Country Health
Inspection history, citations, penalties and survey trends for this long-term care facility in Gifford, Illinois.
- Location
- 2304 C R 3000 N, Gifford, Illinois 61847
- CMS Provider Number
- 145708
- Inspections on file
- 35
- Latest survey
- December 13, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Country Health during CMS and state inspections, most recent first.
A resident did not receive the prescribed increased dose of Hydrocodone-Acetaminophen for about a week after a medication order change. Staff continued to administer the discontinued lower dose due to not removing the old medication card, resulting in a significant medication error. The DON confirmed the error, and records showed the resident received the incorrect dose during this period.
A resident with multiple high-risk conditions and on medications increasing fall risk was found after a fall with no fall mats in place and the bed not in the lowest position. Staff confirmed that required fall prevention interventions were not implemented, leading to the resident sustaining a nasal fracture and laceration requiring sutures.
Two residents with documented exit-seeking and wandering behaviors were not promptly identified in their care plans as being at risk for elopement, nor was the use of departure alert systems included until after physician orders were placed. Despite assessments and behavioral notes indicating risk, care plans were only updated after orders were obtained, contrary to facility policy requiring individualized planning based on cognitive assessments and activity logs.
A resident with a history of falls and mobility limitations was not provided with the required one staff assist during ambulation. Instead, a CNA positioned themselves in front of the resident and allowed the resident to walk independently, resulting in a fall and multiple injuries. Staff interviews confirmed that proper procedures for one staff assist with a gait belt and walker were not followed.
A resident with severe cognitive impairment and multiple medical conditions was left unsupervised in the assisted dining room, leading to a hot tea spill that caused burns and blisters. The facility failed to have nursing staff present, as required, to supervise residents needing assistance with eating.
The facility failed to prevent and treat pressure ulcers for two residents, resulting in one developing an unstageable deep tissue injury and another developing seven stage two wounds. Despite being at risk, daily skin assessments were not documented, and necessary interventions like specialty mattresses and timely treatment orders were not implemented. Observations revealed untreated wounds and inadequate care, contributing to the worsening of the residents' conditions.
A resident with dysphagia experienced a choking incident after an LPN left the room before ensuring the medication was swallowed. Another resident with a history of falls and hallucinations had multiple falls, including one resulting in a broken back, without thorough investigation or documentation. The facility failed to adhere to its medication administration and fall management policies.
The facility failed to implement a performance improvement program project over the past year, affecting all 85 residents. Despite having a policy for a systematic approach to quality improvement, no project was in place involving frontline staff or measures to monitor effectiveness. The administrator acknowledged this deficiency.
The facility failed to properly handle and launder linens exposed to scabies, risking contamination for all residents. Additionally, staff did not follow Enhanced Barrier Precautions for two residents, neglecting to wear gowns during high-contact care activities, despite facility protocols requiring such measures.
The facility failed to administer medications timely and according to physician's orders for four residents, resulting in a 32% medication error rate. Errors included late administration, failure to prime insulin pens, and lack of physician notification. The facility's policy requires notifying the physician of medication errors, but this was not documented.
The facility failed to maintain a clean and homelike environment for two residents, as a chair in their room was found with significant stains. The Housekeeping Supervisor was unaware of the issue, and the chair was removed for cleaning only after the deficiency was identified.
A resident with dementia and muscle weakness was observed with a lap cushion in a wheelchair, functioning as a restraint. The facility lacked a physician's order and consent for its use, and staff were unaware of the resident's inability to remove it. Documentation of restraint reduction attempts was also missing.
A resident with moderate cognitive impairment and hearing loss did not have a care plan addressing their hearing aid use until a specific date. The resident's hearing aids were missing, affecting communication, and staff were not consistently applying the remaining hearing aid. The DON confirmed the absence of a care plan prior to the noted date, leading to the deficiency.
A facility failed to manage and document the care of a resident with a g-tube. The resident received Osmolite 1.5 Cal at 60 ml per hour, but the facility did not check and record gastric residual volume to verify g-tube placement before administering medications. Instead, an RN used the air rush technique, contrary to facility policy. The total volume of feeding and water flushes was not recorded, and there were no orders to routinely check gastric residuals or parameters to hold feeding based on residual volumes. The facility's policies require checking tube placement and documenting these checks, which was not done.
The facility failed to label, store, and change oxygen and nebulizer tubing for three residents, leading to deficiencies in respiratory care. One resident's oxygen tubing was undated and uncovered, with no routine change documented. Another resident's nebulizer equipment was undated and uncovered, with no record of scheduled changes. A third resident's oxygen tubing was outdated, and the resident was unsure of change frequency. Facility policies requiring weekly changes and proper storage were not followed.
The facility failed to implement effective infection control measures for COVID-19, including not stocking isolation carts with N95 masks, missing isolation signage, and improper PPE disposal by staff. A resident with COVID-19 and multiple health conditions did not receive documented symptom monitoring as required. Staff were unaware of proper PPE procedures, increasing exposure risks.
A resident with severe cognitive impairment physically abused another resident in their room. The incident occurred when the aggressor, who has a history of aggressive behaviors, entered the victim's room and struck them in the chest after being asked to leave. The event was witnessed by another resident and reported by a CNA to an LPN, revealing a failure in the facility's policy to protect residents from abuse.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident did not receive pain medication as prescribed following a change in their medication order. After a nurse practitioner increased the resident's Hydrocodone-Acetaminophen dose from 5 mg to 7.5 mg, staff continued to administer the original 5 mg dose for approximately one week. This error was due to staff not removing the discontinued 5-325 mg medication card and instead placing the new 7.5-325 mg card behind it, resulting in the continued administration of the lower dose despite the updated physician's order. The resident reported that they were informed by the DON that the incorrect dose had been given for a week. Medication administration records and controlled drug receipt records confirmed that the resident received the lower dose during this period. The facility's policy requires medications to be administered accurately according to physician orders, but this was not followed, leading to a significant medication error involving the administration of the wrong dose of pain medication.
Failure to Implement Fall Prevention Interventions Resulting in Resident Injury
Penalty
Summary
The facility failed to implement necessary fall prevention interventions for a resident identified as high risk for falls, resulting in a significant injury. The resident had multiple diagnoses including osteoarthritis, heart disease, lumbar disc displacement, anxiety, vertigo, repeated falls, glaucoma, type II diabetes, difficulty in walking, and psychotic disturbance with hallucinations. The resident was prescribed several medications known to increase fall risk, such as Haldol, Dilaudid, and Fentanyl. Despite being assessed as high risk for falls and having a recent history of falls, the resident was found alone in their room after a fall, with no fall mats in place and the bed not in the lowest position. The nightstand was positioned between the wall and the bed, and the resident was found partially under the bed, which was covered in blood along with the nightstand. Staff interviews confirmed that the fall prevention interventions, specifically the use of fall mats and maintaining the bed in the lowest position, were not in place at the time of the incident. The resident sustained an acute nasal fracture and a laceration requiring five sutures as a result of the fall. Observations after the incident further confirmed that the bed was not kept in the lowest position, and the Director of Nursing verified that if the bed had been lowered, the resident would not have been able to get under the bed. The lack of these interventions directly contributed to the resident's fall and subsequent injuries.
Failure to Timely Update Care Plans for Elopement Risk and Departure Alert Systems
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan addressing elopement risk and the use of a departure alert system for two residents identified as exit seeking. Both residents had documented histories of wandering and were assessed as being at risk for exit seeking/wandering, as evidenced by multiple behavioral notes and formal assessments. Despite these findings, their care plans did not reflect their elopement risk or the use of departure alert systems until a much later date, even after incidents such as one resident being found wandering near a door with the alarm sounding. Physician orders for the use of departure alert systems were not placed until after these risks and behaviors had been documented, and the care plans were only updated following the placement of these orders. Staff interviews confirmed that the care plans were not updated to include elopement risk and interventions until the physician's orders were in place, despite facility policy indicating that cognitive assessments and activity logs should inform individualized service plans. This delay resulted in a lack of timely, comprehensive care planning for residents at risk of elopement.
Failure to Provide Required Staff Assistance During Resident Ambulation
Penalty
Summary
A deficiency occurred when a resident, who was at risk for falls due to limited physical mobility, chronic pain syndrome, and osteoarthritis, was not provided with the required one staff assistance during ambulation. The resident's care plan specified the need for one staff assist with a gait belt and walker for transfers. On the day of the incident, a Certified Nursing Assistant (CNA) assisted the resident off the toilet, cleaned the resident, and provided the walker. The CNA then positioned themselves in front of the resident, near the bathroom door, rather than at the resident's side or behind, and allowed the resident to ambulate independently. As the resident attempted to walk toward the CNA, the resident fell backwards, resulting in multiple injuries including a hematoma, bruises, and skin tears. Interviews with facility staff confirmed that the CNA did not follow the proper procedure for assisting a resident who requires one staff assist with a gait belt and walker. The CNA was not in a position to provide support or assist in lowering the resident to the floor if needed, as required by the resident's care plan and standard practice. The incident was witnessed and documented by staff, and the resident was assessed for injuries following the fall.
Lack of Supervision Leads to Resident Injury from Hot Beverage Spill
Penalty
Summary
The facility failed to adequately supervise a resident, identified as R504, after providing a hot beverage, resulting in the resident spilling hot tea on themselves. This incident led to the resident sustaining redness and six blistered areas on their bilateral upper extremities, requiring treatment for three days. The resident, who has severe cognitive impairment and requires supervision or assistance with eating, was in the assisted dining room at the time of the incident, which is designated for residents needing supervision. R504's medical history includes diagnoses such as Congestive Heart Failure, Reflux Disease, Alzheimer's Disease, Dementia, and other conditions that contribute to their need for supervision. The resident's care plan indicates they are at risk for altered nutrition and require queuing in the dining room. On the day of the incident, the resident attempted to remove the lid from their hot tea, resulting in the spill and subsequent burns. Interviews with facility staff revealed that there were no nursing staff present in the dining room at the time of the incident, which is contrary to the facility's requirement for supervision in the assisted dining room. The Director of Nursing confirmed that supervision should include at least one nursing staff member present when residents are in the dining room with food or beverages. The lack of supervision directly contributed to the resident's injury.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide targeted interventions to prevent skin breakdown and did not assess, evaluate, or document resident skin conditions regularly. This resulted in one resident developing a new, unstageable, deep tissue injury and another resident developing seven new stage two pressure wounds. The facility's Wound and Ulcer Policy required daily skin assessments for residents at moderate or high risk, but these were not documented for the affected residents. One resident, identified as R20, was found to have an unstageable deep tissue injury on her left heel, which was not previously documented or treated. Despite being at moderate risk for skin breakdown, R20's medical records did not show daily skin checks. Observations revealed that R20 was not provided with a specialty mattress, and her complaints of foot pain were not addressed. The wound nurse confirmed that the injury had likely been present for several weeks without treatment. Another resident, R58, was identified as having multiple new wounds on her buttocks and thighs, which were not documented or treated according to the facility's protocols. R58 was at high risk for skin breakdown, yet her medical records lacked daily wound assessments. Observations showed that R58 was sitting in a wet brief without dressings on her wounds, and the necessary notifications and treatment orders were not obtained. The facility's failure to implement appropriate interventions and conduct regular skin checks contributed to the development and worsening of these pressure wounds.
Inadequate Monitoring and Documentation in LTC Facility
Penalty
Summary
The facility failed to adequately monitor a resident with dysphagia after administering oral medication, leading to a choking incident. The resident, who was cognitively intact and had a history of muscle weakness and dysphagia, was given a chewable tablet for gas relief by an LPN. The LPN left the room before ensuring the resident had thoroughly chewed and swallowed the medication. Shortly after, the resident began to choke, and staff had to perform the Heimlich maneuver to clear the airway. Additionally, the facility did not thoroughly investigate and document falls for another resident who had experienced multiple falls, including one that resulted in a broken back. The resident, who required significant assistance for mobility and was occasionally incontinent, had a history of hallucinations and falls. The facility's documentation was incomplete, lacking details about the circumstances of the falls, staff interviews, and post-fall assessments. The facility's policies on medication administration and fall management were not followed, contributing to these deficiencies. The medication administration policy required staff to ensure residents took their medication properly, which was not adhered to in the case of the resident with dysphagia. Similarly, the fall management policy required comprehensive documentation and investigation of falls, which was not completed for the resident with multiple falls.
Lack of Performance Improvement Program in Facility
Penalty
Summary
The facility failed to develop, implement, measure, act on, or analyze a performance improvement program project over the past twelve months. This deficiency potentially affects all 85 residents residing in the facility. The facility's Quality Assessment Performance Improvement Policy, dated December 8, 2023, outlines a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality, involving all caregivers in problem-solving. However, the facility did not have a performance improvement project in place for the last four quarters, which included the involvement of frontline staff or measures to monitor effectiveness. The administrator acknowledged the absence of such a project and indicated that performance improvement projects would be integrated into the quality process in the future.
Infection Control and Barrier Precaution Failures
Penalty
Summary
The facility failed to properly store, handle, and launder linens potentially exposed to scabies, affecting all 85 residents. The facility's infection control policy for scabies requires contaminated items to be bagged and washed separately at high temperatures. However, the Housekeeping/Laundry Supervisor was unaware of this protocol, leading to the mixing of potentially contaminated items with other residents' laundry. This oversight occurred despite the Infection Preventionist's awareness of the potential for further infestation and infection. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) for two residents. One resident, with wounds and a urinary catheter, had a care plan requiring staff to wear gowns and gloves during high-contact care. However, during observed care, staff did not wear gowns. Similarly, another resident with a gastrostomy tube required EBP, but staff only wore gloves during medication administration. The facility's protocol mandates gowns and gloves for high-contact activities, which were not followed in these instances.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications timely and according to physician's orders and manufacturer's instructions for four residents. A registered nurse was behind on the morning medication pass, resulting in late administration of medications for one resident, including Lantus insulin, Macrobid, Tylenol, and Metoprolol Tartrate. The nurse did not prime the Lantus insulin pen before administration, and there was no documentation that the physician was notified of the late administration and missed doses. Another resident received Humulin N insulin and Persantine late, and the nurse did not prime the insulin pen before administration, unaware of the requirement. The physician was not notified of the late administration. A licensed practical nurse administered Admelog insulin to a resident without food present, contrary to instructions to administer within 15 minutes prior to a meal or immediately after. Another resident received Brimonidine Tartrate eye drops late due to the nurse being behind in the medication pass. The facility's policy requires notifying the physician of medication errors and missed doses, but this was not documented in the cases reviewed.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for two residents, as required by regulations. During an observation, a light tan fabric chair in the sitting area of the residents' room was found to have dark and light brown stains covering at least half of the seat. The Housekeeping Supervisor, when interviewed, acknowledged that the chairs in residents' rooms are cleaned occasionally and mentioned that most were cleaned by an outside company a few months prior. However, she was unaware of the stained condition of the chair in question. The chair was subsequently removed for cleaning after the issue was identified. The facility's Fabric Furniture Cleaning policy outlines that furniture should be cleaned when soiled, but it appears this procedure was not followed in a timely manner for the chair in the residents' room.
Failure to Obtain Proper Authorization for Restraint Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints without proper authorization and documentation. A resident, diagnosed with unspecified dementia, muscle weakness, and other conditions, was observed with a lap cushion across his lap while in a wheelchair. The resident's care plan noted the lap cushion as a comfort device, and it was documented that the resident could place and remove it independently. However, during observations, the resident was unable to remove the lap cushion upon request, indicating it functioned as a restraint. The facility did not have a physician's order or a signed consent form for the use of the lap cushion as a restraint. The resident's medical records lacked documentation of restraint reduction attempts, and the facility's policies required informed consent and a plan for the progressive removal of restraints. Interviews with facility staff revealed a lack of awareness regarding the resident's inability to remove the lap cushion, and the necessary documentation and consent were not obtained until after the deficiency was identified.
Failure to Implement Hearing Devices and Care Plan for Resident
Penalty
Summary
The facility failed to implement hearing devices and develop a care plan for a resident with hearing loss. The resident, who has moderate cognitive impairment, was documented to have minimal difficulty hearing when using hearing aids. However, the care plan did not address the resident's hearing loss and hearing aid use until a specific date, despite the resident's admission assessment indicating the use of hearing aids for both ears. The resident's family reported that both hearing aids were missing, and although one was found, the other remained missing, impacting the resident's ability to communicate effectively. Staff interviews revealed that the resident was not wearing hearing aids during interactions, and there was confusion among staff regarding the resident's hearing aid needs. A Certified Nursing Assistant admitted to not applying the hearing aid due to fear of losing the remaining one. The Director of Nursing acknowledged that staff should have been applying the hearing aid daily and confirmed the absence of a care plan for the resident's hearing loss and devices prior to the noted date. This lack of a care plan and proper implementation of hearing devices led to the deficiency.
Failure to Properly Manage and Document G-Tube Care
Penalty
Summary
The facility failed to properly manage and document the care of a resident with a gastrostomy tube (g-tube). The resident, identified as R39, was observed receiving Osmolite 1.5 Cal at 60 ml per hour via g-tube, with water flushes set at 200 ml every four hours. However, the facility did not check and record the gastric residual volume to verify the g-tube placement before administering medications, as required by the facility's policy. Instead, a registered nurse used the air rush technique to check tube placement, which is not in line with the facility's protocol. Additionally, the total volume of feeding and water flushes administered was not recorded, and there were no orders to routinely check gastric residuals or parameters to hold feeding based on residual volumes. The resident's care plan and the facility's policies require checking tube placement and gastric contents/residual volume, and documenting these checks, which was not done. The Director of Nursing confirmed that the nurses should be checking g-tube placement by checking gastric residual volume prior to feeding and medication administration, and that water flush orders should be based on the dietitian's recommendations. The facility's policies also require recording the amount of feeding and water flushes administered, which was not adhered to in this case.
Deficiencies in Respiratory Care Equipment Management
Penalty
Summary
The facility failed to properly label, store, and change oxygen and nebulizer tubing for three residents, leading to deficiencies in respiratory care. For one resident, the oxygen tubing was found undated and uncovered on the bed, with no physician order or documentation indicating routine changes. This resident had used oxygen on multiple days over a period of nearly a month. Another resident's nebulizer mask and tubing were also undated and uncovered, with visible splatters of a brown substance on the nebulizer machine. The medication administration record indicated that the nebulizer tubing and mask should be changed weekly, but there was no documentation of this being done as scheduled. A third resident was found using oxygen via nasal cannula with tubing dated ten days prior, and the resident was unsure of the frequency of tubing changes. The treatment administration record indicated that the tubing should be changed weekly, and it was signed as completed on a specific date. A registered nurse confirmed that the oxygen and nebulizer equipment should be labeled with dates, changed weekly, and stored in plastic bags when not in use. The facility's policies on oxygen administration and aerosol treatments also required weekly changes and proper storage, which were not adhered to in these cases.
Inadequate Infection Control Measures for COVID-19
Penalty
Summary
The facility failed to implement effective infection control measures to prevent the spread of COVID-19. Specifically, the facility did not stock isolation carts with N95 masks, failed to post isolation signage, and did not ensure staff discarded personal protective equipment (PPE) upon leaving COVID-19 positive resident rooms. These deficiencies were observed in the care of five residents, where staff did not change their N95 masks after leaving the room of a COVID-19 positive resident, and isolation signage was missing from the doors of rooms housing COVID-19 positive residents. Additionally, the facility's policy required symptom monitoring and vital signs to be taken every four hours for COVID-19 positive residents, but this was not documented in the medical records. One resident, who tested positive for COVID-19, had a history of congestive heart failure, emphysema, atrial fibrillation, and type two diabetes mellitus. Despite the resident's positive COVID-19 test and physician orders for contact/droplet isolation and vital sign monitoring twice daily, there was no documentation of symptom monitoring or respiratory assessments after the initial note. Staff members, including a CNA and a housekeeper, were unaware of the proper procedures for handling PPE and identifying COVID-19 positive rooms, leading to potential exposure risks for other residents and staff.
Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident (R2) from physical abuse by another resident (R1). R1, who has severe cognitive impairment due to dementia, exhibited aggressive behaviors such as yelling, screaming, and physical aggression. On the day of the incident, R1 entered R2's room in a wheelchair and, when asked to leave by R2, became angry and struck R2 in the chest multiple times. This incident was witnessed by another resident (R3) and reported by a Certified Nursing Assistant (V4) to a Licensed Practical Nurse (V3). R2, who is cognitively intact, confirmed the account of the incident, stating that R1 hit them three times in the chest after being asked to leave the room. The facility's policy on abuse and neglect clearly states that all residents have the right to be free from physical abuse, yet this incident indicates a failure to uphold that policy. The report includes interviews with staff and residents, which corroborate the occurrence of the abuse, highlighting a deficiency in the facility's ability to prevent such incidents.
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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