Effingham Healthcare & Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Effingham, Illinois.
- Location
- 1610 North Lakewood Drive, Effingham, Illinois 62401
- CMS Provider Number
- 145514
- Inspections on file
- 43
- Latest survey
- December 24, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Effingham Healthcare & Senior Living during CMS and state inspections, most recent first.
A resident with significant mobility limitations and morbid obesity was being transferred from a shower chair to bed using a mechanical lift by an LPN and a CNA. During the transfer, difficulty maneuvering the lift and lack of communication between staff led to the resident's weight becoming unbalanced, causing the lift to tip over. The resident fell and sustained a head laceration requiring staples, with documentation confirming the incident resulted from improper handling during the transfer.
The facility did not ensure that an RN was present for at least 8 consecutive hours each day as required, with only partial RN coverage on multiple days and no other RNs available to meet the standard. This affected all 32 residents in the facility, as confirmed by review of schedules and staff interviews.
The facility did not provide 8 hours per day, 7 days per week RN coverage, with multiple days lacking an RN or having the DON work less than the required hours. Both the DON and Administrator confirmed awareness of the staffing shortfall, and 37 residents were present in the facility during this period.
The facility did not consistently offer substantial evening snacks to residents, as required by policy. Several residents reported not being asked if they wanted snacks after dinner, and staff confirmed that snack availability depended on what the kitchen left before closing, often resulting in insufficient or non-nutritious options. This inconsistency affected all residents in the facility.
Surveyors found that multiple residents' rooms and common areas were not maintained in a clean or sanitary condition, with soiled briefs and bed pads left on floors, sticky and visibly soiled surfaces, and black substances present in bathroom sinks and shower room grout. Staff confirmed these conditions did not meet facility standards, and facility policy requires regular cleaning and disinfection.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as evidenced by observations and record reviews.
A resident with a history of urinary retention and frequent UTIs was found with a completely full leg catheter drainage bag, causing urine to back up into the tubing. Despite care plan interventions and physician orders to empty and replace the drainage bag as needed, staff failed to check and drain the bag in a timely manner. An LPN acknowledged the risk of infection due to the full bag, and the deficiency was observed during survey.
The facility did not ensure RN coverage for at least eight consecutive hours per day, seven days a week, as required. On multiple occasions, there was either no RN scheduled or the DON worked less than the required hours, affecting all residents in the facility. The issue was attributed to a recent RN resignation and ongoing recruitment challenges.
A resident with severe cognitive impairment was left in urine-soaked clothing during mealtime, highlighting a failure in providing necessary hygiene assistance. Despite requiring supervision for toileting, the resident was observed with wet clothing and a urine puddle beneath him, which staff did not promptly address. This incident reflects a breach of the resident's rights to dignity and respect.
The facility lacks a full-time Registered Dietitian or Certified Dietary Manager, affecting all 34 residents. The Dietary Manager role has been vacant since June, and a Registered Dietitian visits only monthly. Quality Assurance meetings have not had a Dietary Manager present since June, with the Registered Dietitian providing necessary information.
The facility's kitchen was found to be unsanitary, with dirty equipment, improper food storage, and inadequate hand hygiene practices. Observations included dirty stove burners, uncovered drinks at improper temperatures, and a lack of a cleaning log. The administrator intervened to prevent the serving of potentially contaminated drinks.
The facility failed to provide scheduled weekend activities for residents, despite their preferences for such activities being documented in their MDS assessments. The Activity Director did not schedule weekend activities, leaving it to nursing staff, and the facility's calendar showed no activities on several weekends. The Administrator acknowledged the issue but noted the absence of a formal policy on activities.
The facility failed to prepare meals according to the specified diet orders for several residents, resulting in improper food textures being served. During a lunch observation, the cook did not use liquid in the food processor or perform the necessary consistency tests, leading to some residents receiving incorrect meal textures. Additionally, inconsistencies in pureed food preparation were noted, and the dessert did not match the menu description.
The facility failed to implement proper infection control practices, including enhanced barrier precautions for residents with wounds and indwelling devices. Staff did not disinfect a glucometer between uses, placed soiled linens on the floor, and mishandled an ice cooler lid, all contrary to facility policies.
A facility failed to provide written notification to a resident's representative regarding a hospital transfer. The resident, who was only alert to person and not cognitively intact, was admitted to the hospital due to emesis and inability to keep medication down. The administrator confirmed that notification was given via phone but not in writing.
A facility failed to notify a resident's representative in writing of the bed hold policy during a hospital transfer. The resident, not cognitively intact, was admitted to the hospital with emesis and medication issues. The administrator confirmed that the notification was given via phone but not in writing, and the facility lacked evidence of a bed hold policy.
The facility failed to accurately code MDS assessments for three residents, resulting in discrepancies in their records. One resident's MDS incorrectly documented the absence of a Level II PASRR condition despite having a diagnosis of Bipolar Disorder. Another resident's MDS included an incorrect diagnosis due to an unchecked system error. The third resident's MDS inaccurately indicated no serious mental illness despite having multiple psychiatric diagnoses. These errors were identified through observation, interviews, and record reviews, revealing a lack of thorough verification in the assessment process.
Unsafe Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for mobility due to multiple medical conditions including morbid obesity, chronic systolic heart failure, and osteoarthritis, was being transferred from a shower chair to her bed using a mechanical lift. The resident was cognitively intact and required assistance from one to two staff members for transfers, as documented in her care plan and Minimum Data Set. During the transfer, two staff members, an LPN and a CNA, were involved in operating the mechanical lift and guiding the resident. The incident happened when the staff encountered difficulty maneuvering the mechanical lift, particularly with the wheels, while the resident was elevated in the sling. Both staff members reported that the resident's weight became unbalanced during the transfer, specifically when the CNA repositioned the resident's legs while the lift was still in motion. This caused the mechanical lift to tip over, resulting in the resident falling to the floor and the lift striking her on the head, causing a laceration that required two staples. The resident was sent to the emergency room for evaluation and treatment and returned with orders for staple removal in seven days. Interviews with the staff involved and facility leadership confirmed that there was a lack of communication between the LPN and CNA during the transfer, and the resident's weight was close to the mechanical lift's maximum capacity. The facility's investigation and documentation indicated that the unbalanced weight during repositioning and movement of the lift led to the tip-over and subsequent injury. The facility's policy on mechanical lift use emphasized safe lifting principles but did not substitute for manufacturer training or instructions.
Failure to Provide 8-Hour Consecutive RN Coverage Daily
Penalty
Summary
The facility failed to provide the required services of a Registered Nurse (RN) for at least 8 consecutive hours per day, 7 days a week, as mandated by regulation and the facility's own staffing policy. Review of the nursing schedules for August and September 2025 revealed that on several dates, including 8/9/25, 8/23/25, 8/24/25, 9/6/25, and 9/7/25, there was not an RN present for the required 8 consecutive hours. On these dates, the only RN coverage was provided by one RN who worked only 4 hours each day, and no other RNs were present to fulfill the remaining hours. This was confirmed by both the Administrator and the Director of Nursing during interviews, who acknowledged the lack of continuous RN coverage, particularly on weekends. The facility's resident matrix indicated that 32 residents were living in the facility at the time of the deficiency. The Director of Nursing stated that the facility was aware of the shortfall and attributed it to ongoing efforts to recruit additional RNs. The facility's policy, dated 2001, specifically requires that an RN provide services for at least eight consecutive hours every 24 hours, seven days a week, which was not met on the identified dates.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required 8 hours per day, 7 days per week Registered Nurse (RN) coverage, as documented by the facility's nurse schedules and employee timecard reports. On multiple dates across June, July, and August 2025, there was either no RN scheduled or the scheduled RN, who was also the Director of Nursing (DON), worked less than the required 8 hours. Specific dates were identified where no RN was present, and on several occasions, the DON worked between 3 to 7.5 hours instead of the mandated 8 hours. Interviews with the DON and the Administrator confirmed awareness of the RN coverage shortfall. The DON acknowledged gaps in the schedule and noted that a PRN nurse had recently started to help cover shifts, while the facility continued to advertise for an RN position. At the time of the deficiency, 37 residents were residing in the facility, as documented in the Minimum Data Set (MDS) Resident Matrix.
Failure to Routinely Provide Substantial Evening Snacks
Penalty
Summary
The facility failed to provide substantial evening snacks to residents, as required by their policy and regulatory standards. Multiple alert and oriented residents reported that staff did not routinely offer them snacks after dinner or before bedtime, and that they were not asked if they would like a substantial snack such as a half sandwich or yogurt. Some residents stated that while they could request a snack earlier in the day, staff did not proactively offer snacks in the evening. Staff interviews confirmed that the availability and quantity of evening snacks depended on what the kitchen left before closing, with the kitchen being locked after staff left. Commonly available snacks included oatmeal cream pies, chips, graham crackers, and occasionally yogurt or sandwiches, but there were not always enough snacks for all residents, and substantial snacks were rarely provided. The facility's policy required that evening snacks be routinely offered to all residents and that nourishing snacks from the basic food groups be provided if the time between dinner and breakfast exceeded fourteen hours. However, staff interviews revealed inconsistency in snack provision, with some staff stating that there were sometimes not enough snacks for all residents and that the type of snack varied based on kitchen supply. The lack of routine offering and insufficient quantity and quality of snacks had the potential to affect all 37 residents residing in the facility.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
Surveyors observed multiple instances where the facility failed to maintain a clean, safe, and sanitary environment for residents. In several resident rooms, soiled briefs and bed pads were found on the floor for extended periods, and sticky or visibly soiled floors were noted. One room had a large area of dried spilled liquid on the floor, and a bathroom sink was found with a black substance and cracks, with the substance extending into and under the cracks. The south hall shower room contained a black substance along the walls and in the grout, with the substance extending several inches up the walls and between tiles. These conditions were directly observed by surveyors during their visits and were confirmed by staff interviews. Facility staff, including maintenance and nursing personnel, acknowledged that the observed conditions did not meet facility standards or expectations. The facility's own policy requires regular cleaning and disinfection of housekeeping and environmental surfaces, including immediate cleaning when surfaces are visibly soiled. Despite these policies, the observed deficiencies affected all residents reviewed for environmental conditions, indicating a failure to consistently implement cleaning protocols and maintain a homelike and sanitary environment.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews, which revealed that necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently provided to affected residents.
Failure to Timely Drain Catheter Bag Increases Infection Risk
Penalty
Summary
A deficiency occurred when staff failed to timely drain a full indwelling catheter bag for a resident with a history of cerebral infarction, urinary retention, neuromuscular bladder dysfunction, and previous urinary tract infections. The resident's care plan included an intervention to empty the drainage bag as needed, and there was an active order to replace the bedside drainage bag with a leg bag each morning. Despite these directives, observation revealed that the resident's leg catheter drainage bag was completely full, with urine backing up into the tubing. A Licensed Practical Nurse confirmed that the bag was so full that urine was backing up, acknowledging that this situation could lead to infection, especially since the resident was known to have frequent urinary tract infections. The CDC guidelines referenced in the report emphasize the importance of regularly emptying catheter bags to prevent infection, but staff failed to check and empty the resident's drainage bag in a timely manner, resulting in the observed deficiency.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours per day, seven days a week, as required by regulation and facility policy. Review of the May and June 2025 nurse schedules and employee timecard reports revealed multiple days where no RN was scheduled or present, and several days where the Director of Nursing (DON) was scheduled as the RN but worked less than the required eight hours. Specifically, on several dates in May and June, there was either no RN coverage or the DON worked between 5.25 and 7.5 hours instead of the mandated eight hours. Interviews with the DON and the Administrator in Training confirmed awareness of the RN staffing shortages, attributing the issue to a recent RN resignation and ongoing recruitment efforts. The facility did not utilize agency staffing to fill these gaps. At the time of the deficiency, 34 residents were residing in the facility, as documented in the Minimum Data Set (MDS) Resident Matrix.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
The facility failed to ensure proper hygiene care for a resident, identified as R31, who was left in urine-soaked clothing during mealtime. R31, who has a diagnosis of schizophrenia and severe cognitive impairment, requires supervision or assistance for toileting hygiene and lower body dressing. Despite these needs, R31 was observed walking to the dining room with wet clothing and subsequently sat in a chair where urine formed a puddle beneath him. Staff members passed by without addressing the situation until a surveyor intervened, highlighting a lack of timely assistance and attention to the resident's dignity. The resident's care plan indicated a need for supervision and assistance with activities of daily living, including maintaining privacy and dignity. However, during the incident, the resident was left in a wet state, and the area was not promptly cleaned, as evidenced by the Director of Nursing using a paper towel to soak up the urine after the resident had returned to the dining room. The resident's guardian expressed concerns about the resident being left in such a condition, expecting staff to maintain the resident's cleanliness and dignity. This incident reflects a failure to uphold the resident's rights to dignity and respect as outlined in the Illinois Long Term Care Ombudsman Program Residents' Rights booklet.
Lack of Full-Time Dietary Management
Penalty
Summary
The facility failed to employ a full-time Registered Dietitian or a full-time Certified Dietary Manager, which has the potential to affect all 34 residents residing in the facility. On September 17, 2024, a cook stated that there was no one in the Dietary Manager role, as the previous person quit shortly after starting. The facility administrator confirmed on September 20, 2024, that the position has been vacant since June 2024, despite efforts to fill it. Although a Registered Dietitian visits once a month to review residents' nutritional needs, this does not meet the requirement for full-time presence. Additionally, the facility's Quality Assurance monthly meeting records show no attendance by a Dietary Manager since June 2024, with the Registered Dietitian providing necessary information for these meetings.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which has the potential to affect all 34 residents residing in the facility. During an initial tour of the kitchen, several deficiencies were observed, including the absence of paper towels at the hand wash sink, dirty stove top gas burners, and unclean sides of the oven with spilled food and grease. Additionally, the flat top grill's grease/crumb trap was full of old food crumbs and grease, and dried food matter was found under the oven. Non-handle scoops and Styrofoam cups were improperly stored in bulk containers of fortified powder, brown sugar, and sugar. A towel was used to prop open the back door, and a fan with flies and dirt was blowing air into the kitchen, potentially contaminating uncovered drinks. Further observations revealed that glasses of milk, water, and lemonade were left uncovered and not in an ice bath, with the milk temperature recorded at 59 degrees, which was acknowledged as high by the cook. The administrator intervened to prevent the serving of these drinks and instructed the staff to clean the fan. Additionally, it was noted that there was no cleaning log in the kitchen, and a cook was observed handling both dirty and clean dishes without washing hands or using gloves. A cleaning schedule was provided later, indicating a policy for cleaning tasks, but it was not being followed at the time of the survey.
Failure to Schedule Weekend Activities for Residents
Penalty
Summary
The facility failed to provide scheduled daily activities that met the goals and preferences of six residents, as identified during interviews and record reviews. These residents had various diagnoses, including hemiplegia, major depressive disorder, dementia, bipolar disorder, anxiety disorder, chronic obstructive pulmonary disease, and post-traumatic stress disorder. Their Minimum Data Set (MDS) assessments indicated that activities such as reading, listening to music, being around animals, participating in group activities, and going outside for fresh air were important to them. However, during a resident council meeting, these residents reported that no activities were scheduled on weekends, which was a concern for them. The Activity Director, V12, confirmed that no activities were scheduled for weekends, leaving it to the nurses and certified nurse assistants to engage residents. The facility's September 2024 activities calendar corroborated this, showing no activities scheduled on several weekend dates. The Administrator, V1, acknowledged having discussed the need for weekend activities with the Activity Director but noted that the facility lacked a formal policy on activities, instead claiming to follow regulations. This lack of scheduled activities on weekends led to the deficiency identified by the surveyors.
Failure to Prepare Meals According to Diet Orders
Penalty
Summary
The facility failed to prepare food in the proper form according to the diet orders for five residents, leading to a deficiency in meeting the nutritional needs of these residents. During a lunch meal observation, the cook did not prepare the meals according to the specified mechanical soft and pureed diet textures. Specifically, the cook did not use any liquid in the food processor while blending the food, which is necessary to achieve the correct consistency. Additionally, the cook did not perform the required spoon tilt test to ensure the proper food consistency was obtained. As a result, some residents received regular meatloaf instead of the required mechanical soft meatloaf, and one resident was observed coughing while eating. The report also highlights inconsistencies in the preparation of pureed food, with family members noting that the food's consistency varied from being too thin and runny to too thick. The cook admitted to not adding liquid to the pureed or mechanical soft diets, fearing it would make the food too runny, and also forgot to prepare pureed bread for the meal. Furthermore, the dessert served did not match the menu description, as the fruited gelatin did not set properly and was runny. The cook expressed uncertainty about why the gelatin did not set, despite preparing it in advance. A CNA, who previously worked in the kitchen, mentioned that she had trained the cook to use hot liquid to achieve the correct consistency for pureed food items.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement and follow proper infection prevention and control practices for several residents, particularly those with wounds and indwelling medical devices. During an initial tour, it was observed that there were no signs indicating residents were on enhanced barrier precautions, despite the presence of residents with conditions that warranted such measures. The Director of Nursing and the Administrator acknowledged that enhanced barrier precautions had not been implemented, and it was noted that staff had not received comprehensive training on these precautions. Additionally, there were specific instances of non-compliance with infection control protocols. A Licensed Practical Nurse was observed using a glucometer on multiple residents without disinfecting it between uses, contrary to the facility's policy requiring cleaning between each resident to prevent cross-contamination. Another LPN was seen placing soiled linens on the floor during catheter care, which is against the facility's policy, as confirmed by the Administrator. Furthermore, a Certified Nurse Assistant was observed mishandling an ice cooler lid by placing it back on the cooler after it had fallen on the floor, without cleaning it. This action was not in line with the expected infection control procedures. These observations highlight a pattern of inadequate adherence to infection control practices, which could potentially compromise resident safety.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide written notification to the resident's representative regarding a hospital transfer. The resident, identified as R3, was admitted to the facility on 7/21/06 and was only alert to person. R3's responsible party was documented as V22, the guardian. On 8/23/24, R3 was transported and admitted to a local hospital due to reddish/brown emesis and an inability to keep medication down. During an interview on 09/19/24, the administrator, V1, stated that the resident and/or their representative were notified of the hospital transfer via phone but confirmed that no written documentation was provided to the resident representative. V1 also noted that R3 was not cognitively intact as their baseline status.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to notify a resident's representative in writing of the bed hold policy during a transfer to a hospital. The resident, who was only alert to person and not cognitively intact, was admitted to the facility on 7/21/06 and had a guardian as their responsible party. On 8/23/24, the resident was transported to a local hospital due to reddish/brown emesis and an inability to keep medication down. The facility's administrator stated that the resident's representative was informed of the bed hold policy via phone and that the information was sent with the resident, but confirmed that no written documentation was provided. Additionally, the facility could not provide evidence of a policy and procedure for bed holds upon request.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded for three residents, leading to discrepancies in their records. For one resident, the MDS inaccurately documented the absence of a Level II Preadmission Screening and Resident Review (PASRR) condition despite having a diagnosis of Bipolar Disorder and a Level II PASRR outcome. Another resident's MDS incorrectly included a diagnosis of a psychotic disorder, which was not present, due to an automatic system error that was not double-checked by the MDS Coordinator. The third resident's MDS inaccurately indicated no serious mental illness despite having diagnoses of schizoaffective disorder, borderline personality disorder, and major depressive disorder. These inaccuracies were identified through observation, interviews, and record reviews, highlighting a lack of thorough verification and manual correction of automatically populated data in the MDS. The MDS Coordinator acknowledged the errors and the need for corrections, indicating a lapse in the facility's process for ensuring accurate resident assessments. These deficiencies in the MDS assessments could potentially impact the care and services provided to the residents.
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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