Cedar Ridge Health & Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Lebanon, Illinois.
- Location
- One Perryman Street, Lebanon, Illinois 62254
- CMS Provider Number
- 145571
- Inspections on file
- 35
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Cedar Ridge Health & Rehab Ctr during CMS and state inspections, most recent first.
Multiple residents with significant mobility and cognitive impairments experienced unsafe conditions when staff failed to follow transfer and fall-prevention practices. A resident fell in the shower after being placed on a small shower chair without brakes and without a gait belt. Another resident, care planned for a non-skid mat after sliding from a w/c, was later observed being transferred without the mat in place. A third resident, fully dependent for mobility, was left hanging in a mechanical lift without hands-on support when the lift battery failed and staff attempted to complete the transfer with the lift legs stuck. A fourth resident, care planned for fall mats and a low bed due to dementia and multiple comorbidities, was observed in bed while the fall mat was folded and stored at the head of the bed instead of positioned for use.
Two residents did not receive timely and hygienic incontinence care as required by their care plans and facility policy. One resident with multiple comorbidities and total dependence for toileting and hygiene remained in saturated linens and briefs from overnight into late morning on multiple occasions before CNAs provided care. Another resident, always incontinent of bowel and bladder, received peri-care in which CNAs repositioned the resident onto stool-soiled linens, allowed a stump to move through stool, and touched the pubic area with soiled gloves, leaving stool residue before completing cleansing. These practices did not align with the facility’s incontinence care policy for keeping skin clean, dry, and free of contamination.
A resident with multiple health issues experienced ongoing pain during peri-care due to inadequate pain management by facility staff. Despite having a care plan for pain management, staff failed to document pain scores, offer breaks, or apply the prescribed barrier cream, leading to the resident expressing significant discomfort. Facility policies on pain management were not followed, resulting in the resident's ongoing pain and discomfort.
The facility failed to maintain resident dignity during feeding and ensure call lights were accessible for four residents. A CNA was observed standing while feeding two residents, contrary to policy, and two residents had call lights out of reach, affecting their ability to request assistance. These actions violated the facility's policies on meal assistance and call light accessibility.
The facility failed to provide adequate feeding assistance to residents dependent on staff for meals. A resident with moderate cognitive impairment was left without help, while another with severe impairment began eating only after assistance arrived. A cognitively impaired resident was found with an untouched meal tray and no staff present, and another resident struggled to eat due to hand pain and lack of assistance. These instances show a failure to adhere to the facility's policy on maintaining residents' nutrition.
The facility failed to supervise residents adequately, leading to unsafe transfer practices and potential safety hazards. A resident was transferred using a mechanical lift without proper contact, causing her to swing freely. Another resident's call light was out of reach, increasing fall risk. Additionally, a resident was allowed to keep cigarettes and a lighter, violating the facility's smoking policy.
The facility failed to provide adequate incontinent care for several residents, leading to deficiencies. One resident was left in wet pants, while others received incomplete cleaning during care. CNAs did not clean all necessary areas or apply skin protective lubricant, as required by the facility's policy. These actions affected residents with various medical conditions, including cognitive impairments and incontinence.
The facility failed to provide palatable and attractive food to residents, with several expressing dissatisfaction with the taste and appearance of meals. Observations confirmed issues such as tough meat and bland vegetables, contrary to the facility's Food and Nutrition Services Manual standards.
The facility failed to perform proper hand hygiene and glove changes during resident care. A CNA fed two residents without hand hygiene, and an RN administered medications without hand hygiene, handling pills with bare hands. Additionally, two CNAs did not change gloves or perform hand hygiene during incontinent care, using the same towel and gloves throughout the process, contrary to facility policies.
The facility failed to confirm the need for antibiotics and ensure residents received all doses as ordered, affecting five residents. The Infection Preventionist could not confirm specific infections or reasons for antibiotic use, and the infection control log lacked essential details. One resident experienced significant medication errors with multiple missed doses of prescribed antibiotics, which could potentially worsen the infection. These deficiencies indicate a failure to adhere to the facility's Antibiotic Stewardship Policy.
A resident with a history of chronic osteomyelitis, cellulitis, and diabetic foot ulcers did not receive proper wound care as per the prescribed orders. The dressing on the resident's left foot was found to be improperly applied, missing essential components, and saturated with drainage. The facility lacked a policy on diabetic ulcer care, contributing to the deficiency.
A resident readmitted with pressure sores did not receive timely skin assessments or appropriate treatment, despite being at high risk for skin breakdown. Staff failed to consistently implement care plan interventions, leading to inadequate pain management and communication lapses. The facility did not adhere to its policies for pressure ulcer prevention and management.
A resident with a wound infection did not receive multiple doses of prescribed IV antibiotics, Ceftriaxone and Vancomycin, as documented in the MAR. The facility's policy required proper administration and documentation, which was not followed, leading to significant medication errors. The pharmacist confirmed the severity of the missed doses.
Failure to Ensure Safe Transfers, Fall Interventions, and Proper Equipment Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfers, implementation of fall interventions, and provision of appropriate equipment, resulting in accidents for multiple residents. One resident with hemiplegia, COPD, atrial fibrillation, and other conditions, cognitively intact and requiring partial/moderate assistance with wheelchair transfers and showers, slipped and fell in the shower. The resident reported that a CNA did not use a gait belt, transferred her onto a small shower chair without brakes, and the chair moved out from under her during the transfer, causing her to fall onto the shower floor and bruise her side. The CNA later stated she used the small shower chair because the other type was not available, confirmed the chair had no brakes, and acknowledged the resident did not have a gait belt on. Another resident with facial weakness after cerebral infarction, diabetes with CKD, dysphagia, and other diagnoses was identified as high risk for falls and required partial/moderate assistance with transfers. After this resident was found on the floor and reported having tried to get to the bathroom and sliding out of the wheelchair, the root cause was identified as slipping from the wheelchair and an intervention of a non-skid mat to the wheelchair was documented. However, during a later observation of a CNA transferring this resident from bed to wheelchair, no non-skid mat was present on the wheelchair seat, and subsequent inspection by an RN confirmed there was no non-skid mat in the wheelchair or anywhere in the room, indicating the fall intervention was not in place as planned. A third resident with metabolic encephalopathy, pulmonary fibrosis, hemiplegia, chronic respiratory failure, CHF, and repeated falls, who was moderately cognitively impaired and dependent on staff for all mobility and transfers, was observed being transferred via mechanical lift by two CNAs when the lift battery failed, leaving the resident suspended in the air with the lift legs stuck in the closed position. One CNA stated they would have to transfer the resident sideways, then removed her hands from the resident and sling, leaving the resident hanging from the lift without staff support while the other CNA operated the emergency release and the wheelchair was repositioned and tilted to complete the transfer. A fourth resident with dementia, COPD, PVD, prior MI, artificial hip, osteoarthritis, knee pain, and total dependence for ADLs, who was incontinent and care planned for fall risk with interventions including fall mats and keeping the bed in low position, was repeatedly observed in bed with the fall mat folded and stored upright at the head of the bed rather than in use. The administrator stated there was no fall prevention policy, only a statement at the end of another policy, while existing policies required safe transfers using gait belts and lifts and required IDT investigations and implementation of appropriate interventions after accidents.
Failure to Provide Timely and Hygienic Incontinence Care
Penalty
Summary
The deficiency involves failure to provide timely and complete incontinence care and proper peri-care technique for two residents. One resident with dementia, CKD stage 3, polyneuropathy, osteoarthritis, depression, a history of pressure ulcers, and documented bowel and bladder incontinence was care planned as dependent on staff for toileting, bathing, and personal hygiene, with interventions including peri-care after each incontinent episode and use of barrier products. Surveyors observed this resident’s bed linens saturated with urine and noted a strong urine odor when the resident was transferred from bed to a recliner. On the following day, the resident reported during breakfast that she had not been cleaned up, remained wet from overnight, and later that morning still had not been checked or cleaned. When CNAs eventually provided peri-care, the incontinence brief was observed to be saturated with urine. CNAs interviewed stated they check residents every two hours and perform incontinence care when getting residents up in the morning, indicating a delay between overnight incontinence and morning care for this resident. The second resident, cognitively intact and always incontinent of bowel and bladder per the MDS and care plan, was to be checked and changed every two hours and PRN. During observed incontinence care, the resident was incontinent of urine and stool. CNAs cleansed only part of the buttocks and anal area, then repositioned the resident onto her back on a stool-soiled bath blanket. While cleansing the peri-area and inner thighs, the resident’s stump moved through stool, and the CNA touched the pubic area with soiled gloves, leaving stool on the pubis. The resident was then turned again and the anus and inner thighs were cleansed. These actions did not follow the facility’s Incontinent Care policy, which requires washing all soiled skin areas, drying well, and changing gloves and performing hand hygiene as required to prevent cross-contamination.
Inadequate Pain Management During Peri-Care
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as R10, who was experiencing ongoing pain during peri-care. R10 was readmitted to the facility with multiple diagnoses, including surgical aftercare on the digestive system and acute and chronic respiratory failure. The resident was moderately cognitively impaired and dependent on staff for various activities of daily living. Despite having a care plan that included interventions for pain management, the facility did not adequately address R10's pain during peri-care, as evidenced by the resident's verbal and non-verbal expressions of pain. On multiple occasions, staff members, including CNAs and an LPN, were observed performing peri-care on R10 without adequately managing the resident's pain. During these care sessions, R10 expressed significant discomfort, crying out in pain and grimacing when reddened areas with open wounds were wiped. The staff failed to document pain scores on the day of the observation and did not offer R10 any breaks or alternative pain-relieving measures during the care process. The CNAs applied petroleum-based ointment instead of the prescribed barrier cream, which was not in R10's active orders at the time. The facility's policies on Activities of Daily Living Support and Management of Pain emphasize the importance of appropriate pain management and resident comfort. However, the staff did not adhere to these policies, as they did not promptly assess or address R10's pain, nor did they document or report the resident's pain complaints effectively. The facility administrator stated that CNAs are expected to report pain to other staff, but this expectation was not met in R10's case, leading to inadequate pain management and ongoing discomfort for the resident.
Failure to Ensure Resident Dignity and Accessibility of Call Lights
Penalty
Summary
The facility failed to uphold resident dignity during feeding assistance and ensure call lights were within reach for four residents. A Restorative CNA was observed standing while feeding two residents simultaneously, which is against the facility's policy that requires staff to sit while assisting residents with meals. One resident, who was cognitively intact but dependent on staff for eating, was fed in this manner, while another resident, who was severely cognitively impaired, required moderate assistance but was documented as needing to eat independently. The Director of Nursing later intervened by providing a chair to the CNA, indicating a lapse in adherence to the facility's meal assistance policy. Additionally, the facility did not ensure that call lights were within easy reach for two residents, compromising their ability to call for assistance. One resident, who was cognitively intact and dependent on staff for most activities of daily living, had a call light on the floor and another hooked to a privacy curtain, making it inaccessible. Another resident, who was severely cognitively impaired and required substantial assistance, had a call light placed on a fall mat on the floor, out of reach. Despite the facility's policy requiring call lights to be within reach, these instances demonstrate a failure to comply with established procedures, impacting the residents' ability to exercise their rights to self-determination and communication.
Failure to Provide Adequate Feeding Assistance to Residents
Penalty
Summary
The facility failed to provide adequate feeding assistance to residents who were dependent on staff for their meals. Resident R24, who has a moderate cognitive impairment and requires supervision and cueing for eating, was observed sitting at a dining table without touching his food. The CNA present was the only staff member assisting multiple residents and was unable to provide the necessary assistance to R24. Similarly, Resident R59, with severe cognitive impairment requiring substantial assistance, was left without help until another CNA arrived, at which point R59 began eating. Both residents had care plans indicating their need for assistance, yet the facility did not ensure staff availability to meet these needs. Resident R11, who is cognitively impaired and requires supervision for eating, was found in bed with an untouched breakfast tray and no staff present to assist. Despite expressing a desire to eat, R11 did not receive the necessary help, and the tray was removed without any food being consumed. Resident R37, with mild cognitive impairment and requiring setup assistance, was observed eating with his hands due to difficulty using silverware and opening food containers. R37 reported pain in his hands and a lack of staff assistance, which hindered his ability to eat. The facility's policy mandates providing necessary services to maintain residents' nutrition, yet these instances demonstrate a failure to adhere to this policy, resulting in unmet nutritional needs for the residents involved.
Inadequate Supervision and Unsafe Practices in Resident Care
Penalty
Summary
The facility failed to provide adequate supervision and safe transfer practices for several residents, leading to potential safety hazards. One resident, who requires a mechanical lift for transfers due to multiple health conditions including Parkinson's and amputations, was observed being transferred in a manner that caused her to swing freely in the lift. This was due to improper handling by the CNAs, who did not maintain contact with the resident during the transfer, causing her to feel unsafe and at risk of falling. Another resident, who is mildly cognitively impaired and requires substantial assistance, was also transferred using a mechanical lift without proper contact, allowing her to swing freely. This lack of supervision during the transfer process indicates a failure to adhere to the facility's policy on safe lifting practices, which requires staff to ensure the stability and security of the lift and sling before moving residents. Additionally, the facility did not implement adequate fall prevention measures for a resident at high risk for falls, as evidenced by the call light being out of reach. Furthermore, a resident with a history of smoking in his room was allowed to keep cigarettes and a lighter, contrary to the facility's smoking policy, which mandates staff control over smoking materials. This lack of supervision and adherence to policies poses significant safety risks to the residents.
Inadequate Incontinent Care for Residents
Penalty
Summary
The facility failed to provide timely and complete incontinent care for several residents, leading to deficiencies in care. One resident, who was frequently incontinent of both bowel and bladder, was observed with saturated pants after being assisted out of the restroom. The CNA did not change the resident's wet pants before breakfast, despite having a clean pair available. This resident had a history of urinary incontinence and required assistance with activities of daily living due to multiple medical conditions, including traumatic brain injury and diabetes. Another resident, who was always incontinent of urine and occasionally of bowel, was observed receiving incomplete peri-care. The CNAs did not clean all necessary areas, such as the buttocks and abdominal fold, and failed to dry the resident properly. The resident's care plan required two-person assistance for toileting and transfers, and the resident had severe cognitive impairment, making them dependent on staff for care. Additional observations included a resident who was frequently incontinent of bowel and received inadequate cleaning during incontinent care. The CNAs did not clean all soiled areas or apply skin protective lubricant as required by the facility's policy. Another resident, who was always incontinent of urine and frequently of bowel, was also observed receiving incomplete care, with the CNA using the same towel for multiple areas and failing to clean all necessary parts. These deficiencies highlight a pattern of inadequate incontinent care across multiple residents.
Deficiency in Food Quality and Presentation
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at a safe and appetizing temperature for seven residents. Interviews with residents revealed dissatisfaction with the taste and appearance of the food, with some residents opting to purchase and store their own food due to the poor quality of meals provided. Observations and record reviews confirmed these complaints, with specific instances of food being described as 'nasty,' 'grubby,' and 'not appealing.' The Resident Council Meeting Minutes also documented ongoing issues with the quality of the food, noting that meat was tough and dinners were not fresh. During a survey, a sample tray was tested, revealing that the stuffed pepper was not intact, with the meat separated from the pepper and the sauce spread over both, while the buttered corn was bland. Additionally, a resident was observed struggling with a tough and hard-to-chew sausage during breakfast, further highlighting the facility's failure to meet its own standards as outlined in their Food and Nutrition Services Manual. The manual specifies that food should be prepared to conserve nutritive value, flavor, and appearance, and be served in a manner that meets residents' needs, which was not adhered to in these instances.
Inadequate Hand Hygiene and Glove Use in Resident Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene and glove-changing protocols, as observed in multiple instances involving both nursing staff and residents. A Restorative CNA was seen feeding two residents without performing hand hygiene between assisting them. One resident was cognitively intact and dependent on staff for eating, while the other had a severe cognitive impairment and required moderate assistance. Additionally, a Registered Nurse was observed administering medications to residents without performing hand hygiene between residents. The nurse handled pills directly with bare hands, which is against the facility's medication administration policy. In another instance, two CNAs were observed performing incontinent care on a resident without following proper glove-changing and hand hygiene procedures. The resident was incontinent of bowel and bladder and required staff assistance for toileting. The CNAs used the same towel and gloves throughout the process, including washing the resident's neck, breast, and vaginal area, and then dressing the resident without changing gloves. This was contrary to the facility's incontinent care policy, which requires changing gloves and performing hand hygiene to prevent cross-contamination.
Deficiencies in Antibiotic Stewardship and Administration
Penalty
Summary
The facility failed to confirm the need for antibiotics and ensure residents received all doses as ordered, affecting five residents. The Infection Preventionist was unable to confirm the specific infections or reasons for antibiotic use for several residents, and the facility's infection control log lacked essential details such as culture results, medical record numbers, and documentation of antibiotic administration. For instance, Resident R39 had an unknown infection with no culture results documented, yet received Linezolid as per the Physician Order Sheet. Resident R85 was similarly affected, with no documentation of culture results or organism identification, yet received Cefdinir for an unspecified infection. Resident R95's records indicated a urinary tract infection, but again, no culture results were documented, and the infection control log did not record the antibiotics administered. These lapses in documentation and tracking highlight a systemic issue in the facility's antibiotic stewardship program. Resident R89 experienced significant medication errors, with multiple missed doses of prescribed antibiotics, including Ceftriaxone and Vancomycin, as documented in the Medication Administration Record. The Director of Nursing acknowledged the issue, and the Pharmacist confirmed the severity of the missed doses, which could potentially worsen the resident's infection. The facility's Antibiotic Stewardship Policy emphasizes appropriate antibiotic use, yet the observed deficiencies indicate a failure to adhere to this policy, compromising resident care.
Failure to Follow Wound Care Orders for Resident with Diabetic Ulcers
Penalty
Summary
The facility failed to follow wound care orders for a resident with a complex medical history, including chronic multifocal osteomyelitis, cellulitis, type two diabetes mellitus with foot ulcer and neuropathy, peripheral vascular disease, and an acquired absence of the right leg above the knee. The resident required substantial assistance for lower body dressing and was dependent on staff for footwear. The care plan outlined specific interventions for diabetic ulcers on the resident's left heel and midfoot, including detailed instructions for wound observation, documentation, and treatment application. On a specific date, the resident's left foot dressing was observed to be not intact, with the gauze saturated and dangling on the floor. The wound care nurse confirmed that the dressing was improperly applied, missing essential components such as an elastic wrap. Despite the wound care orders specifying a detailed dressing procedure, including the use of silver sulfadiazine, collagen hydrogel, and other materials, the staff failed to adhere to these instructions. The facility also lacked a policy on treatment and care for diabetic ulcers, contributing to the deficiency.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate treatment and services to prevent and heal pressure ulcers for a resident, identified as R10, who was readmitted from the hospital with multiple medical conditions, including surgical aftercare, pancreatitis, and respiratory failure. Upon readmission, R10 was noted to have pressure sores on her right and left buttocks. Despite being at high risk for skin breakdown, as indicated by her Braden Scale score, the facility did not complete a skin and wound assessment, measurements, or an initial treatment plan for the pressure ulcers in a timely manner. The facility's policies required daily skin assessments for high-risk residents and immediate initiation of treatment plans upon identification of pressure ulcers, which were not adhered to in R10's case. R10's care plan documented her dependency on staff for activities of daily living and her risk for impaired skin integrity, yet staff failed to consistently implement interventions to prevent further skin damage. R10 reported that staff did not change her frequently enough, and she experienced significant pain during peri-care, which was not adequately addressed. The staff's inaction and lack of communication regarding R10's skin condition and pain management contributed to the deficiency. R10's complaints of pain and the presence of open wounds were not promptly reported to the nursing staff, and appropriate barrier creams were not applied consistently as per the orders. Interviews with staff revealed a lack of awareness and communication regarding R10's skin condition and pain. The wound nurse was not informed of R10's pressure sores until weeks after her readmission, and the necessary skin inspections and assessments were not conducted as required by the facility's policies. The facility's failure to adhere to its own policies and procedures for pressure ulcer prevention and management resulted in inadequate care for R10, highlighting significant gaps in communication and care coordination among the staff.
Significant Medication Errors in Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of intravenous antibiotics. The resident, who was cognitively intact and dependent on staff for certain transfers, had a care plan indicating a risk for complications related to a wound infection, requiring antibiotics. Physician's orders were in place for the administration of Ceftriaxone and Vancomycin to treat the infection. However, the Medication Administration Record (MAR) showed multiple instances where these antibiotics were not documented as administered on specific dates in December 2024 and January 2025. The Director of Nursing acknowledged the missed doses and provided documentation for review, which confirmed the absence of records for morning doses of the antibiotics. The facility's Medication Administration Policy required that medications be administered safely and documented as required, which was not adhered to in this case. The pharmacist confirmed that the number of missed doses constituted a significant medication error, potentially affecting the resident's recovery from the infection.
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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