Eastview Healthcare & Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Sullivan, Illinois.
- Location
- 100 Eastview Place, Sullivan, Illinois 61951
- CMS Provider Number
- 146039
- Inspections on file
- 41
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Eastview Healthcare & Senior Living during CMS and state inspections, most recent first.
A resident with a history of seizures and on anticoagulant therapy experienced repeated refusals of prescribed anticonvulsant medication, which were not reported to medical providers. No new interventions were implemented to address the increased seizure risk, and the resident's bed was not kept in the low position. The resident subsequently had a seizure, fell from bed, and sustained a significant head injury, including a scalp laceration and subdural hematoma. Staff confirmed the lack of seizure precautions and absence of a facility policy addressing such risks.
A resident who was dependent on staff for toileting and frequently incontinent reported waiting up to an hour for call light responses during certain shifts, resulting in being left in urine or feces. Multiple complaints about slow call light response times were documented, and staff confirmed that inadequate CNA staffing contributed to these delays, contrary to facility policy requiring prompt responses.
A resident who was dependent on staff for bathing did not receive scheduled showers as required, with gaps in shower documentation and no records of refusals or alternative arrangements. The DON confirmed incomplete documentation and missed showers, resulting in a deficiency related to activities of daily living care.
A CNA failed to change gloves between cleaning a resident's buttocks and vaginal area during incontinence care, resulting in cross contamination. The resident, who was always incontinent and dependent on staff for hygiene, had a recent UTI with positive cultures for ESBL-producing organisms and was receiving antibiotics. The CNA acknowledged not following proper glove-changing protocol as required by facility policy.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. The report does not specify further details about the individuals involved or the exact nature of the hazards.
The facility did not have a designated full-time DON for several weeks, as confirmed by staffing schedules and staff interviews. No interim DON was appointed during this period, affecting oversight of nursing services for 50 residents.
The facility did not employ a certified dietary manager to oversee food services. All dietary staff had food safety certifications, but the dietary manager lacked the required certification and was not enrolled in a certification course. The RD, who consults part-time, confirmed the deficiency, which could impact all 50 residents.
Surveyors found that food and drink served to residents was not consistently palatable, attractive, or at a safe and appetizing temperature, as required by regulations.
Multiple incidents occurred in which a resident made physical contact with several other residents, including entering rooms uninvited and making contact with their hands, wrists, and forearms. Staff and resident interviews, as well as facility investigations, confirmed that these events took place and that the same resident was involved in repeated abusive interactions, indicating a failure to protect residents from physical abuse.
Two residents, one with severe cognitive impairment and another with a history of aggression, were involved in a physical altercation in a common area. Staff, including two LPNs, witnessed one resident holding and punching another while yelling. The facility's abuse policy was not effectively enforced, resulting in a failure to protect residents from physical abuse.
A resident with multiple psychological and physical diagnoses was found with fingerprint-pattern bruises on her inner thighs. The facility did not thoroughly investigate the injury, failing to interview male CNAs who provided care prior to the discovery of the bruises, despite the resident's statement implicating a male and the care plan's requirement for comprehensive investigation. The incident report also incorrectly cited anticoagulant use as a cause, though the resident was not prescribed such medication.
The facility failed to employ a full-time DON and did not provide the required eight consecutive hours of RN coverage on four days within a two-week period. The absence of a DON since September and the lack of RN coverage were confirmed by the Regional Administrator, potentially affecting all 42 residents.
The facility failed to ensure required personnel attended QAA committee meetings, potentially affecting all 42 residents. The DON was absent from all meetings in 2024, and the IP was absent from the January meeting, as confirmed by the Regional Administrator.
Staff in a LTC facility failed to use appropriate PPE and follow infection control protocols while caring for COVID-19 positive residents. A CNA did not wear gloves or a gown when obtaining vital signs, and an LPN did not change gloves or perform hand hygiene during medication administration. Another CNA assisted a resident with eating while improperly wearing a surgical mask, contrary to facility policy.
The facility failed to properly assess and manage physical restraints for two residents, leading to deficiencies in care. One resident had a loosely applied seat belt that was not released every two hours, while another had a lap tray used without a documented medical need, causing skin tears. The facility did not adhere to its policy requiring a medical diagnosis for restraint use and regular release for repositioning.
Two residents, both severely cognitively impaired and dependent on staff for personal hygiene, did not receive timely and appropriate incontinence care. One resident was left in a wheelchair with saturated clothing and urine puddles, while another received care that did not follow hygiene protocols, with a saturated brief and no barrier cream applied. The facility's Regional Director confirmed that such care should be provided every two hours to prevent UTIs.
A facility failed to properly store and date nebulizer tubing for a resident with COPD and other medical conditions. The nebulizer tubing was found in a drawer with personal items instead of being stored in a plastic bag as per facility policy. An LPN confirmed the tubing should be changed weekly and stored properly, and the Regional Director of Operations acknowledged the lapse in following the policy.
The facility failed to provide required therapy services for five residents after discontinuing therapy on February 19, 2024. Residents did not receive their prescribed speech, occupational, and physical therapy, leading to a decline in their conditions.
Failure to Implement Seizure and Fall Precautions for High-Risk Resident
Penalty
Summary
The facility failed to implement appropriate interventions to prevent a fall for a resident with a history of seizures and on anticoagulant therapy. The resident had multiple diagnoses, including epileptic seizures, peripheral vascular disease, chronic kidney disease, muscle weakness, difficulty walking, osteoarthritis, major depression, and a history of subarachnoid hemorrhage with residual hemiplegia and hemiparesis. The resident was prescribed Eliquis and Keppra, but there were repeated refusals of the seizure medication Keppra over several days. There was no documentation that these refusals were reported to the physician or nurse practitioner, nor were new interventions initiated to address the increased seizure risk. On the day of the incident, the resident was found on the floor next to the bed after experiencing a seizure, with significant bleeding from a head wound. The bed was not in the low position, and no fall mats or side rails were in use. Staff interviews confirmed that the bed was not kept in the low position prior to the fall, and that refusals of seizure medication were not routinely reported to medical providers. The facility also lacked a specific policy for seizure precautions. As a result of the fall, the resident sustained a six-centimeter scalp laceration requiring evacuation of a hematoma and sutures, as well as a subdural hematoma.
Delayed Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure timely response to call lights for a resident who was dependent on staff for toileting and was frequently incontinent of urine and always incontinent of bowel. The resident reported waiting up to an hour for call light responses during second and third shifts, resulting in being left in urine or feces. The resident also stated that call light response times were a recurring topic in resident council meetings. A grievance report documented complaints from unidentified residents about slow call light responses on third shift, specifically regarding the need to be changed. Staff interviews confirmed that the number of CNAs on duty was insufficient to meet residents' toileting needs in a timely manner, affecting call light response times. The facility's policy required call lights to be answered as soon as possible, but no later than five minutes, with urgent requests addressed immediately.
Failure to Provide Scheduled Showers and Maintain Documentation
Penalty
Summary
The facility failed to provide scheduled showers for a resident who was dependent on staff for bathing due to above knee amputations and was cognitively intact. According to the facility's policy, showers are to be provided twice weekly, refusals are to be documented, and supervisors notified if a resident refuses. The resident reported not receiving showers for two weeks and expressed confusion about changes to the shower schedule. The resident's care plan specified the need for assistance with activities of daily living, including scheduled showers twice weekly. Review of the facility's shower documentation for November and December revealed gaps, with showers only documented on a few dates and no consistent twice-weekly pattern. The DON confirmed that the available documentation was incomplete and acknowledged the gaps. There was no documentation of refusals or alternative arrangements during the periods when showers were missed, despite facility policy requiring such records. The lack of consistent documentation and missed showers led to the deficiency.
Failure to Prevent Cross Contamination During Incontinence Care
Penalty
Summary
During incontinence care for one resident, a Certified Nursing Assistant (CNA) failed to follow proper infection control procedures as outlined in the facility's Perineal Care policy. The CNA, after cleaning the resident's vaginal area in a front to back motion, turned the resident to cleanse the buttocks but did not change gloves before applying a clean brief and subsequently cleaning the vaginal area again. This sequence of actions resulted in the use of contaminated gloves to clean the resident's vaginal area after having cleaned the buttocks, which is contrary to the facility's policy requiring glove changes when moving from soiled to clean areas. The resident involved had moderate cognitive impairment, was always incontinent of bowel and bladder, and was dependent on staff for toileting hygiene. Medical records indicated the resident had a recent history of urinary tract infection (UTI) with urine cultures showing significant growth of Klebsiella Oxytoca ESBL and Escherichia Coli, and was receiving antibiotic treatment. The CNA confirmed during interview that gloves should have been changed between cleaning the buttocks and the vaginal area, acknowledging the lapse in infection control practice.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions by staff or details about the residents involved are not provided in the report. No further information about the circumstances or individuals affected is included.
Failure to Maintain Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate and maintain a full-time Director of Nursing (DON) as required. Review of staffing schedules over a one-month period confirmed that no licensed nurse was assigned as DON, and no interim appointment was made during this time. Interviews with staff, including an LPN, the Administrator, and a Corporate Nurse, confirmed that the facility had been without a DON for several weeks, with no interim DON in place. The facility census indicated that 50 residents were present during this period.
Lack of Certified Dietary Manager in Food Services
Penalty
Summary
The facility failed to employ a certified dietary manager to oversee food services, as required. Review of dietary staff certifications showed that while all dietary staff had food safety certifications, none held a Dietary Manager Certification. The current dietary manager confirmed she is not certified in dietary management, and the administrator and regional nurse verified that she is not enrolled in any certification courses. The registered dietician, who consults for the facility and is present approximately 16 hours per month, also confirmed that the dietary manager is not certified. This deficiency has the potential to affect all 50 residents currently residing in the facility, as documented in the facility census.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the meals did not consistently meet standards for taste, appearance, or temperature at the time of service.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents' rights to be free from resident-to-resident physical abuse, as evidenced by multiple documented incidents involving one resident making physical contact with several other residents. According to the facility's own investigations, one resident was involved in repeated incidents where they entered other residents' rooms, went through their belongings, and made physical contact with their hands, wrists, and forearms. These incidents were reported by both staff and residents, and the facility's investigations confirmed that the events occurred as described. Staff interviews and record reviews further confirmed that the same resident was known to have been involved in multiple abusive incidents affecting at least three other residents. The incidents occurred in various settings, including during one-to-one care and while other residents were engaged in activities such as playing cards. The facility's abuse prevention program states that residents have the right to be free from all forms of abuse, but the repeated nature of these incidents demonstrates a failure to uphold this standard for the affected residents.
Failure to Prevent Physical Abuse Between Residents
Penalty
Summary
The facility failed to protect two residents from physical abuse, as required by its abuse prevention policy. One resident with severe cognitive impairment and a history of dementia, agitation, and behavioral disturbance was observed by staff holding another resident by the collar and punching him in the back of the head while yelling. This incident occurred in a common area and was witnessed by two LPNs, one of whom described seeing the altercation upon entering the kitchen, and another who observed the event during breakfast in the dining room. The facility's records confirm that the resident who initiated the altercation had a care plan noting impaired cognitive function, while the other resident involved was cognitively intact but had a documented history of aggressive behavior and threats toward staff. The facility's abuse policy, which strictly prohibits any form of abuse, was not effectively implemented in this case. Documentation and staff interviews confirm that the physical altercation occurred, and the administrator acknowledged awareness of the incident but was unable to provide an explanation for its cause. The failure to prevent this altercation resulted in a violation of the residents' right to be free from physical abuse.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident who was found with multiple bruises in a fingerprint pattern on her inner thighs. The resident, who has diagnoses including psychological disorders, schizophrenia, major depressive disorder, and peripheral vascular disease, was noted to be moderately cognitively intact. The care plan required that any allegations or signs of mistreatment, such as physical marks or injuries, be investigated, including conducting skin checks and interviewing staff assigned to the resident's care. Despite this, the facility's investigation into the bruising did not include interviews with male CNAs who had provided care to the resident in the days prior to the discovery of the bruises, even though the bruises were described as looking like fingerprints and the resident had made a statement to a family member implicating a male individual. Additionally, the facility's incident report incorrectly attributed the bruising to the resident being on an anticoagulant, when a review of the resident's medications showed no such prescription. The administrator acknowledged not realizing that aspirin is not classified as an anticoagulant and stated she did not think there were any male staff on the schedule who could have been involved, despite evidence to the contrary. The investigation did not include interviews with all relevant staff, specifically the male caregivers who were scheduled during the period in question, and failed to fully address the resident's and family member's concerns.
Failure to Employ Full-Time DON and Provide RN Coverage
Penalty
Summary
The facility failed to employ a full-time Director of Nurses (DON) and did not provide the required eight consecutive hours of Registered Nurse (RN) coverage on four specific days within a two-week period. This deficiency was identified through a review of the Facility Nursing Staff Daily Assignment Sheets, which documented the absence of RN coverage for at least eight consecutive hours on November 5, 8, 9, and 10, 2024. Additionally, the facility has been without a DON since September 18, 2024, as confirmed by the Regional Administrator. These failures have the potential to affect all 42 residents residing in the facility, as there was no DON observed working in the facility from November 12 to November 15, 2024.
QAA Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the required personnel attended the Quality Assessment and Assurance (QAA) committee meetings, which has the potential to affect all 42 residents in the facility. Specifically, the January 2024 QAA meeting attendance signature sheet did not document the presence of the Director of Nursing (DON) or the Infection Preventionist (IP). Additionally, the attendance sheets for the April, July, and November 2024 QAA meetings did not document the presence of the DON. This was confirmed by the Regional Administrator, who reviewed the last four quarterly QAA sign-in sheets and noted the absence of the DON at all meetings and the absence of the IP at the January 2024 meeting.
Inadequate PPE Use and Infection Control in LTC Facility
Penalty
Summary
Facility staff failed to adhere to proper infection prevention and control protocols, particularly in the use of Personal Protective Equipment (PPE) while caring for residents with COVID-19. A Certified Nurse Aide (CNA) did not wear gloves or a protective gown when obtaining vital signs for two COVID-19 positive residents, despite clear signage indicating the need for contact and droplet precautions. The CNA's clothing came into contact with surfaces in the residents' room, and the CNA admitted to not following proper hand hygiene or equipment cleaning procedures between residents. Additionally, a Licensed Practical Nurse (LPN) failed to change gloves and perform hand hygiene during the administration of medication to a resident. The LPN used the same gloves to handle a resident's oxygen nasal cannula from the floor and then administered medication without changing gloves or sanitizing hands. Furthermore, another CNA was observed assisting a COVID-19 positive resident with eating while only wearing a surgical mask that did not cover her nose, contrary to the facility's policy requiring an N95 mask, gloves, gown, and eye protection. The CNA was unaware of the proper PPE requirements during a COVID-19 outbreak.
Improper Use and Management of Physical Restraints
Penalty
Summary
The facility failed to properly assess and manage the use of physical restraints for two residents, R24 and R28, leading to deficiencies in care. For R24, the facility did not identify a specific medical condition necessitating the use of a self-releasing seat belt, which was applied loosely and inconsistently. Observations showed that R24's seat belt was not released every two hours as required, and the resident was unable to remove it independently, despite being ambulatory and having no musculoskeletal or neurological disorders that would interfere with ambulation. Staff interviews revealed that the seat belt was used to prevent R24 from standing, but it was not effectively monitored or adjusted, posing a potential safety hazard. For R28, the facility used a lap tray as a restraint without documenting a specific medical need. Despite R28's severe cognitive impairment, the resident was observed attempting to remove the tray and stand up from the wheelchair. Staff reported that the lap tray was used to prevent R28 from getting up, but it was not released every two hours as required. Additionally, the tray caused skin tears, leading staff to place pool noodles on it to prevent further injury. The facility's failure to properly assess and document the need for the lap tray, as well as to ensure its safe use, contributed to the deficiency. Overall, the facility did not adhere to its policy on physical restraints, which requires a documented medical diagnosis for their use and mandates that restraints be released every two hours for repositioning and care. The lack of proper assessment, documentation, and monitoring of restraints for R24 and R28 resulted in deficiencies that affected the residents' safety and well-being.
Inadequate Incontinence Care for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide timely and appropriate incontinence care for two residents, R22 and R10, who were both severely cognitively impaired and dependent on staff for personal hygiene and toileting. R22 was observed sitting in a wheelchair for extended periods without being offered or assisted with incontinence care, resulting in her pants and mechanical lift sling being saturated with urine, and urine puddles forming on the floor. Staff admitted to not having provided incontinence care to R22 during their shift, despite her evident need. Similarly, R10, who has a history of urinary tract infections, was provided incontinence care that did not adhere to the facility's standards. The CNA failed to follow proper hygiene protocols, such as changing gloves and using hand hygiene, and did not apply barrier cream or dry the resident after cleansing. R10's incontinence brief was found to be thoroughly saturated and had a strong urine smell, indicating a lack of timely care. The Regional Director of Operations confirmed that residents should receive incontinence care every two hours and that improper care could lead to UTIs.
Improper Storage and Dating of Nebulizer Tubing
Penalty
Summary
The facility failed to properly store and date nebulizer tubing for a resident, identified as R5, who was reviewed for oxygen use. The facility's policy requires nebulizer tubing to be stored in a plastic bag and changed weekly. However, observations revealed that R5's nebulizer tubing was not stored according to these guidelines. On one occasion, the nebulizer machine was found on R5's bedside dresser with a plastic bag labeled with a date, but the tubing itself was stored in a drawer with other personal items. This was confirmed by a Licensed Practical Nurse (LPN), who acknowledged that the tubing should be changed weekly and stored in a plastic bag when not in use. R5's medical history includes diagnoses of Dementia, Intellectual Disabilities, Chronic Obstructive Pulmonary Disorder (COPD), Glaucoma, Chronic Systolic Heart Failure, and a dependence on a wheelchair, requiring assistance with personal care. Despite being cognitively intact, as documented in the Minimum Data Set (MDS), the facility did not adhere to the physician's order to change the nebulizer tubing weekly and store it properly. The Regional Director of Operations also confirmed that all respiratory tubing should be stored in a clean plastic bag when not in use, indicating a lapse in following the facility's policy and physician's orders.
Failure to Provide Required Therapy Services
Penalty
Summary
The facility failed to ensure therapy services were provided for five residents who required them. Therapy services were discontinued on February 19, 2024, and a new therapy provider had not yet started by the time of the survey on March 20-21, 2024. As a result, residents R1, R2, R3, R4, and R5 did not receive their prescribed therapy services, which included speech, occupational, and physical therapy. The lack of therapy services was confirmed through interviews with staff and residents, as well as a review of medical records and therapy notes. Resident R3 was admitted with orders for speech, occupational, and physical therapy, but their last therapy sessions were in mid-February. Resident R4 had orders for occupational therapy, with the last session on February 13, 2024. Resident R5, who was working on walking, had their last therapy session on February 16, 2024. Resident R1 had orders for both occupational and physical therapy, but therapy was discontinued in mid-February. Resident R2, who was receiving speech therapy to help with eating, also had their therapy discontinued. Staff and family members noted the residents' progress with therapy and their subsequent decline after therapy services were halted.
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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