercation and substantiated the allegation, but the care plan for R2 showed no new or revised interventions after this event. A second substantiated incident involved another resident (R4), who had schizoaffective disorder, anxiety disorder, dementia, and depression, with a BIMS score of 12 indicating moderate cognitive impairment. In the dining room, CNAs reported that an agitated R2 became combative, swung fists and a board removed from the wall, struck a CNA, threw a heavy Christmas decoration, and then hit R4 on the top of the head with facility signage. R4 described the event as a “shock” and stated that R2 “does crazy things.” The investigation form documented an injury location as the top of the scalp at the time of incident, although no visible injuries were later observed. Despite this second substantiated resident‑to‑resident altercation, R2’s care plan still reflected only the original interventions from the earlier date, with no documented additions or modifications to address the repeated aggression toward other residents. A third incident involved R1, who had COPD, panlobular emphysema, and dysphagia, and was cognitively intact with a BIMS score of 15. R1 and his family member (V9) reported that R2 approached R1 from behind in the dining room, rammed R2’s wheelchair into R1’s wheelchair, hit or punched R1 in the back, yelled at him, and pulled on his blanket until another resident verbally intervened. V9 stated she immediately reported the incident to the LPN on duty (V3), who then moved R2 away and, according to V9, instructed her to email the administrator with a full account, which V9 did that evening. Staff interviews indicated that R2 had a history of conflict and physical aggression with multiple residents, and that it was common for R2 to become aggressive. The administrator later acknowledged awareness of the prior substantiated incidents between R2 and R3 and between R2 and R4, but did not initially report the incident involving R1 and did not revise R2’s care plan beyond the original interventions, demonstrating a failure to identify patterns of abuse and to implement effective protective measures for other residents. The facility’s own Abuse Prevention and Reporting policy stated that residents have the right to be free from abuse and that the facility would identify occurrences and patterns of potential mistreatment, promptly investigate all allegations, and make necessary changes to prevent future occurrences. In practice, the facility substantiated multiple resident‑to‑resident altercations involving R2 but limited its response to minimal, case‑specific actions and did not update or expand R2’s care plan interventions after the initial date. The administrator also delayed reporting the incident involving R1 until after receiving a letter from R1’s family member to corporate, despite the family member’s contemporaneous email describing the assaultive behavior. These actions and inactions resulted in multiple residents being subjected to physical aggression by R2 without adequate, timely, and comprehensive protective measures in place, contrary to the facility’s abuse prevention policy and the requirement to keep residents free from abuse.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of resident-to-resident abuse to the state survey agency and other required authorities, as required by its abuse reporting policy. One resident (R1), who was cognitively intact with a BIMS score of 15 and had diagnoses including COPD, panlobular emphysema, and dysphasia, alleged that another resident (R2), who had anxiety disorder, depression, dementia, and a BIMS score of 6 indicating severe cognitive impairment, physically assaulted him in the dining room. R1 stated that while he was sitting in his wheelchair after the evening meal talking with his family member (V9), R2 came up behind him, rammed R2’s wheelchair into R1’s wheelchair, and began punching him in the back. R1 reported that another male resident yelled at R2 to stop, after which R2 rolled away, and that his family member immediately went to get a nurse, leading R1 to assume the facility was aware of the incident. V9, R1’s family member, reported that she had previously been told by various staff that R2 could become physically aggressive and that staff had described R2 as combative, aggressive, and dangerous, with one staff member stating it was inevitable someone would get hurt with R2 in the building. V9 described that on the date of the incident, R2 rolled up behind R1 in the dining room, hit R1’s wheelchair with his own, and when R1 did not move, R2 began punching R1 in the back and pulling on his blanket while yelling at him. Another resident (R7) verbally intervened, and V9 went to get staff assistance. V9 stated that LPN V3 responded, assisted R2 back to his room, and instructed V9 to report the incident directly to the Administrator (V1). That same evening, V9 sent an email to V1 at 9:55 PM describing that R1 had been attacked or harassed twice that day by R2, including being pushed, slapped/hit, yelled at, and having his blanket yanked, and noted that V3 had asked her to report directly to V1. Despite this contemporaneous email report, the Administrator did not initiate timely external reporting. V1 later stated she was not aware of the 12/16/25 incident until 1/6/26, when V9 came to speak with her, and that she did not report the incident at that time because she believed it was unfounded. Email documentation shows that on 1/6/26, V9 forwarded the original 12/16/25 email to V1, copying the DON (V2), and explained that she had assumed the matter was addressed because the aggressor was absent from the facility the following days. The facility’s own Abuse Prevention and Reporting policy requires that when an allegation of abuse occurs, the resident’s representative and the Department of Public Health regional office be informed by telephone or fax, and that if there is suspicion a crime has been committed without serious bodily injury, a report to local law enforcement and the Department of Public Health must be made as soon as possible but within 24 hours of when the suspicion was formed. Contrary to this policy, the Administrator did not report the allegation to the Illinois Department of Public Health until 02/03/26, as documented on the Report to IDPH marked Initial & Final, which listed the incident date as 02/03/2026 and summarized that R1’s daughter had reported weeks after the incident that R2 grabbed R1’s blanket and hit his back. V1 acknowledged that she ultimately reported the 12/16/25 incident on 2/3/26 only after V9 sent a letter to corporate, demonstrating that the facility failed to timely report the abuse allegation in accordance with regulatory and policy requirements. The facility’s abuse policy further requires that an initial report to the Department of Public Health include the resident’s name, age, diagnosis, mental status, type of abuse reported, and the date, time, location, and circumstances of the alleged incident, and that a complete written final investigation report be submitted within five working days of the report. In this case, the initial external report was delayed for several weeks after the alleged incident and after the Administrator had been made aware of the allegation through direct communication from the resident’s representative. The Administrator’s decision not to report when first informed, based on her belief that the allegation was unfounded, and the failure to act upon the original 12/16/25 email describing a physical assault, are the actions and inactions that led to the cited deficiency for failure to timely report suspected abuse as required by the facility’s own policy and state and federal regulations.
Failure to Timely and Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to timely initiate and complete a thorough investigation of an alleged resident‑to‑resident abuse incident. One resident (R1), who was cognitively intact with a BIMS score of 15 and had diagnoses including COPD, panlobular emphysema, and dysphasia, alleged that another resident (R2), who was severely cognitively impaired with a BIMS score of 6 and had diagnoses including anxiety disorder, depression, and dementia, rammed his wheelchair into R1’s wheelchair and punched R1 in the back while they were in the dining room. R1 reported that a male resident yelled at R2 to stop, after which R2 rolled away, and that a nurse came and assisted R2 back to his room. R1 believed the facility was aware of the incident because his family member/POA (V9) went to get a nurse immediately after the event. V9 stated that on the date of the incident she witnessed R2 roll up behind R1 in the dining room, hit R1’s wheelchair, punch R1 in the back, yell at him, and pull his blanket, and that another resident verbally intervened. V9 reported that she went to get an LPN (V3), who then came to the dining room and assisted R2 away from R1. V9 said V3 instructed her to report the incident directly to the Administrator (V1), and that she sent an email to V1 that same evening describing that R1 had been pushed, slapped/hit, yelled at, and had his blanket yanked by R2. V9 further reported that she had been told by multiple staff that R2 was combative, aggressive, and dangerous, and that she had been actively trying to keep R1 away from R2. V9 later wrote a formal letter stating that the assault had been unreported and mishandled, and that to her knowledge no formal report had been filed and no meaningful safeguards had been implemented. Staff accounts and facility documentation showed that the facility did not promptly or thoroughly investigate the allegation as required by its abuse policy. V3 acknowledged being approached by V9 on the date of the incident but stated that V9 only reported verbal abuse and that she did not tell V9 to report to V1; V3 also confirmed that V1 later questioned her about when V9 had reported the incident. CNAs reported that R2 had a history of conflicts and physical aggression toward residents, including grabbing R1’s wheelchair and raising his fist toward others, but there was no evidence these observations were incorporated into a timely investigation of the specific allegation involving R1. The Administrator (V1) stated she did not become aware of the 12/16 incident until weeks later and did not start an investigation at that time because she believed the incident was unfounded. V1 reported that she only initiated an investigation on 2/3 after receiving a letter to corporate, and she submitted an initial and final report to the state on the same day, documenting that residents and staff were interviewed with no concerns identified. However, V1 admitted she had not yet interviewed all staff working at the time of the incident or the residents involved, had not spoken to R1, and could not explain how she could conclude there were no concerns without these interviews. This sequence of events demonstrates the facility’s failure to follow its own abuse prevention and reporting policy, which required immediate internal reporting, prompt initiation of an investigation, interviews of the reporter, involved residents, and relevant staff, and a complete written report within five working days of the allegation. The facility’s written Abuse Prevention and Reporting policy required that upon learning of a report of potential abuse, the Administrator or designee initiate an incident investigation, document all incidents, and ensure that any allegation involving abuse results in an investigation. The policy specified that the investigator must at minimum attempt to interview the person who reported the incident, anyone likely to have direct knowledge, and the resident if interviewable, and that a complete written report of the conclusion of the investigation be sent to the Department of Public Health within five working days. In this case, the Administrator acknowledged not initiating an investigation when first informed of the allegation weeks after the incident, and when an investigation was eventually started, it was incomplete at the time the final report was submitted. The final report to the state characterized the daughter’s report as being made weeks after the incident, stated that at the time of the incident she did not mention any hitting, and concluded that residents and staff interviewed had no concerns, despite the Administrator’s admission that she had not interviewed all relevant parties, including R1. These actions and omissions constitute the failure to timely initiate and complete a thorough investigation of an alleged resident‑to‑resident abuse incident as required by facility policy and regulatory expectations.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage each day, as required, for all 37 residents. Review of the November and December 2025 nurse schedules showed that there were multiple days in both months when no RN was present for the required 8 consecutive hours. Specifically, there was no RN coverage for 8 consecutive hours on several dates in November and on two dates in December. The Assistant Director of Nursing, who was the only full-time RN employed at the facility, confirmed that she worked Monday through Friday for 8 consecutive hours but that there was not always RN coverage on weekends. The Director of Nursing had been on medical leave since early November, and the facility did not have a staffing policy in place, instead stating that they followed regulations.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide 8 hours of daily Registered Nurse (RN) coverage as required, affecting all 35 residents in the facility. Review of the nursing schedules for June and July showed that there was no RN on shift for 8 consecutive hours on five specific dates. The Director of Nursing confirmed that there were no RN hours documented on those days, and both the Regional Reimbursement Specialist and the Administrator acknowledged the lack of required RN coverage. The Administrator also stated that the facility does not have a staffing policy, although it follows federal and state staffing regulations.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, resulting in a Stage 4 pressure ulcer not being treated as ordered by the physician for nine days. The resident, who was admitted with multiple pressure ulcers, including a Stage 1 pressure ulcer and two unstageable pressure ulcers, did not receive the necessary assessments and treatments as per physician orders. The resident's care plan included interventions such as administering medications, monitoring wound healing, and repositioning, but these were not consistently followed. The resident's physician orders included specific treatments for pressure ulcers on the coccyx, heels, and other areas, but these were not implemented or documented properly. Observations revealed that the resident's pressure ulcers were not assessed or measured regularly, and the treatments were not updated according to the wound specialist's recommendations. The facility's Director of Nurses admitted to being behind on the wound log and acknowledged that the most recent physician orders were not followed. Interviews with staff indicated a lack of communication and documentation regarding the resident's pressure ulcer care. The Licensed Practical Nurse responsible for the resident's care was unaware of the wound specialist's orders, and the Director of Nurses had not ensured that the orders were communicated and implemented. The facility's policy on pressure injury and skin condition assessment was not adhered to, leading to inadequate monitoring and treatment of the resident's pressure ulcers.
Failure to Ensure RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to ensure Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days per week, which is a requirement for long-term care facilities. This deficiency was identified through interviews and record reviews. The facility's schedule for February and March 2025 showed multiple days without RN coverage, specifically on 2/1, 2/8, 2/15, 2/22, 2/28, 3/1, 3/13, 3/14, 3/15, 3/22, and 3/29. During an interview on 03/19/2025, the Director of Nursing (V2) confirmed the lack of RN coverage on these dates and mentioned that they usually lack coverage on Saturdays, with some Sundays being covered by an RN who works as needed. A resident also expressed concerns about insufficient staffing at times. The facility's current census is 26 residents, all of whom could potentially be affected by this deficiency.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement adequate interventions to prevent falls for a resident with severe cognitive impairment and a history of falls. The resident, who was admitted with diagnoses including dementia, depression, hypertension, and low back pain, experienced multiple falls over several months. Despite the implementation of various interventions such as physical and occupational therapy evaluations, frequent checks, and the use of alarms, the resident continued to fall. The care plan included the use of fall mats on both sides of the bed, but during an observation, it was noted that the mats were not in place, indicating a lapse in following the prescribed interventions. The facility's Fall Prevention Program policy aims to ensure resident safety by assessing fall risks and implementing appropriate interventions. However, the failure to consistently apply these interventions, as evidenced by the absence of fall mats during an observation, suggests a deficiency in the facility's adherence to its own policies. This oversight was confirmed by a Licensed Practical Nurse/Care Plan Coordinator, who acknowledged that the resident should have had fall mats on both sides of the bed, highlighting a gap in the supervision and implementation of fall prevention measures.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum living space of 80 square feet per resident in multiple occupancy rooms for eight residents. During a survey conducted from March 17 to March 20, 2025, the administrator measured ten rooms that were certified for four beds each, and all were found to be below the required space per bed. The measurements ranged from 72.3 to 78.9 square feet per bed, which is below the regulatory requirement. Despite the deficiency in room size, the residents occupying these rooms did not express any concerns about the space during interviews, and no issues were noted in the Resident Council meeting minutes from the past six months. The survey also noted that some rooms were not being used to their certified capacity, with fewer beds than certified, and some rooms were used for storage. For instance, one room had only two beds instead of four, and another had three beds and additional furniture, indicating that the rooms were not fully utilized as four-bed rooms. Despite these observations, the facility did not meet the regulatory requirement for room size, leading to the deficiency finding.
Failure to Administer Doctor-Ordered Wound Care
Penalty
Summary
The facility failed to provide doctor-ordered wound care for a resident, identified as R5, who was admitted with multiple diagnoses including Type 1 Diabetes Mellitus with diabetic kidney disease, end-stage renal disease, muscle wasting, and acquired absences of both legs below the knee. R5, who is cognitively intact and dependent on staff for personal care, reported that his wound care treatment, ordered to be administered twice daily, was often only performed once per day. Despite R5's communication with the nursing staff about the incomplete care, the issue persisted. The Physician's Order Sheet documented the requirement for twice-daily application of Santyl ointment starting from January 8, 2025. However, the Treatment Administration Record showed several missed treatments without any documentation of refusal by R5. Interviews with staff, including a Licensed Practical Nurse and a Certified Nursing Assistant, confirmed the inconsistency in treatment administration. The facility administrator acknowledged the deficiency and suspected undocumented refusals, although no such documentation was found in R5's records.
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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