Axiom Healthcare Of Rosiclare
Inspection history, citations, penalties and survey trends for this long-term care facility in Rosiclare, Illinois.
- Location
- 1807 Fairview Rd, Rosiclare, Illinois 62982
- CMS Provider Number
- 145759
- Inspections on file
- 22
- Latest survey
- December 9, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Axiom Healthcare Of Rosiclare during CMS and state inspections, most recent first.
The facility failed to maintain a full-time DON and did not have an RN on duty for at least 8 consecutive hours a day, 7 days a week. This deficiency affected all 34 residents, with multiple dates lacking RN coverage. Staff interviews confirmed the absence of a DON since April 2024 and ongoing efforts to hire a full-time RN. Despite the lack of RN coverage, no residents currently require treatments that only RNs can perform.
A facility failed to complete a Level II PASRR for a resident diagnosed with a psychotic disorder. The resident was admitted with a diagnosis requiring a Level II screening, but the PASRR Level I outcome incorrectly stated no Level II was needed. The Business Office Manager was unaware of the oversight, and the administrator acknowledged the error, noting non-compliance with the facility's PASRR policy.
The facility failed to ensure residents were free from unnecessary psychotropic medications, as evidenced by inadequate documentation and follow-up on gradual dose reduction (GDR) recommendations for two residents. One resident was prescribed multiple psychotropic medications without a documented rationale for declining a GDR, and there was a significant delay in addressing the pharmacist's recommendation. Another resident did not receive timely evaluations for GDRs, with a lapse in the required quarterly assessments. The facility lacked a specific GDR policy, contributing to these deficiencies.
Two residents with severe cognitive impairment and incontinence were not repositioned or provided with incontinence care as required by their care plans. Both residents remained in the day area for nearly three hours without being checked, leading to skin redness and soiled undergarments. The facility's policy on preventative skin care was not followed, resulting in a deficiency.
The facility failed to maintain an effective pest control program, leading to the presence of flies and roaches, potentially affecting all 40 residents. Observations revealed live roaches in the kitchen and multiple flies in the dining area. Residents reported seeing pests in their rooms, and staff confirmed the issue, noting that the exterminator had visited but the problem persisted. The facility's pest control policy requires monthly treatments, but these measures were insufficient to control the infestation.
The facility failed to adhere to food safety and sanitation standards, with uncovered and undated food in the refrigerator and unsanitary conditions in the kitchen, including pest issues and residue buildup. The absence of pest control services since December 2023 and inadequate cleaning practices contributed to these deficiencies, potentially affecting all 40 residents.
A high-risk resident in an LTC facility developed an unstageable pressure ulcer on the right heel due to the facility's failure to implement necessary interventions. Despite the resident's severe cognitive impairment and total dependence on staff, the care plan to float heels was not consistently followed. Observations showed the resident's heels were often flat on the bed, and the facility's wound tracking logs initially failed to document the new ulcer. The facility lacked a DON to oversee wound care, and the MDS Coordinator was unable to manage all responsibilities, contributing to the deficiency.
The facility failed to maintain an effective pest control program, affecting all 40 residents. Surveyors observed roaches and flies, and staff confirmed the absence of pest control services since December 2023. Residents and staff reported sightings of various pests, and the facility had not implemented internal measures to address the issue.
The facility failed to ensure privacy for female residents by not providing adequate curtains for commode stalls in the women's bathroom. Observations showed that only one of three stalls was fully covered, while the others were either partially covered or lacked curtains entirely. Interviews with staff and residents indicated that this issue had persisted for months, violating residents' rights to dignity and respect.
A resident in an LTC facility was consistently woken up early by staff to assist the day shift, despite their preference to sleep in. The facility's care plan did not address the resident's waking time preferences, and the resident's family had previously raised concerns. Staff interviews and the resident's own statements confirmed the early waking practice, which contradicted the facility's policy on resident rights.
A facility failed to report an alleged abuse incident to the State Survey Agency. A family member reported seeing a nurse yelling at and pushing a resident, but the facility's investigation could not substantiate the claim due to a lack of specific identification. The resident involved had a severe cognitive deficit and hearing issues, requiring specific communication strategies. Despite the facility's policy, the administrator did not report the incident, citing the absence of a specific resident name.
A facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving a resident with severe cognitive deficits and hearing impairment. The incident was reported by a visitor who observed a nurse allegedly yelling at and pushing the resident. The facility's administrator did not initiate a new investigation, believing it to be the same as a previous unsubstantiated incident, and did not follow the facility's comprehensive investigation policy.
The facility failed to provide timely incontinence care for two residents with moderate cognitive impairments. One resident was left in saturated clothing for an extended period, despite staff claims of having provided care. Another resident was observed with wet clothing and a wet chair cushion, indicating a lack of timely assistance. The facility's administrator acknowledged the expectation for timely care to prevent skin issues, highlighting a failure to adhere to care plans.
A resident with severe cognitive deficits and a high risk of falls did not have the prescribed body pillow in place to prevent rolling out of bed, as observed on multiple occasions. Despite the care plan's directive and previous incidents, staff failed to ensure the intervention was consistently implemented, citing the pillow was in the laundry. The facility's fall prevention policy was not adequately followed, leading to a lapse in safety measures.
A resident with moderate cognitive impairment and multiple diagnoses did not receive incontinence care per current standards. A CNA failed to wash near the labia during perineal care and did not perform proper hand hygiene after removing gloves. The facility's policy requires washing the pubic area, including the labia, and washing hands after glove removal.
Failure to Maintain RN Coverage and Director of Nursing
Penalty
Summary
The facility failed to maintain a full-time Director of Nursing (DON) and did not have a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week. This deficiency was identified through observation, interviews, and record reviews. The facility's nursing schedules revealed multiple dates where there was no RN coverage, affecting the care of all 34 residents residing in the facility. The absence of a DON has been ongoing since April 29, 2024, and the facility has been actively trying to hire a full-time RN to address this issue. Interviews with facility staff, including the Administrator, Regional Manager, Assistant Director of Nursing, and a Licensed Practical Nurse (LPN), confirmed the lack of RN coverage and the absence of a DON. The Assistant Director of Nursing, who is an LPN, stated that there has not been a DON since she started working at the facility in June 2024. Additionally, the LPN mentioned that there are many days without an RN on shift, although currently, no residents require treatments that only RNs can perform, such as intravenous antibiotics. The facility's personnel policy emphasizes compliance with federal, state, and local laws, but the current staffing situation does not meet these standards.
Failure to Complete PASRR Level II Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident diagnosed with a mental disorder. The resident, identified as R27, was initially admitted to the facility on January 23, 2023, and had a current admission date of May 10, 2024, with a diagnosis of psychotic disorder with delusions. Despite this diagnosis, the PASRR Level I Screen Outcome dated May 7, 2024, indicated that no Level II screening was required, stating there was no evidence of a PASRR condition of an intellectual/developmental disability or serious behavioral health condition. However, the resident was prescribed Zyprexa for altered mental status, which was not reflected in the PASRR Level I determination. The Business Office Manager, responsible for ensuring PASRR screenings, was unaware of why a Level II screening was not completed for R27, as the admission occurred before her employment. The facility's administrator acknowledged the error and noted that the staff did not follow the facility's PASRR policy, which requires a Level II screening referral if the Level I screen indicates a mental disorder. The facility's policy, dated November 13, 2018, outlines the procedure for conducting Level I screens and referring for Level II screenings when necessary, which was not adhered to in this case.
Failure to Ensure Residents Are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, specifically in the cases of two residents, R5 and R24. R5 was prescribed multiple psychotropic medications, including sertraline, without a documented patient-specific rationale for declining a recommended gradual dose reduction (GDR). The physician, V6, did not provide the required rationale for why a GDR was clinically contraindicated, and there was a significant delay in addressing the pharmacist's recommendation, as the consultation report was not signed until over two months later. For R24, the facility did not conduct timely evaluations for GDRs of Risperidone, as required by CMS guidelines. Although a GDR was accepted by the physician in August 2023, there was no subsequent pharmacy consultation report available for August 2024, when the next GDR was due. The facility only provided a new consultation report during the survey in November 2024, indicating a lapse in the required quarterly evaluations. The facility lacked a specific GDR policy, and the administrator was unaware of whether the new owners had implemented one. This lack of policy and adherence to regulatory guidelines contributed to the failure to ensure residents were free from unnecessary medications, as evidenced by the delayed and incomplete documentation and follow-up on GDR recommendations.
Failure to Assist with Repositioning and Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with repositioning and incontinence care for two residents, R5 and R15, who were dependent on staff for these activities of daily living. R5, who has severe cognitive impairment and is always incontinent of bowel and bladder, was observed sitting in a geriatric recliner in the day area for nearly three hours without being repositioned or receiving incontinence care. Despite the care plan indicating the need for repositioning and peri care every two hours, R5 remained in the same position, leading to noted redness in the peri area and thighs when care was eventually provided. Similarly, R15, who also has severe cognitive impairment and requires substantial assistance for toileting and dressing, was observed in a wheelchair in the day area for the same duration without being repositioned or receiving incontinence care. R15's care plan also required checks every two hours and assistance with toileting, which was not adhered to, as evidenced by the presence of urine in the disposable undergarment when care was finally given. Both residents' care plans and the facility's policy on preventative skin care were not followed, resulting in a deficiency in the care provided.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and roaches, which could potentially affect all 40 residents. During the survey, live roaches were observed under the three-compartment sink and in the dry food storage area, while multiple flies were seen in the food preparation area. The Dietary Manager acknowledged the issue, stating that the exterminator had visited and was expected to return soon. However, the presence of pests persisted, as evidenced by multiple observations of flies in the dining room over two days. Residents also reported issues with pests. An alert and oriented resident mentioned having seen flies frequently, with one observed flying around her head and over her bed table. Another resident reported seeing roaches in his room and stated he would stomp on them when seen. Staff members, including cooks and dietary aides, confirmed the presence of roaches and flies, indicating that they had informed the Maintenance Director, who had been spraying. The Maintenance Director and Administrator both acknowledged the pest problem, with the Administrator noting that the pest control company was aware of the infestation and had indicated it could take six months to a year to eradicate the roaches. The facility's pest control policy requires monthly preventative treatments, with additional treatments as needed, but it appears these measures were insufficient to control the pest issue effectively.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety and maintain a sanitary environment in the kitchen, which has the potential to affect all 40 residents residing in the facility. During the survey, it was observed that fruit in the refrigerator was left uncovered and undated, contrary to the facility's policy requiring all food to be covered and dated. Additionally, a roach was seen crawling in the kitchen, and the Dietary Manager acknowledged an increase in roaches due to the absence of pest control services since December 2023. The Administrator confirmed that pest control services had been called but had not yet arrived. Further observations revealed unsanitary conditions in the kitchen, including a trash bag with dirty linens on the floor, a scaly and rust-colored residue on the ice machine, and a soiled wet blanket on the floor due to a backed-up drain. The kitchen floors and walls were dirty, with greasy and black residues observed in various areas. The Maintenance Director and a Dietary Aid acknowledged the presence of these residues and stated that cleaning efforts were underway, although a deep clean had not yet been completed. The facility's policies on kitchen sanitation and refrigerator storage were not being followed, contributing to the unsanitary conditions.
Failure to Prevent Pressure Ulcer Development in High-Risk Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development of new pressure ulcers for a resident identified as high risk. The resident, who was severely cognitively impaired and totally dependent on staff for activities of daily living, developed an unstageable pressure ulcer on the right heel. Despite having a care plan that included floating the heels while in bed, this intervention was not consistently implemented, as observed during multiple instances where the resident's heels were flat on the bed. The resident's medical history included conditions such as dementia, diabetes mellitus, and decreased mobility, which increased the risk for pressure ulcers. The facility's records indicated that the resident was on a standard mattress instead of a specialized air loss mattress, which was recommended for high-risk individuals. The facility's staff, including CNAs and an LPN, were aware of the need to float the resident's heels but failed to do so consistently. Additionally, the facility's wound tracking logs did not initially document the pressure ulcer on the right heel, indicating a lack of timely identification and monitoring. The facility's staff, including the MDS Coordinator/Infection Preventionist, acknowledged the oversight in wound care and prevention. The physician expected the facility to follow orders for wound care and prevention, including the use of specialized mattresses and floating the heels. However, the facility did not have a Director of Nursing to oversee wound care, and the MDS Coordinator was unable to fulfill all the responsibilities due to limited availability. This lack of oversight and adherence to care plans contributed to the development of the unstageable pressure ulcer on the resident's right heel.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, which has the potential to affect all 40 residents residing there. On multiple occasions, surveyors observed pests such as roaches and flies within the facility. The Dietary Manager acknowledged the absence of pest control services and noted an increase in roach sightings. The Maintenance Director provided an outdated pest control summary and was unable to confirm any recent pest control visits, citing a possible company bankruptcy as a reason for the lapse in service. Additionally, the Administrator confirmed that no pest control services had been conducted since December 2023 and expressed concerns about using chemicals suggested by the pest control company. Residents and staff reported sightings of roaches, spiders, water bugs, ants, and flies throughout the facility. A family member was observed swatting flies away from a resident's food, and several CNAs confirmed the presence of flies and roaches. Despite having a policy that mandates monthly pest control treatments, the facility had not implemented any internal measures to mitigate the pest issue. The Administrator mentioned that the pest control company had been contacted but had not yet visited the facility as scheduled.
Privacy Violation in Women's Bathroom
Penalty
Summary
The facility failed to protect the privacy of its female residents by not providing adequate curtains or doors to cover the commode stall areas in the women's common bathroom. During the survey, it was observed that out of three commode stalls, only one had a curtain fully covering it, while the second stall had a curtain that was missing hooks and could only partially cover the entrance. The third stall had no curtain at all. Interviews with staff and residents revealed that the curtains had been missing or inadequate for an extended period, with some staff indicating that the issue had persisted since they began working at the facility. Residents expressed uncertainty about the absence of curtains, and staff members provided inconsistent explanations, suggesting that the curtains were either in the laundry or had been missing for months. The facility's administrator acknowledged the issue and mentioned plans to replace the curtains. The lack of privacy in the bathroom area was a clear violation of the residents' rights to dignity and respect, as outlined in the facility's resident rights policy.
Failure to Honor Resident's Right to Choose Waking Time
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not allowing them to choose their waking time. A resident, identified as R12, was consistently woken up early by the midnight shift staff to assist the day shift, despite the resident's preference to sleep in. This practice was confirmed by multiple staff members and the resident's family member, who had previously raised concerns during a care plan meeting. The facility's care plan for R12 did not address the resident's preferences regarding waking times, and the resident's assessment indicated it was somewhat important for them to choose their own bedtime, but did not document their preferred waking time. Interviews with staff and the resident's roommate revealed that R12 was routinely woken up at 5:00 AM, even though the resident expressed a desire not to be up that early. The facility's administrator claimed that R12 only got up early when they wanted to, but this was contradicted by the resident's own statements and observations from others. The facility's policy on resident rights, provided to the surveyor, stated that residents have the right to choose their schedules, including sleeping and waking times, which was not upheld in this case.
Failure to Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Survey Agency for a resident reviewed for abuse. The incident involved a newly admitted resident's family member who reported witnessing a nurse yelling at a resident and pushing them down the hall. The facility's investigation could not substantiate the claim as the family member could not identify the staff member or the resident involved. The administrator did not report the allegation to the State Survey Agency, citing the lack of a specific resident name as the reason. The resident in question, who was potentially involved in the incident, had a severe cognitive deficit and was hard of hearing, which required staff to speak loudly for communication. The resident's care plan included specific communication strategies to address these needs. Despite the facility's policy requiring the reporting of suspected mistreatment to the State Survey Agency within 24 hours, the administrator did not report the incident due to the absence of a specific resident name, leading to a deficiency in the facility's abuse prevention program.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving a resident identified as R3. The incident was initially reported by a visitor, V21, who observed a nurse allegedly yelling at a resident and pushing them down the hall. The facility's administrator, V1, was informed of this allegation but did not initiate a new investigation, believing it to be the same as a previous incident documented on 5/24/24. The previous investigation concluded that the claim could not be substantiated, as the nurse involved stated that the resident, R3, was hard of hearing and required loud communication. The facility's investigation into the initial allegation was inadequate, as it did not include interviews with all potential witnesses or the resident involved. The administrator did not interview other staff members or residents who might have witnessed the incident, nor did she start a new investigation when the surveyor reported the allegation on 6/3/24. The facility's policy on abuse prevention requires a comprehensive investigation process, which was not followed in this case. Resident R3, who was involved in the incident, has a severe cognitive deficit, as indicated by a BIMS score of 01, and a history of falls with injuries. The resident's care plan includes specific communication strategies due to their hearing impairment and cognitive issues. Despite these documented needs, the facility did not adequately address the allegation of abuse, failing to ensure the resident's right to be free from mistreatment.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, R12 and R16, as observed by surveyors. R12, who has a moderate cognitive impairment and is dependent on staff for toileting, was not checked or changed for an extended period after being up since 5:00 AM. Despite staff claims of having changed R12 after breakfast, observations indicated that R12's incontinence brief and clothing were saturated with urine by the time care was eventually provided. This discrepancy in care timing suggests a failure to adhere to the resident's care plan, which includes scheduled toileting and assistance as needed. Similarly, R16, who also has a moderate cognitive impairment and requires supervision for toileting, was observed with wet clothing and a wet chair cushion, indicating a lack of timely assistance. Despite being redirected by staff, R16 was not provided with immediate care, and her condition remained unchanged for a significant period. The facility's administrator acknowledged the expectation for residents to receive timely care to prevent skin breakdown and infections, highlighting a failure to follow the care plan that mandates assistance with toileting and regular checks.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement and follow interventions to prevent falls for a resident identified as being at high risk for falls. The resident, who has severe cognitive deficits and a history of falls with injuries, was admitted with diagnoses including left hip nailing, dementia, osteoarthritis, depression, and anemia. The resident's care plan included the use of a body pillow for comfort and positioning to prevent rolling out of bed, an intervention that was not consistently implemented. Observations on multiple occasions revealed the absence of the body pillow in the resident's bed, despite the care plan's directive and previous incidents of the resident rolling out of bed. The facility's fall prevention policy outlines procedures for assessing residents after falls and implementing new interventions, yet these were not adequately followed in this case. Staff were aware of the missing body pillow, with explanations given that it was in the laundry, but no immediate alternative was provided until prompted by the surveyor. The facility administrator acknowledged the oversight and the need for a backup pillow, indicating a lapse in ensuring the resident's safety measures were consistently in place as per the care plan and facility policy.
Inadequate Incontinence Care and Hand Hygiene
Penalty
Summary
The facility failed to provide incontinence care according to current standards of practice for a resident with moderate cognitive impairment and multiple diagnoses, including intractable seizures, debility, depression, and anxiety. The resident was dependent on staff for toileting, as documented in the Minimum Data Set. During an observation, a Certified Nursing Assistant (CNA) did not perform perineal care correctly. The CNA used a washcloth with no rinse peri wash to clean the resident's pubic area and inner thighs but failed to wash near the labia, which is a required step according to the facility's Perineal Cleansing policy. Additionally, the CNA did not follow proper hand hygiene protocols. After completing the incontinence care, the CNA removed their gloves and donned a new pair without washing their hands, which is against the facility's policy. The facility's Perineal Cleansing policy specifies that gloves should be removed and hands washed with soap and water or a cleansing gel after providing care. The facility administrator confirmed that the expectation was for incontinence care to be provided per current standards of practice.
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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