Countryside Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Macomb, Illinois.
- Location
- 400 West Grant Street, Macomb, Illinois 61455
- CMS Provider Number
- 146080
- Inspections on file
- 43
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Countryside Care Center during CMS and state inspections, most recent first.
The facility failed to provide adequate nursing and support staff to meet residents’ daily care needs, resulting in prolonged call light response times, missed or delayed morning assistance, and inconsistent bathing. Over several months, residents reported being left in bed past breakfast and activities, going a week or more without showers, and waiting 30–60 minutes for call lights to be answered, with one resident experiencing incontinent episodes while waiting for toileting assistance. Residents also described long waits for meals and food often being served cold. Staff and leadership acknowledged frequent CNA call-offs, retention issues, lack of night and weekend laundry staff, and CNAs performing laundry duties, all of which reduced time available for direct resident care.
The facility failed to consistently post and retain required Daily Staffing Reports, affecting all 44 residents. On the day reviewed, the report on the bulletin board was from the prior day and had not been updated by midday. When surveyors requested the last two weeks of reports, the DON stated she did not have them and did not know what happened to the reports once removed. The DON reported that a night-shift nurse was supposed to complete and post the report but acknowledged this did not always occur, and that she sometimes completed it later in the morning. The administrator in training stated that the DON was expected to keep the reports for several years and that they should be posted early in the morning, but also confirmed there was no written policy governing the posting of the Daily Staffing Report.
Surveyors identified multiple failures in dietary services, including unlabeled and undated frozen, refrigerated, and dry food items, as well as opened and prepared foods held past their documented expiration periods. Numerous items such as partial bags of frozen products, prepared sandwiches, cooked meats, condiments, cereals, pasta, and bread lacked required labels or dates. During steam table checks, a cook handled ready-to-serve food and used a thermometer without gloves, directly touching food items, and reheated mechanical chicken only to 140°F instead of the required 165°F before planned service. These actions and inactions occurred while 44 residents were in the facility.
The facility failed to complete its facility-wide assessment by not documenting the number of RNs, LPNs, and CNAs needed to meet the needs of its resident population. Although the assessment stated it was a comprehensive review of human and physical resources for day-to-day and emergency operations and listed a daily average census of 49, it omitted required RN and LPN staffing levels and recorded that 0 CNAs were needed. The AIT confirmed that the necessary staffing numbers for RNs, LPNs, and CNAs were not included in the assessment, despite the presence of 44 residents in the facility.
The facility failed to follow its IPCP policy requiring monitoring of employee health and safety by not maintaining any tracking or logs of staff who called in sick due to infection or illness. The IPCP policy specified that employees, contractors, vendors, visitors, and volunteers must report infections or avoid the facility in certain situations, but the LPN serving as Infection Preventionist and Assistant DON confirmed there was no system in place to record such illness-related call-offs before January 2026. At the time of the survey, 44 residents were documented as residing in the facility.
Surveyors found that the facility did not follow its written COVID-19 vaccination policy requiring that all staff be educated about the COVID-19 vaccine, offered immunization, and have their vaccination status documented. During interview and record review, an LPN serving as Infection Preventionist/Assistant DON acknowledged there was no documentation that employees were offered the COVID-19 vaccine and stated that employees were not being offered the vaccine through the facility, and that this requirement was not known. At the time of the survey, 44 residents were documented as residing in the facility.
The facility did not ensure CNAs received and completed required dementia and abuse prevention training within a 12‑month period for all 44 residents. Facility assessment documents stated that CNAs must receive abuse and dementia training upon hire and annually, but the HR/Business Office Manager reported she could not locate the required training records, did not know what a prior DON had done with the training information, and could not confirm that CNAs had actually received the required education. The AIT similarly confirmed he could not provide CNA training records, leaving the facility unable to demonstrate that mandated dementia and abuse training had been provided.
The facility failed to provide scheduled showers and bathing care to multiple dependent residents, despite a policy requiring assistance with showers/baths/bed baths and resident care plans specifying shower frequency. Resident Council minutes and resident interviews described ongoing problems with irregular showers, including reports of going a week or more without bathing and needing to beg staff for showers. Surveyors observed a resident with a strong urine odor whose record showed no showers over a two‑week period despite an order for twice‑weekly showers, and another resident with an open chest area who reported not receiving showers and had no showers documented for several weeks without explanation. A cognitively impaired, fully dependent resident also had no showers documented for nearly a month. A CNA stated that showers often were not done and depended on staffing, and the DON reported being unaware that residents were not receiving showers.
Surveyors found that staff did not follow facility policy for oxygen therapy, including failing to label oxygen tubing and humidification bottles with change dates and not posting required "Oxygen in Use" signs on room doors for several residents receiving oxygen via nasal cannula. Residents with conditions such as COPD, asthma, chronic respiratory failure, and obstructive sleep apnea were observed on oxygen without door signage, and some had undated tubing and humidification bottles despite weekly change requirements. A CNA, the ADON, and the DON confirmed that tubing and bottles should be dated and changed weekly and that oxygen safety signs should be posted when a resident uses oxygen.
A resident who is cognitively intact and uses a wheelchair was repeatedly observed sitting on a cotton pad cloth smeared with brown fecal matter in the wheelchair seat. Over several observations, the soiled pad remained in place, and the resident reported that this occurred consistently and that staff often told her they had run out of pad cloths when she requested a change. A CNA confirmed the presence of fecal matter on the wheelchair, and the ADON acknowledged that staff should always change the pad and that the resident should not have to sit in a dirty wheelchair, indicating a failure to uphold resident dignity and to follow the facility’s equipment cleaning policy.
Two residents reported that their mail and packages were sometimes delivered already opened, with one resident stating this occurred frequently and identifying the Social Service Director as the staff member who usually opened their items outside the resident’s presence. The facility’s resident rights materials state that mail must be delivered promptly and may not be opened without the resident’s permission. The Social Service Director admitted to opening residents’ mail with scissors before taking it to their rooms, without the residents being present or aware.
A resident reported that a male CNA smacked her buttocks while assisting with toileting and stated she was very angry and bothered by the incident, which she reported to staff. The facility’s abuse policy requires prompt reporting and thorough investigation of all abuse allegations, but the abuse coordinator/Administrator in Training later acknowledged that, although he was aware of the incident, he had not conducted or documented an abuse investigation, had not interviewed the CNA about the specific allegation, and had not interviewed other residents about the CNA. No investigation records or related documentation were available, demonstrating a failure to implement the facility’s abuse policy and to thoroughly investigate the alleged staff-to-resident abuse.
A resident reported that while being assisted with toileting by a male CNA, the CNA adjusted the resident’s underwear contrary to her directions and then smacked her on the butt, causing the resident to become angry and order him to leave her room. The facility’s abuse policy requires investigation and timely reporting of all abuse allegations, but the resident’s record contained no documentation of any incident or investigation. The DON acknowledged being told the resident needed to speak with her about what she was saying, and the abuse coordinator/Administrator in Training confirmed he was notified of the allegation but did not report it, did not conduct or document interviews specific to the allegation, did not interview other residents about the CNA, and had no investigation records related to the incident.
The facility failed to provide the ombudsman with accurate admission, transfer, and discharge information for a resident with multiple chronic conditions, including chronic respiratory failure, COPD, atrial fibrillation, and CKD. Nursing notes and the census list showed multiple hospital transfers for respiratory distress and subsequent readmissions, but the monthly Admission/Discharge Reports omitted these events. The ombudsman reported that the lists she received were not complete or accurate, and the Administrator in Training explained that only residents absent for a certain number of days, based on payer source, were included on the discharge sheet, leading to incomplete notification to the ombudsman.
A resident’s MDS assessment was inaccurately coded to show use of an anticoagulant medication, despite the MAR for the corresponding period showing no administration of any anticoagulant. The facility’s policy requires comprehensive and accurate MDS assessments, but the DON confirmed that the resident’s medical record did not indicate anticoagulant use and that she did not recall the resident ever receiving such medication, indicating the MDS was coded incorrectly.
A resident with multiple mental health diagnoses, including bipolar disorder, major depressive disorder with psychotic features, PTSD, and later Schizophrenia, did not receive an updated PASRR Level II evaluation after the new Schizophrenia diagnosis, despite facility policy requiring referral for a Level II review with significant status changes or newly evident serious mental disorders. Existing PASRR Level I and II screenings listed several mental health conditions and recommended ongoing mental health follow-up and psychotropic medications, and the resident’s care plan included psychotropic use for Schizophrenia and other conditions. The Admissions Coordinator and Social Service Director were responsible for PASRR updates, but the diagnosis was not incorporated into PASRR documentation, and leadership acknowledged that a new Level II PASRR should have been requested but was not.
The facility failed to ensure required Level II PASARR evaluations were completed and accurately documented for two residents with significant mental health diagnoses. One resident with psychoactive substance abuse, alcohol dependence, major depressive disorder, mood disorder, and schizoaffective disorder had no Level II PASARR in the record, and the existing Level I PASARR omitted key mental health and substance-related diagnoses while indicating no serious mental illness. Another resident with schizophrenia, bipolar disorder, generalized anxiety disorder, unspecified intellectual disabilities, and other mental health conditions was referred for a Level II PASARR on the Level I screen, but no Level II PASARR was found in the medical record. The admissions coordinator, who manages PASARR screenings, confirmed the absence of the required Level II evaluations and lack of awareness of one resident’s schizoaffective disorder diagnosis.
Residents and staff reported ongoing issues with food quality, including burnt, undercooked, or cold meals, small portions, and menu substitutions due to the kitchen running out of items. Multiple complaints were documented in resident council meetings, and staff confirmed that grievances about food preparation and portion sizes were not addressed. These deficiencies affected all residents in the facility.
Two residents with complex medical and psychiatric histories experienced acute medical deterioration due to a nurse's failure to monitor, document, and treat their conditions during the night shift. The nurse did not provide necessary interventions or accurately record medication administration, leading to both residents requiring emergency hospitalization for severe respiratory and psychiatric symptoms.
A resident with multiple chronic conditions and intact cognition sustained significant facial bruising and pain after tripping over a rug with an upturned edge, which had been previously reported as a hazard by residents and staff. Despite these reports, the rug was not removed until after the injury occurred, resulting in the resident requiring emergency room evaluation.
A resident receiving hospice care was prescribed multiple controlled substances for pain management, including Morphine. Over several days, an LPN administered significant amounts of Morphine but failed to document these doses in the MAR or on official count forms. The facility could not account for the missing medication, did not follow its own policies for reporting and investigating the loss, and lacked required medication error reports. The investigation was incomplete, and the facility was without a DON during this period, contributing to the deficiency.
Multiple residents and staff reported that food was frequently burnt and unpalatable, with specific complaints about eggs, chicken, and tuna patties. Observations confirmed that meals were overcooked, and staff indicated that a malfunctioning oven was the cause. The dietary manager and cook both stated the oven regulators had not worked for months, resulting in ongoing issues with food preparation.
The facility did not consistently offer bedtime snacks to residents, including those with diabetes, as required by its policy. Several residents reported never receiving snacks at bedtime despite wanting them, and staff confirmed that snacks were not offered daily.
The facility did not maintain its kitchen ovens in working order, leading to repeated instances of burned food being served to residents. Multiple residents and staff reported that food was frequently overcooked or inedible due to malfunctioning ovens, and the issue persisted because the building lacked a maintenance supervisor and the problem was not communicated to maintenance staff.
Mechanical lifts used for dependent resident transfers were found to be unsafe, with one lift wobbling and having an incorrect replacement bolt, and another with a malfunctioning remote that required manual adjustment to operate. A CNA demonstrated these issues, and a resident reported feeling unsafe during transfers. Maintenance staff were unaware of the problems due to lack of communication and absence of a maintenance supervisor.
Nursing staff were observed removing medications from their original packaging and placing them in labeled cups in advance of administration for multiple residents. Staff admitted to preparing medications ahead of time for convenience, despite facility policy requiring medications to remain in their original containers until administration. The DON confirmed that staff had been instructed not to engage in this practice, but it continued to occur.
A resident with stage three pressure ulcers did not receive wound care in accordance with facility policy and physician orders. A registered nurse failed to perform hand hygiene and change gloves between dirty and clean steps during dressing changes, and wound treatments were missed on multiple shifts. The DON confirmed that required treatments were not completed as ordered.
A CNA failed to follow Enhanced Barrier Precautions and proper hand hygiene while providing catheter care to a resident with a suprapubic catheter. The CNA did not wear a gown, nor did they change gloves or perform hand hygiene before applying a new incontinence brief and repositioning the resident, contrary to facility policy and infection control protocols.
A resident with severe cognitive and physical impairments, dependent on staff for eating and drinking, was given a hot chocolate that had not been temperature-checked and was left unsupervised, resulting in the resident spilling the beverage and sustaining second-degree burns to the hip and thigh. Staff interviews and records confirmed that required supervision and safety protocols were not followed, and the facility lacked a hot liquid risk assessment and temperature monitoring for beverages.
A resident sustained burns after spilling hot chocolate, but immediate notification to the family, physician, and IDPH was not made as required. The LPN documented the initial injury but did not notify the responsible parties until the next day, after blistering developed and further assessment was completed by the DON. The incident was also not reported to IDPH, contrary to facility policy.
A resident with chronic pain was supposed to receive a Kenalog injection intra-articularly, but due to an incorrect order entry, it was administered intramuscularly. The error was not immediately identified, and the facility's policies on medication administration and error reporting were not adequately followed, leading to a less effective treatment.
The facility failed to employ a qualified Dietary Manager, impacting all 46 residents. The current manager lacks the necessary certification and training, having been placed in the role by the previous administration without proper preparation. The Administrator is aware of the manager's lack of qualifications.
The facility failed to follow infection control practices in the Laundry Room, did not conduct accurate Legionella Risk Assessments, and neglected Enhanced Barrier Precautions during wound care for a resident. The Laundry Room lacked necessary PPE, and the Legionella Risk Assessment contained inaccuracies. A nurse did not wear the required PPE during a resident's wound care, despite the resident being on Enhanced Barrier Precautions.
A resident was found with medications left in a cup during a routine observation, indicating a failure to ensure ingestion. The LPN admitted to not observing the resident take all medications, and the DON confirmed the resident was not assessed for self-administration, violating facility policy.
A resident's discharge summary was incomplete at the time of a planned discharge. The facility's policy requires a comprehensive interdisciplinary discharge summary, but only the Nursing Service Summary was completed, leaving sections for medications, social service, dietary, activity, and rehab services blank. The DON confirmed the deficiency.
A resident missed a dental appointment due to transportation issues, highlighting ongoing problems with medical appointment transport. Another resident with a fungal infection did not receive proper assessment and treatment, with confusion over medication orders. Additionally, a resident with mobility issues was not provided with a necessary wheelchair cushion, leading to discomfort and improper positioning.
A facility failed to identify PTSD triggers and develop care plan interventions for a resident with PTSD. The resident's trauma screen indicated traumatic experiences and symptoms, but potential triggers and interventions were not documented. The care plan lacked PTSD-related interventions, and RNs were unaware of the resident's PTSD. The DON confirmed the absence of a necessary PTSD care plan.
The facility failed to accurately monitor infections and antibiotic use for three residents, as required by its antibiotic stewardship program. Medical records lacked documentation of hospitalizations and infection details, and the Monthly Infection and Antibiotic Tracking log was incomplete. The DON was unaware of certain hospitalizations and infections, indicating a lack of communication and documentation.
A resident with a history of falls and high fall risk did not receive the recommended physical and occupational therapy evaluations after multiple falls. Despite documented interventions in the care plan, therapy was not provided after the resident's falls, as confirmed by staff interviews and lack of documentation.
A facility failed to develop a care plan and implement behavioral interventions for a resident prescribed haloperidol, an antipsychotic medication. The resident's care plan lacked documentation for psychotropic medication use and behavioral interventions, and the behavior tracking binder did not include a tracking sheet. The PRN order for haloperidol exceeded the 14-day limit, with the resident receiving the medication multiple times in October. The DON confirmed these deficiencies.
A resident with severe cognitive impairment was served an incorrect diet, leading to a choking incident. The dietary aide, lacking proper training and working alone, failed to provide the prescribed mechanically soft diet with ground meat and gravy. The resident, requiring extensive assistance, choked on the improperly prepared meal, necessitating emergency intervention and hospital evaluation.
The facility failed to train dietary staff on safe food handling, affecting all 49 residents. Despite job requirements for food safety training, interviews revealed no training documentation for dietary staff. The Dietary Aide reported no training, and the Dietary Manager confirmed the absence of training since starting, with the Administrator in Training unaware of any educational efforts.
The facility failed to provide adequate staffing in the dietary department, affecting meal services for all 49 residents. The new Dietary Manager reported inconsistent scheduling and insufficient personnel, with staff often working alone. The Administrator in Training did not verify dietary schedules, and residents expressed concerns about the lack of help in the kitchen, particularly at night and on weekends.
A resident with Type II Diabetes Mellitus was given GlucaGen instead of insulin despite having elevated blood glucose levels, leading to worsened hyperglycemia and requiring emergency room treatment. The error was realized shortly after administration, and the resident was treated for multiple conditions at the hospital.
A facility failed to prevent the misappropriation of a resident's Norco medication. An RN received four cards of Norco from the pharmacy but only documented and stored three. Video footage showed the RN placing one card under the desk and later bringing her backpack to the nurse's station. The discrepancy was discovered the next day, leading to an investigation and police involvement. The RN was suspended and did not return to the facility.
Inadequate Staffing Leading to Delayed Care, Missed Showers, and Call Light Response Failures
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient direct care staff to meet residents’ needs and ensure timely care on a daily basis. The facility assessment dated 5/29/25 states that the facility must have sufficient staff with appropriate competencies to assure resident safety and maintain residents’ highest practicable well-being, considering resident number, acuity, and diagnoses. Resident Council minutes over multiple months document ongoing concerns: residents reported that nurses and CNAs were not responding to situations on time, including one resident who fell in the bathroom and yelled for help but received no response. Residents also reported not being assisted in the mornings, being left in bed past breakfast and morning activities, and not being showered regularly, with some going a week or more without a bath or shower. Some residents attributed missed showers to a lack of washcloths. At a resident group meeting, several residents stated that when the facility is short staffed, call lights can take 30 to 60 minutes to be answered, leading at least one resident who is intermittently incontinent and wears a brief to have incontinent accidents while waiting for help to the bathroom. Multiple residents stated they do not receive weekly showers, with one reporting showers only every two weeks and sometimes going three weeks without one, and another stating they have to beg for a shower. Residents also reported that there is no laundry staff at night or on weekends, causing shortages of towels and washcloths and resulting in CNAs doing laundry instead of providing care and answering call lights. Staff interviews confirmed that showers are often not given when staffing is short and that CNA call-offs and retention issues contribute to inadequate staffing. The Administrator in Training confirmed the lack of laundry services during nights and weekends and acknowledged that CNAs performing laundry could affect their ability to provide required resident care. Resident Council minutes and resident group reports also documented delays in meal service, with residents often waiting in the dining room for extended periods and receiving food that is cold by the time it is served.
Failure to Post and Retain Daily Nurse Staffing Reports
Penalty
Summary
The facility failed to post the required Daily Staffing Report for 1/14/26 and failed to retain copies of prior Daily Staffing Reports, affecting all 44 residents documented on CMS Form 671. On the morning of 1/14/26 at 9:10 AM, the staffing report displayed on the bulletin board was still dated 1/13/26 and had not been updated by 12:30 PM. When surveyors requested the last two weeks of Daily Staffing Reports at 11:27 AM, the DON stated she did not have them and did not know what happened to the reports once they were taken down. The DON reported that the third-shift nurse was supposed to complete and post the Daily Staffing Report, but acknowledged this did not always occur, and that she would sometimes complete the posting at 8:00 AM if the nurse had not done so. Later, the Administrator in Training stated that the DON was supposed to keep the Daily Staffing Reports for a couple of years and that there was no reason the previous days’ sheets were not immediately available, and also stated that the Daily Staffing Report should be posted by 6:00 AM. The Administrator in Training further confirmed there was no policy in place regarding posting the Daily Staffing Report.
Food Storage, Labeling, and Temperature Control Deficiencies in Dietary Services
Penalty
Summary
The deficiency involves failure to maintain sanitary food storage, labeling, dating, and preparation practices, as well as failure to ensure proper food temperatures and glove use, with the potential to affect all 44 residents in the facility. Surveyors reviewed facility policies dated 12/30/2024, which required all food to be appropriately dated, expiration dates to be observed with a three-day expiration once food is opened, and prepared food stored in the refrigerator until service to be dated. Policies also required food to be stored per local, state, and federal guidelines and hot foods being reheated to reach at least 165°F for 15 seconds. During an initial kitchen visit, surveyors observed multiple unlabeled and undated items in the freezer, including partial bags of frozen sugar cookies, fish patties, garlic bread slices, and hamburger patties. In the refrigerator, they observed an opened margarine bar with no date; three ham and cheese sandwiches covered with plastic wrap without labels or dates; a diced pears tub made on 01/05/2026 with an expiration date of 01/09/2026; a medium container with a brown substance covered with plastic wrap and no label or date; a container with four cooked chicken breasts made on 12/29/2025 with an expiration date of 01/04/2026; and several condiment and food containers (mayonnaise, soy sauce, Italian dressing, sliced cheese, and pineapple chunks) that were not labeled or dated. In the dry storage room, surveyors observed a basket with five snack-size plastic bags of cereal and chocolate chips that were not labeled or dated, a container of rolled oats without a date, a half bag of elbow macaroni without a date, and a half loaf of raisin bread without a date. During steam table temperature checks, a cook did not wear gloves while using the facility food thermometer to check chicken tenders on the steam table, touching the chicken directly, and then picked up a roll with bare hands while acknowledging that gloves should have been worn. The cook continued taking temperatures and, when checking mechanical chicken tenders, obtained a reading of 112°F, then reheated the chicken to 140°F and stated it was supposed to be at 140°F, despite facility policy requiring reheating to at least 165°F. The mechanical chicken was not served to residents after the dietary manager intervened. The facility’s CMS Form 671 documented that 44 residents resided in the facility at the time of the survey.
Incomplete Facility Assessment of Required Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive facility-wide assessment that accurately documented the number of RNs, LPNs, and CNAs needed to meet resident needs during routine and emergency operations. The CMS Form 671, dated 1/12/26 and signed by the Administrator, documented that 44 residents resided in the facility. The facility’s written Facility Assessment, revised 5/29/25 by the Administrator in Training, stated that it was intended to be a complete review of internal human and physical resources required to care for residents competently during day-to-day and emergency operations, and that it would identify the facility’s capabilities as a skilled nursing service provider and serve as the basis for surveyors to determine preparedness. Despite this stated purpose, the Facility Assessment listed a daily average census of 49 but did not specify the number of RNs or LPNs required to meet the needs of the residents and documented that 0 CNAs were needed. During an interview on 1/14/26 at 2:55 PM, the Administrator in Training verified that the staffing numbers needed for RNs, LPNs, and CNAs were not documented in the Facility Assessment and acknowledged that they should have been. This omission affected the accuracy and completeness of the facility’s assessment of necessary staffing resources for its resident population.
Failure to Track Employee Illnesses Under Infection Control Program
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Prevention and Control Program (IPCP) policy regarding monitoring employee health and safety by not recording and tracking employee-reported illnesses. The facility’s IPCP policy, dated 10/28/24, states that an infection prevention and control program is to be established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including having policies and procedures for when employees, contractors, vendors, visitors, and volunteers should report infections or avoid the facility. During an interview on 1/14/26, the LPN serving as Infection Preventionist and Assistant DON confirmed that the facility did not have any tracking or logs to monitor when an employee called in sick and acknowledged there was no tracking of employee illness for call-offs from infection or illness prior to January 2026. The CMS Form 671, dated 1/12/26 and signed by the Administrator in Training, documented that 44 residents resided in the facility at the time of the survey.
Failure to Offer and Document COVID-19 Vaccination for Staff
Penalty
Summary
The facility failed to follow its own COVID-19 Vaccination policy, dated 7/15/21, which requires an infection control program that reduces the incidence of COVID-19 by offering immunization to all employees and residents, unless medically contraindicated or already immunized, and by maintaining documentation that staff received education on vaccine benefits and risks and were offered the vaccine or information on obtaining it. During an interview and record review, the Infection Preventionist/Assistant DON (an LPN) confirmed that the facility did not have documentation showing that employees were offered the COVID-19 vaccine and stated that employees were not being offered the vaccine by the facility and that they were not aware this was a requirement. The CMS Form 671, signed by the Administrator in Training, documented that 44 residents resided in the facility at the time of the survey. This deficiency was identified based on the lack of documented evidence that staff were provided COVID-19 vaccine education and offers of vaccination, as required by the facility’s written policy and applicable CMS expectations, and the admission by facility leadership that employees were not being offered the COVID-19 vaccine through the facility.
Failure to Provide and Document Required Dementia and Abuse Training for CNAs
Penalty
Summary
The facility failed to ensure CNAs received and completed required dementia and abuse prevention training within a 12‑month period, as identified through interview and record review. The CMS Form 671, signed by the Administrator, documented that 44 residents resided in the facility, and the facility’s Facility Assessment, revised on 5/29/25 by the Administrator in Training, specified that CNAs should receive abuse and dementia training upon hire and annually. During the survey, the Human Resources/Business Office Manager stated she could not provide the required training records for CNAs, did not know what the prior DON had done with the training information, and acknowledged she could not say that CNAs had received the required training, noting she only had some in‑services but not the required training. The Administrator in Training also verified that he could not provide training records for the CNAs, resulting in the inability to demonstrate that any of the 44 residents’ CNAs had received the mandated dementia and abuse training during the relevant 12‑month period. This deficiency was based solely on the lack of documentation and confirmation of required CNA training in dementia care and abuse prevention for all residents in the facility, as revealed by the facility’s own assessment documents and staff interviews.
Failure to Provide Scheduled Showers and Document Bathing Care
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled bathing and shower care, as required by its Shower Care policy and residents’ care plans, for six residents who needed assistance with activities of daily living. The facility policy, revised 12/24/2020, states that residents are to be assisted with showers, baths, or bed baths per regulation and personal preference to maintain hygiene and help prevent skin issues. Resident Council minutes from two separate meetings document ongoing complaints that residents were not being showered regularly, with some going a week without a bath or shower, reports that staff would put a resident down and forget about her, and a report that a resident was not being showered properly. During a resident group meeting, multiple residents stated they did not receive weekly showers, with one reporting usually only one shower every two weeks and sometimes going three weeks without one, and another stating they had to beg for a shower. Individual record reviews and observations confirmed missed showers without documented reasons. One resident reported not receiving weekly showers, sometimes only every two weeks or longer, and was observed in bed with eyes open and a strong urine odor; this resident’s care plan required showers twice weekly, yet the shower task record showed no showers over a two‑week period and no documentation explaining the omission. Another resident reported not receiving showers due to an open chest area; this resident’s shower task record showed no showers for nearly a month, again with no documentation explaining why. A CNA reported that showers often were not given and that completion depended on staffing and call‑ins, and stated that one resident had an offensive odor and likely had not had a recent shower. A third resident, dependent on staff for bathing and cognitively impaired per the MDS, had no documented showers over almost a month and no explanation in the electronic record. The DON stated she was not aware that residents were not receiving showers.
Failure to Maintain and Label Oxygen Equipment and Post Oxygen Safety Signage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and storage policy regarding equipment labeling and oxygen safety signage for multiple residents receiving oxygen therapy. The policy, revised 3/8/2022, requires staff to label tubing connected to oxygen concentrators with the time and date of change and to place an “Oxygen in Use” sign on the resident’s door or door frame. Surveyors observed several residents on oxygen without required door signage: one resident with chronic respiratory failure with hypercapnia, COPD, panlobular emphysema, atrial fibrillation, chronic kidney disease, hypertension, depression, and anxiety was receiving 2–4 L/min oxygen by nasal cannula every shift with no oxygen sign on the door; another resident with bipolar disorder, obsessive-compulsive personality disorder, and asthma, with an order for 2 L/min oxygen by nasal cannula as needed and a care plan indicating oxygen therapy, was also on oxygen without door signage; and a third resident with COPD, asthma, and shortness of breath, ordered 2–4 L/min oxygen by nasal cannula every shift and care planned for oxygen related to COPD and asthma, was similarly observed on oxygen without an oxygen sign on the door. The DON later confirmed that residents using oxygen should have a sign posted outside their room and acknowledged that these residents did not. Additional deficiencies were identified in the maintenance and labeling of oxygen equipment. One resident was observed sitting on the edge of the bed with oxygen via nasal cannula, and the oxygen tubing and humidity bottle were not dated; the resident stated she did not think anyone checked the oxygen and did not know how staff would be alerted if the tank ran out. The DON confirmed that oxygen tubing and humidity bottles should be dated when changed and stated they are supposed to be changed weekly with a label indicating the date of change. Another resident with obstructive sleep apnea, COPD, and shortness of breath had an oxygen machine in the room with unlabeled oxygen tubing and a humidification bottle dated 1/2/2026 on two separate observations. A CNA confirmed the absence of a label on the tubing and the date on the humidification bottle, and the ADON confirmed that all oxygen tubing should be dated and that humidification bottles and tubing should be changed weekly. These observations and interviews demonstrate that the facility did not consistently maintain and label oxygen equipment or post required oxygen safety signage in accordance with its policy for residents receiving oxygen therapy.
Failure to Maintain Dignity and Cleanliness of a Resident’s Wheelchair
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s dignity and to follow its own policy for cleaning and disinfecting reusable resident care equipment, specifically a wheelchair. The facility’s Resident Rights policy requires care that maintains dignity, and the Cleaning and Disinfection of Resident Care Equipment policy requires reusable equipment, including wheelchairs, to be cleaned and disinfected after use by one resident and before use by another. The resident involved, identified as cognitively intact with a BIMS score of 15 and documented wheelchair use on the MDS, was repeatedly observed with a cotton pad cloth in the wheelchair seat that had brown fecal matter smeared on it. Surveyors observed on multiple days that the resident’s wheelchair contained a cotton pad cloth with brown fecal matter smeared on it, including while the resident was sitting in the wheelchair. On one occasion, after the resident stood up, the soiled cotton pad cloth was visible underneath. The resident reported that there was always brown fecal matter in the wheelchair and that when she asked staff to change the pad cloth, she was often told they had run out of pad cloths. A CNA confirmed the presence of brown fecal matter on the wheelchair, and the Assistant DON stated that staff should always change the resident’s cotton pad cloth and that the resident should not have to sit in a dirty wheelchair with fecal matter in it.
Failure to Protect Residents’ Privacy of Mail
Penalty
Summary
The facility failed to ensure residents’ mail was delivered unopened, as required by resident rights materials stating that mail must be delivered and sent promptly and may not be opened without the resident’s permission. During interviews, one resident reported that their mail had been opened on at least one occasion and that they had reported this to the Administrator in Training. Another resident stated that staff opened their packages and envelopes “all the time,” not in the resident’s presence, and identified the Social Service Director as the person who usually opened them. In a subsequent interview, the Social Service Director acknowledged that she had opened residents’ mail and packages with scissors before delivering them to resident rooms, explaining that she did this so she would not have to bring scissors to the rooms, and confirmed that residents were not present and were not aware when their mail was opened.
Failure to Implement Abuse Policy and Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and thoroughly investigate an allegation of staff-to-resident physical/sexual abuse. The facility’s written policy on residents’ right to freedom from abuse, neglect, and exploitation states that all associates must not use verbal, mental, sexual, or physical abuse and that, when abuse is identified, the facility will take steps to prevent further potential abuse, report alleged violations within required timeframes, and conduct thorough investigations of all allegations. The policy further specifies that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property must be reported and thoroughly investigated. During an interview, one resident (R12) reported that a male CNA (V12) smacked her behind while assisting her with toileting, and she stated she was very angry and bothered by the incident and had informed facility staff. The Administrator in Training (V1), who also serves as the facility’s abuse coordinator, initially stated there were no abuse investigations for the past six months and was unaware of any prior allegations or where such investigations would be kept. Later, V1 confirmed there had been an incident between this resident and the CNA in December 2025 but acknowledged there were no interviews or documentation related to investigating the allegation that the CNA hit the resident on the behind. V1 stated he had only interviewed the CNA about other staff issues, had not interviewed other residents about this employee, and had no investigation or related documentation to provide regarding this incident, demonstrating a failure to follow the facility’s abuse policy and to conduct and document a thorough investigation of the allegation.
Failure to Investigate and Document Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to investigate and document an allegation of staff-to-resident physical/sexual abuse as required by its own abuse policy. The facility’s policy dated 10/16/23 states that residents have the right to be free from abuse, neglect, and exploitation, and that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property will be investigated and reported within required timeframes. Despite this, the medical record for one resident contained no documentation of any investigation, incident report, or interventions related to an allegation of abuse by staff. During observation and interview, the resident reported that while being assisted with toileting by a male CNA, she repeatedly tried to direct him to pull her underwear up in the front, but he continued pulling from the back until he finally adjusted them correctly. She stated that when she bent forward to position herself to walk back to bed, the CNA then took his hand and smacked her on the butt, which made her angry and led her to tell him to leave her room. The DON acknowledged being informed on the morning after the incident that the resident needed to speak with her about what she was reporting, and the Administrator in Training, who is the abuse coordinator, confirmed he was notified of an allegation involving this resident and the CNA. However, the abuse coordinator stated he did not report the allegation, did not conduct or document interviews related to this allegation, did not interview other residents about the CNA, and had no investigation or related documentation to provide.
Failure to Accurately Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The deficiency involves the facility’s failure to provide the state ombudsman with accurate notifications of resident admissions, transfers, and discharges as required by its own discharge/transfer policy. The facility’s undated Discharge/Transfer policy states that before a transfer or discharge, the facility must notify the resident and representative in writing, send a copy of the notice to the state long-term care ombudsman, and maintain documentation that the notice was sent. The policy also requires proper documentation of resident transfers and discharges. However, the facility’s Admission/Discharge Reports for the months reviewed did not accurately reflect all of one resident’s hospital transfers and readmissions. The resident involved was admitted with multiple chronic conditions, including chronic respiratory failure with hypercapnia, depression, atrial fibrillation, panlobular emphysema, COPD, anxiety, stage 3 chronic kidney disease, and essential hypertension. Nursing notes document that the resident was transferred to the hospital for shortness of breath and low oxygen levels on two separate occasions and subsequently readmitted to the facility each time. The census list confirms these hospital stays and return dates, but the Admission/Discharge Reports for August and September did not include the resident’s transfer to the hospital, nor the subsequent readmissions and second hospital transfer. The ombudsman reported receiving a monthly list of admissions and discharges that she did not believe was complete and accurate, and the Administrator in Training stated that only residents absent for a specified number of days, varying by payer source, were included on the discharge sheet, resulting in incomplete reporting to the ombudsman.
Inaccurate MDS Coding of Anticoagulant Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment for a resident in relation to medication use. The facility’s MDS policy, dated 11/05/2019, requires comprehensive, accurate, and standardized assessments of each resident’s functional capacity using the MDS 3.0 PDPM User’s Manual. For one resident (R2), the MDS dated 10/XX/2025 documented that the resident was receiving an anticoagulant medication. However, review of the Medication Administration Record (MAR) for the period 10/1/25–10/31/25 showed no documentation that an anticoagulant medication was administered during that time. During an interview on 1/14/2026 at 1:00 p.m., the Director of Nursing (V2) confirmed that R2’s medical record did not show that the resident was taking an anticoagulant at the time of the assessment and stated she did not recall the resident ever being on an anticoagulant. V2 acknowledged that the MDS assessment for R2 must have been coded incorrectly, demonstrating that the MDS did not accurately reflect the resident’s actual medication regimen.
Failure to Obtain Updated PASRR Level II After New Schizophrenia Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to coordinate with the PASRR program by not obtaining an updated Level II PASRR after a resident was diagnosed with Schizophrenia. The facility’s PASRR policy dated 2/2/24 states that any Level II resident who experiences a significant change in status, or any resident who exhibits a newly evident or possible serious mental disorder, must be promptly referred to the State mental health authority for a Level II resident review. The resident was originally admitted with diagnoses including Bipolar Disorder and Obsessive-Compulsive Personality Disorder and later readmitted with Schizoaffective Disorder and Post-Traumatic Stress Disorder. A PASRR Level I dated 10/16/24 listed mental health diagnoses of Major Depression and Bipolar Disorder, and a PASRR Level II dated 10/19/24 identified conditions including Depression, Bipolar Disorder, Major Depressive Disorder with psychotic features, Anxiety Disorder, and Post-Traumatic Stress Disorder, with recommendations for routine mental health follow-up and specific psychotropic medications. On 1/21/25, the resident was diagnosed with Schizophrenia, and the current care plan reflects the use of psychotropic medications for Major Depressive Disorder, Anxiety, Schizophrenia, Obsessive-Compulsive Disorder, and Post-Traumatic Stress Disorder. However, review of the medical record on 1/14/26 showed no evidence that the facility obtained an updated Level II PASRR after the Schizophrenia diagnosis. The Admissions Coordinator stated she is responsible for PASRR screenings on admission and with updates but is not in the building full time and relies on facility staff to notify her or the Social Service Director when new diagnoses are added so residents can be re-screened. She confirmed that all mental illness diagnoses should be included on Level I and Level II screenings. The Administrator in Training acknowledged that the resident had the diagnosis of Schizophrenia before 1/21/25, but it was not identified in the chart until an audit after a change of ownership, and that a new Level II PASRR was not requested despite the documented diagnosis.
Failure to Complete and Accurately Document Required Level II PASARR Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents with mental illness diagnoses received required Level II PASARR evaluations and that PASARR documentation accurately reflected their mental health conditions. The facility’s policy dated 2/2/24 states that all individuals with a mental disorder or intellectual disability applying for admission will be screened in accordance with state Medicaid rules and that recommendations from Level II PASARR determinations will be incorporated into assessments and care plans. For one resident (R43), the care plan dated 5/27/25 shows an admission date of 5/27/22 and diagnoses including psychoactive substance abuse, alcohol dependence, major depressive disorder, mood disorder, and schizoaffective disorder. However, the current medical record does not contain a Level II PASARR, and the Level I PASARR dated 4/29/22 does not list the resident’s substance abuse-related disorders or schizoaffective disorder and indicates that a Level II PASARR is not required due to no serious mental illness or related conditions. Another resident (R2) had a care plan dated 6/4/25 with an admission date of 5/22/24 and diagnoses including schizophrenia, bipolar disorder, insomnia due to another mental disorder, paraphilia, generalized anxiety disorder, unspecified intellectual disabilities, and cognitive communication deficit. R2’s Level I PASARR dated 3/21/22 documented that the resident was referred for a Level II PASARR, but the current medical record contains no documentation that a Level II PASARR was ever completed. During an interview on 1/14/25, the Admissions Coordinator (V10) stated she is responsible for PASARR screens on admission and with updates and acknowledged she could not locate a Level II PASARR for R2 in the system or in the electronic medical record. V10 also stated she was not aware of R43’s schizoaffective disorder diagnosis and did not realize it was missing from the Level I PASARR, confirming that R43 should have been referred for a Level II PASARR and that mental illness diagnoses should be included on PASARR screenings so appropriate support services can be obtained.
Failure to Provide Palatable, Properly Prepared, and Menu-Compliant Meals
Penalty
Summary
The facility failed to provide residents with food that was palatable, properly prepared, and consistent with posted menus, as evidenced by multiple resident and staff interviews, record reviews, and resident council minutes. Residents reported receiving food that was burnt, undercooked (including bloody chicken), cold, and not matching the posted menu. There were repeated complaints about small portion sizes, lack of food variety, and the kitchen running out of menu items, resulting in substitutions or residents not receiving their requested meals. Residents requiring special diets, such as mechanical soft diets, did not consistently receive necessary accommodations like gravy to aid in chewing, due to the facility running out of these items. Staff members corroborated these concerns, stating that food was often burnt, overcooked, or undercooked, and that portion sizes were inadequate. Resident council meeting minutes documented ongoing complaints about food quality, including hard or burnt toast, grilled cheese, and cookies, as well as repeated instances of undercooked chicken being served. Despite grievances being submitted to the administrator, there was no documentation of follow-up or resolution. The issues affected all residents in the facility, as indicated by the resident roster and the scope of complaints.
Failure to Monitor and Treat Acute Medical Conditions Resulting in Hospitalization
Penalty
Summary
The facility failed to monitor and treat acute medical conditions for two residents, resulting in both requiring hospitalization. One resident with multiple chronic conditions, including COPD, congestive heart failure, and chronic respiratory failure, experienced severe respiratory distress during the night shift. The assigned nurse did not adequately assess or document the resident's deteriorating condition, failed to provide timely interventions, and did not properly record the administration of nebulizer treatments. The resident's oxygen saturation remained critically low until the day shift nurse intervened, at which point emergency services were called and the resident was hospitalized in the intensive care unit for respiratory failure, pneumonia, and other complications. Another resident with psychiatric and cardiac diagnoses, including schizophrenia, bipolar disorder, and congestive heart failure, exhibited severe anxiety, sweating, and difficulty breathing during the night shift. Although the medication administration record indicated that scheduled medications were given, the resident repeatedly stated that medications were not received, and staff observed ongoing distress. The nurse on duty did not provide adequate monitoring or intervention, and emergency services were called by the day shift nurse, resulting in the resident being sent to the hospital for evaluation. Multiple staff members, residents, and council notes documented ongoing concerns about the night shift nurse's failure to administer medications, perform treatments, and respond to residents' needs. Reports indicated that the nurse often did not complete medication passes, failed to document care appropriately, and was frequently unresponsive to requests for assistance. These actions and inactions directly contributed to the acute deterioration and subsequent hospitalization of the two residents.
Failure to Remove Known Trip Hazard Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent an injury to a resident. The incident involved a female resident with multiple medical diagnoses, including systemic lupus erythematosus, chronic kidney disease, osteoporosis, hypertension, and anxiety disorder. The resident was cognitively intact and independent in mobility and activities of daily living. She sustained significant bruising and pain after tripping over a rug with an upturned edge in a hallway, striking her head on a doorway. The injury resulted in a large hematoma under both eyes and across the bridge of her nose, requiring evaluation in the emergency room. Prior to the incident, both residents and staff had identified the rug as a trip hazard. The resident council president and other residents had complained to facility administration about the rug, and a family member had also tripped on it, though without injury. Staff, including a registered nurse, reported the hazard to maintenance and administration, and temporary measures such as taping down the rug were attempted. Despite these reports and complaints, the rug was not removed or replaced until after the resident was injured. Documentation in the medical record, incident reports, and interviews confirm that the rug remained in place for several weeks after initial complaints. The facility's fall reduction policy required maintaining an environment as free of accident hazards as possible, but this was not followed in practice. The failure to address the known hazard directly led to the resident's injury, as confirmed by staff, resident, and ombudsman interviews, as well as medical and wound documentation.
Failure to Document and Investigate Missing Controlled Substance
Penalty
Summary
The facility failed to properly identify, reconcile, document, and investigate a missing controlled substance, specifically Morphine Sulfate, for one resident who was under hospice care and had multiple orders for pain management, including Morphine and Fentanyl. The facility's policies required strict documentation and inventory control of controlled substances, including shift-to-shift counts, immediate reporting of discrepancies, and thorough investigation of any loss. However, for a period covering several days, there was a lack of documentation in both the Medication Administration Record (MAR) and the controlled substance count forms regarding the administration and inventory of Morphine for the resident. During this period, a contracted LPN reported administering large amounts of Morphine to the resident, but failed to document these administrations in the MAR or on the official pharmacy-generated count forms. The LPN stated that the resident was yelling throughout the night and that nearly a whole bottle of Morphine was used, but the count sheet and the empty bottle were never found. The facility's investigation into the missing Morphine was incomplete, lacking essential details such as the resident's name, and did not include interviews with pharmacy staff, the physician, other residents, or employees. Additionally, the investigation relied on informal statements and did not follow the facility's established procedures for reporting and investigating medication errors or losses of controlled substances. The facility was unable to produce required medication error reports for the relevant period, and staff interviews confirmed that no comprehensive investigation was conducted. The LPN involved had a documented history of disciplinary issues related to medication administration and documentation. At the time, the facility was also without a Director of Nursing, which contributed to lapses in oversight and follow-up regarding the missing controlled substance.
Failure to Provide Palatable and Properly Prepared Food Due to Equipment Malfunction
Penalty
Summary
The facility failed to prepare and serve palatable food to its residents, as evidenced by multiple observations, interviews, and record reviews. The daily census confirmed that 47 residents were present at the time of the deficiency. Resident council minutes documented ongoing complaints about the quality of food, specifically noting issues such as burnt eggs, watery food, and undercooked or overcooked meals. Direct observations on 6/20/25 revealed that tuna patties served to residents were hard and overdone. Multiple residents reported that food, including chicken, tuna patties, and eggs, was frequently burnt and sometimes inedible. Staff members, including CNAs and the cook, corroborated these complaints, stating that food was often burnt and that residents were not consistently offered bedtime snacks. Further investigation revealed that the root cause of the issue was a malfunctioning oven, as stated by the dietary manager and cook, who both confirmed that the oven regulators had not been working since before the current company took over in November 2024. This equipment failure led to food being consistently overcooked or burnt. The facility's job description for dietary staff emphasized the importance of preparing food in a safe and palatable manner, but this standard was not met due to the ongoing equipment issues and lack of corrective action.
Failure to Routinely Offer Bedtime Snacks to Residents
Penalty
Summary
The facility failed to offer bedtime snacks daily to residents, contrary to its own policy which requires evening snacks to be routinely offered to all residents not on diets prohibiting bedtime nourishment. Record review showed that 47 residents were present in the facility, with a list provided of residents diagnosed with diabetes. Multiple residents, including those with diabetes, reported not being offered bedtime snacks, expressing a desire for them and noting that they never receive them. Staff interviews confirmed that bedtime snacks are not offered every day, and the Regional Administrator acknowledged that all residents should be offered a bedtime snack. These findings indicate that the facility did not consistently provide bedtime snacks as required by policy and resident needs.
Failure to Maintain Kitchen Ovens Results in Burned Food
Penalty
Summary
The facility failed to maintain the kitchen ovens in proper working condition, as evidenced by multiple observations, interviews, and record reviews. The Maintenance Director's job description and the facility's Equipment and Supplies policy require that all equipment, including kitchen appliances, be kept in safe and operating condition. However, staff interviews revealed that the ovens' regulators have not worked since before the current company took over, resulting in food being consistently burned. The Dietary Manager and Cook both confirmed the ovens do not function correctly, and the Maintenance staff member stated he was unaware of the issue and that the building currently lacks a maintenance supervisor. Residents reported that food, including chicken, tuna patties, and eggs, was frequently burned and sometimes inedible. On one occasion, tuna patties served to residents were observed to be hard and overdone. Multiple residents independently stated that their food was often or always burnt, with one describing the tuna patty as "like eating a hockey puck." The facility's daily census indicated that 47 residents could be affected by this ongoing equipment failure.
Unsafe Mechanical Lifts Used for Resident Transfers
Penalty
Summary
The facility failed to ensure that mechanical lift machines used for transferring dependent residents were safe and in proper working condition. Observations revealed that one mechanical lift (model HPL700) wobbled from side to side and had casters that did not roll smoothly. Additionally, a bolt at the bottom right-side axle had been replaced with an incorrect, non-manufacturer bolt. During a transfer, a resident expressed concern about the lift's instability and squeaking. Another mechanical lift (model 450/600) had a malfunctioning remote that would stop working mid-transfer, requiring the cord to be wiggled to function. These issues were demonstrated by a CNA, who confirmed ongoing problems with both lifts, including faulty wiring and improper repairs. Interviews with staff indicated that the maintenance department was unaware of the mechanical lift issues, as the building did not have a maintenance supervisor and the acting maintenance staff had not been informed of the problems. The regional administrator acknowledged that staff should have reported the broken lifts and that the equipment needed to be taken out of service. The facility's failure to maintain the mechanical lifts in safe and good repair directly affected five residents who required mechanical lifts for transfers.
Medications Removed from Original Packaging Prior to Administration
Penalty
Summary
Nursing staff failed to ensure that medications and biologicals were stored in their original packaging until the time of administration for 18 residents reviewed for medication storage. During observations, surveyors found multiple medication cups containing loose tablets and capsules, each labeled with resident names, stored in the top drawers of medication carts. These medications had been removed from their original packaging in advance of administration, contrary to facility policy and federal regulations. Interviews with nursing staff revealed that medications were routinely prepared ahead of scheduled administration times. One RN admitted to removing medications from their original packaging and placing them in labeled cups to expedite the medication pass process, acknowledging awareness that this practice was not permitted. Another RN stated that they typically prepared all medications for the day in advance and stored them in the medication cart, further confirming that this was a common practice among staff. Facility policies reviewed by surveyors clearly stated that medications must not be prepared in advance and must remain in their original containers until administration, with any removed but unadministered medications to be destroyed per policy. The Director of Nursing confirmed that staff had been repeatedly instructed not to remove medications from their packaging ahead of time, indicating that the staff were aware of the correct procedures but did not follow them. The deficiency was identified through direct observation, staff interviews, and review of medication administration records for the affected residents.
Failure to Follow Hand Hygiene and Wound Care Orders During Pressure Ulcer Treatment
Penalty
Summary
The facility failed to follow proper hand hygiene and glove-changing protocols during wound care for a resident with stage three pressure ulcers on the right thigh and right heel. During observed wound care, a registered nurse removed old dressings, changed gloves without performing hand hygiene, and proceeded to clean and dress both wounds without changing gloves or sanitizing hands between dirty and clean procedures or between each wound. The nurse confirmed awareness of the correct protocol but did not follow it during the treatment. The facility's wound care policy requires hand hygiene and glove changes between dirty and clean steps and between different wound treatments, which was not adhered to in this instance. Additionally, the facility failed to administer physician-ordered wound treatments as scheduled. Documentation showed that the resident's prescribed wound care for the right heel and right posterior thigh was not completed on two evening shifts. The resident reported that wound treatments were sometimes missed by nursing staff, and the Director of Nursing confirmed that the treatments were not signed out for the specified shifts, indicating they were not performed as ordered.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to implement its infection prevention and control program by not adhering to Enhanced Barrier Precautions (EBPs) and proper hand hygiene during high-contact care activities for a resident with an indwelling suprapubic catheter. Specifically, a CNA performed catheter care for a female resident with spina bifida, paraplegia, and urinary retention, but did not wear a gown as required by facility policy for high-contact care involving indwelling medical devices. After completing the washing, rinsing, and drying of the catheter tubing and perineal area, the CNA did not change gloves or perform hand hygiene before applying a new incontinence brief and repositioning the resident in bed. The facility's policies clearly state that staff must wear gowns and gloves during high-contact care activities and must change gloves and perform hand hygiene after such procedures. The CNA acknowledged not following these procedures, and the DON confirmed that the correct protocol was not followed. The resident involved had a physician-ordered suprapubic catheter and required enhanced barrier precautions, as documented in her medical record and the facility's infection control policies.
Failure to Supervise and Ensure Safe Beverage Temperature Results in Resident Burn
Penalty
Summary
A deficiency occurred when staff failed to check the temperature of a hot beverage before serving it and did not provide necessary assistance and supervision to a resident who was dependent on staff for eating and drinking. The resident, who had severe cognitive impairment, multiple physical and mental health diagnoses, and was on hospice care, was known to require full assistance with eating and drinking, as documented in her care plan and Minimum Data Set (MDS) assessment. Despite these documented needs, the resident was given a hot chocolate that had not been temperature-checked and was left unsupervised, resulting in her spilling the beverage on herself. The incident led to the resident sustaining second-degree burns on her left hip and thigh, which caused her pain and required ongoing wound care and pain management. Interviews and records revealed that the hot chocolate was prepared in the kitchen, placed in a cup without a lid, and delivered to the resident without verifying the temperature or ensuring staff were present to assist. Staff statements confirmed that the resident typically sat at a table where assistance was provided during meals, but at the time of the incident, it was not mealtime and no staff were present to help her with the drink. The facility did not have a hot liquid risk assessment in place for the resident, and there was no documentation of hot beverage temperatures being checked or logged. The facility's policies required that residents who are unable to feed themselves be fed with attention to safety, comfort, and dignity, and that staff be trained to identify and prevent accident hazards. However, these protocols were not followed in this case. The lack of supervision and failure to check the temperature of the hot beverage directly resulted in the resident's injury, as confirmed by multiple staff interviews and medical documentation.
Failure to Immediately Notify Family, Physician, and IDPH After Resident Burn Incident
Penalty
Summary
The facility failed to immediately notify a resident's family, physician, and the Illinois Department of Public Health (IDPH) following an incident in which the resident sustained burns from spilling hot chocolate on herself. On the day of the incident, the resident was observed with a red area on her left hip after the spill, but there was no documentation that the family or physician were notified at that time. The following day, blistering was noted on the resident's left waist and upper thigh, at which point the Director of Nursing contacted the resident's primary care physician and power of attorney. Both the physician and the family confirmed they were not notified until the day after the incident. The facility's policies require immediate notification of serious incidents to the resident's physician, family, and the IDPH, with specific procedures for reporting and documentation. Despite these requirements, the incident was not reported to the IDPH, and the notifications to the family and physician were delayed until after the resident's condition worsened. The staff involved stated that they believed notifications had been made, but there was no documentation to support this, and the responsible parties confirmed they were unaware of the incident until the following day.
Medication Administration Error Due to Incorrect Order Entry
Penalty
Summary
The facility failed to correctly enter and follow a physician's order for a resident requiring steroid injections, leading to a medication error. The resident, an elderly male with multiple diagnoses including chronic pain and osteoarthritis, was supposed to receive a Kenalog injection intra-articularly for shoulder pain. However, due to a miscommunication and incorrect entry of the order, the medication was administered intramuscularly instead. The error occurred when a nurse entered the order incorrectly as an intramuscular injection instead of intra-articular, and another nurse administered the medication based on this incorrect order. The nurse who administered the injection did not verify the correct route and dosage, leading to the medication being given in a less effective manner. The error was compounded by the fact that the order was entered as a monthly dose instead of every three months, which was the correct frequency. The facility's policies on medication administration and error reporting were not adequately followed, as the error was not immediately identified or reported. The Director of Nursing and other staff members were aware of the discrepancy but did not take timely action to rectify the situation. The pharmacist confirmed that the order was incorrectly entered, and the medication should not have been given intramuscularly. This series of errors highlights a breakdown in communication and adherence to established procedures within the facility.
Dietary Manager Lacks Required Qualifications
Penalty
Summary
The facility failed to employ a Dietary Manager with the necessary competencies and skills to fulfill the role of Food Service Director, potentially impacting all 46 residents in the facility. The job description for the Food Service Director requires a Bachelor of Science degree in Foods and Nutrition or completion of a course in food service supervision with specific qualifications. However, the current Dietary Manager, identified as V9, lacks the required certification and training for the position. During interviews, V9 admitted to not having a Dietary Management Certificate and acknowledged being unqualified for the role. V9 was placed in the position by the previous administration approximately one month prior and has not received any training for the role. The facility's Administrator, V1, confirmed awareness of V9's lack of qualifications for the position.
Infection Control and Legionella Risk Assessment Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection control practices in the Laundry Room, as observed on November 20, 2024. The Laundry Room lacked gowns and masks for use, and there were no towels available for hand hygiene. The Housekeeping Supervisor admitted to handling transmission-based precautions (TBP) laundry with only gloves, without wearing a gown, contrary to the facility's policy. The Director of Nursing confirmed that laundry staff should wear gloves and gowns when handling all linen, and paper towels should be available for hand washing. The facility also failed to conduct accurate and annual Legionella Risk Assessments with the designated team members. The Legionella Management Procedure required a comprehensive risk assessment of the facility's water system, including storage tanks and pipework, to prevent Legionnaires Disease. However, the Maintenance Director was unaware of a Water Management Plan and had not participated in a Legionella Risk Assessment. The Legionella Risk Assessment completed on November 5, 2024, contained inaccuracies, such as incorrect information about the facility's water system and infrastructure, indicating it may have been from another facility. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) during wound care for a resident with a surgical site on the right hip. Despite the resident being on EBP, the Licensed Practical Nurse only wore gloves during the wound care procedure, failing to use the required gown and eye protection. The nurse later confirmed the oversight, acknowledging that gloves, gown, and eye protection should have been worn during the procedure.
Failure to Ensure Resident Ingested Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R2, ingested his medications as required during a routine medication pass observation. The facility's policy on administering medication mandates that medications remain secured unless in direct view of the administering individual and that self-administration is only permitted when approved by the attending physician and the interdisciplinary care planning team. However, during an observation, R2 was found in the dining room with a clear medicine cup containing two oblong white pills, which he had not yet taken. R2 confirmed that the nurse had given him the medications earlier, and he was still working on taking them. The Licensed Practical Nurse (LPN), identified as V3, admitted to giving R2 his medications but acknowledged that she should have stayed with him until he took all of them. The Director of Nursing (DON), identified as V2, confirmed that all residents should be observed taking their medications unless they have been assessed and care planned to self-administer. It was confirmed that R2 had not been assessed or approved to self-administer his medications, indicating a failure to adhere to the facility's medication administration policy.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a completed discharge summary for a resident at the time of a planned discharge. The facility's Transfer/Discharge policy requires an interdisciplinary discharge summary to be completed, which includes sections for medications, social service summary, dietary service summary, activity service summary, and rehab service summary. However, for the resident in question, only the Nursing Service Summary was filled out, leaving the other sections blank. This deficiency was confirmed by the Director of Nursing, who acknowledged that the discharge summary was incomplete.
Deficiencies in Resident Care and Transportation
Penalty
Summary
The facility failed to ensure proper transportation arrangements for a resident, R17, who missed a long-awaited dental appointment due to the unavailability of transportation staff. Despite the facility's policy to assist residents with transportation, the appointment was canceled without notifying the resident's family, who could have provided transportation. This issue was part of a broader problem with transportation to medical appointments, as noted by the ombudsman during a Resident Council Group meeting. The facility also failed to adequately assess, document, and treat a fungal infection for resident R8. Despite receiving oral antifungal medication, R8's condition showed no improvement, and there was a lack of documentation regarding the skin impairment's characteristics. Additionally, there was confusion over the use of Nystatin cream, which was not ordered by a physician but was recorded in the treatment administration record. The absence of proper documentation and treatment led to the persistence of R8's skin condition. Furthermore, the facility did not utilize a necessary wheelchair positioning cushion for R8, who has cerebral palsy and other conditions affecting mobility. R8 was observed leaning uncomfortably in her wheelchair without the required cushion, which was found in another resident's room. The care plan did not include the use of this cushion, leading to improper positioning and discomfort for R8. This oversight was due to multiple room changes and a lack of communication among staff regarding the cushion's importance for R8's positioning needs.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to identify triggers for PTSD and develop care plan interventions for a resident diagnosed with PTSD. The resident's medical record included a Trauma Informed Care Screen indicating the resident had experienced traumatic events and exhibited symptoms such as nightmares and avoidance behaviors. However, the section for potential triggers and interventions was left blank. The resident's care plan did not address PTSD triggers or interventions. Registered Nurses were unaware of the resident's PTSD, and the Director of Nurses acknowledged the absence of a PTSD care plan, which should have been created upon identification of the condition.
Deficiency in Antibiotic Stewardship Program Monitoring
Penalty
Summary
The facility failed to ensure its antibiotic stewardship program accurately monitored infections and antibiotic use according to its policy. This deficiency was identified for three residents in a sample of 46. The facility's policy required the Antibiotic Stewardship Committee to assess residents for infections using standardized tools, reassess the appropriateness of antibiotic use, and maintain a system to monitor antibiotic use. However, the facility's medical records lacked documentation of hospitalizations, reasons for visits, and findings for residents R7, R17, and R25. Specifically, R7's medical record did not document a hospital visit on 10/24/24, and the Medication Record showed treatment with Bactrim without proper documentation of the infection's source or test results. Additionally, the facility's Monthly Infection and Antibiotic Tracking log was incomplete, missing critical information such as infection dates, culture results, and prescribing physician names for the residents involved. The Director of Nursing (V2) was unaware of certain hospitalizations and infections, indicating a lack of communication and documentation. The tracking log did not exist prior to October 2024, further highlighting the deficiency in monitoring and documenting antibiotic use and infections. This lack of documentation and oversight led to the failure in accurately monitoring and managing antibiotic use for the residents involved.
Failure to Implement Post-Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement post-fall interventions for a resident identified as R1, who was at high risk for falls due to a history of multiple falls. R1's care plan and fall investigation reports documented several falls occurring on different dates, with new interventions recommended each time, including requests for physical and occupational therapy evaluations. Despite these documented interventions, there was no evidence that therapy evaluations were conducted following the falls on 9/19/24, 9/25/24, and 10/21/24. Interviews with facility staff revealed that R1 had not received therapy since August 21, 2024, and the therapy company had not received any orders for evaluations in September or October 2024. The Director of Nursing confirmed the lack of documentation for therapy evaluations in R1's medical record, indicating a failure to follow through on the recommended interventions to address R1's fall risk.
Failure to Develop Care Plan and Implement Behavioral Interventions for Antipsychotic Use
Penalty
Summary
The facility failed to develop a comprehensive plan of care for a resident prescribed an antipsychotic medication, haloperidol, and did not implement necessary behavioral interventions. The facility's policy requires that a care plan identify target behaviors and include approaches and goals to address these behaviors, along with a behavioral tracking sheet to monitor them. However, the resident's care plan, initiated on 8/30/24, lacked any plan for the use of psychotropic medications or behavioral interventions. Additionally, the behavior tracking binder and the resident's medical record did not contain a behavior tracking sheet or documented behavioral interventions. The resident, who did not have a history of mental illness according to a PASRR screen dated 8/2/24, was prescribed haloperidol with an initial order on 9/17/24 and an increased dosage on 10/2/24. The PRN order for haloperidol was active for 30 days, exceeding the 14-day limit set by the facility's policy. The resident received the medication multiple times in October 2024. The Director of Nursing confirmed that the medication order extended past 14 days and acknowledged the absence of a care plan and behavioral interventions for the resident's use of haloperidol.
Failure to Provide Correct Diet Leads to Choking Incident
Penalty
Summary
The facility failed to provide a mechanically altered diet as ordered by the physician for a resident, resulting in a choking incident. The resident, who had severe cognitive impairment and required extensive assistance, was served a pork fritter that was not ground or accompanied by gravy, contrary to the prescribed mechanical soft diet with ground meat and gravy. This oversight led to the resident choking on the food, necessitating back thrusts and the Heimlich maneuver, and resulted in the resident being transferred to a local hospital for evaluation. The dietary aide responsible for serving the meal was not adequately trained and was working alone on the night of the incident. The aide admitted to not knowing the specific dietary needs of the residents and attempted to modify the meal by cutting the meat and suggesting an alternative condiment due to the lack of gravy. The aide's lack of training and the absence of proper supervision contributed to the resident receiving the incorrect diet. The incident was further compounded by the facility's staffing issues, as the dietary aide was left to manage meal preparation without sufficient support. The certified nurse aide, aware of the dietary error, was unable to rectify the situation due to being overwhelmed with other duties. This lack of attention and supervision allowed the resident to attempt to eat the incorrect meal, leading to the choking incident.
Lack of Dietary Staff Training in Safe Food Handling
Penalty
Summary
The facility failed to provide training for dietary staff on safe food handling or any other dietary-specific training, which has the potential to affect all 49 residents residing in the facility. The job description for Diet Aides, dated October 2016, requires that they pass the Food Protection Manager exam or be willing to take a course approved by the facility and receive food handler training within 30 days of employment. However, interviews and record reviews revealed that dietary staff, including the Dietary Aide, Dietary Manager, and Director of Nursing, confirmed the absence of any training or education documentation for the dietary staff. The Dietary Aide reported not receiving any training and mentioned that the previous Dietary Manager did not follow the menu or order the correct groceries, leaving the aide without a recipe to follow. The Administrator in Training was unaware of any training or education for dietary staff and deferred to the Dietary Manager or Director of Nursing for information. The Dietary Manager admitted to not having received any training since starting and acknowledged the lack of training documentation for the dietary staff.
Inadequate Dietary Staffing Affects Resident Meal Services
Penalty
Summary
The facility failed to provide adequate staffing in their dietary department, which has the potential to affect all 49 residents residing there. The deficiency was identified through interviews and record reviews, revealing that the dietary department lacked consistent scheduling and sufficient personnel. The new Dietary Manager, who took over on July 1, 2024, reported that schedules were previously done on paper and discarded, leading to inconsistency and instances where staff had to work alone. A Dietary Aide confirmed the lack of training and frequent instances of working alone, resulting in delayed meal services. The Administrator in Training admitted to assuming the previous Dietary Manager was handling schedules correctly but never verified or reviewed them. A review of timecard punches confirmed that a Dietary Aide worked alone on a specific night, and no dietary schedules were available for review for the past year. Residents expressed concerns about the lack of help in the kitchen, particularly at night and on weekends, indicating a widespread issue with dietary staffing at the facility.
Medication Error Leads to Worsened Hyperglycemia
Penalty
Summary
The facility failed to accurately administer physician-ordered GlucaGen to a resident with Type II Diabetes Mellitus, resulting in the resident's hyperglycemia worsening and requiring emergency room treatment. The resident had a physician order for GlucaGen to be administered intramuscularly for low blood glucose and insulin for high blood glucose. However, the resident was given GlucaGen despite having elevated blood glucose levels, which exacerbated her condition. On the day of the incident, the resident was observed acting off and was found to have a blood glucose level of 432 mg/dl. Despite this, an LPN administered GlucaGen, a medication intended to raise blood sugar, instead of insulin. The error was realized shortly after administration, and the resident was subsequently transferred to the hospital. The resident's blood glucose level was recorded as high by the ambulance paramedic and later confirmed to be 713 mg/dl in the emergency room. Interviews with the staff involved revealed that there was confusion and a lack of proper verification before administering the medication. The LPN who administered the GlucaGen acknowledged the mistake, and the resident's physician confirmed that the administration of GlucaGen in this situation would worsen hyperglycemia. The resident was treated for hyperglycemia, septic shock, urinary tract infection, and acute kidney injury at the hospital.
Misappropriation of Resident's Medication
Penalty
Summary
The facility failed to prevent the misappropriation of property for one resident, specifically involving the disappearance of a card of Norco medication. The incident began when the pharmacy delivered medication to the facility, which was received by a registered nurse (RN) during the night shift. The RN was observed on video placing one of the four cards of Norco under the desk and later bringing her backpack to the nurse's station. The next day, the discrepancy was discovered when another nurse noticed that only three cards of Norco were present instead of four. An investigation was initiated, and the police were notified. The RN involved was suspended and did not return to the facility. The Director of Nursing (DON) and other staff members reviewed the video footage, which showed the RN handling the medication and placing one card under the desk. The RN was also seen filling out only three Controlled Substance Proof of Use sheets instead of four. The police officer who reviewed the footage found the situation suspicious but did not have enough evidence to make an arrest. The facility's documentation, including the Pharmacy Delivery Receipts and Narcotic Reconciliation Sheets, confirmed that four cards of Norco were delivered and signed for by the RN. The facility's Abuse Prevention Program policy affirms the residents' right to be free from misappropriation of property. Despite this policy, the facility failed to prevent the misappropriation of a resident's medication. The investigation revealed that the RN had signed for the delivery of four cards of Norco but only documented and stored three cards. The missing card was never recovered, and the RN did not return to the facility after being suspended. The police investigation is ongoing, and the facility has taken steps to replace the missing medication.
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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