Evercare Of Lebanon
Inspection history, citations, penalties and survey trends for this long-term care facility in Lebanon, Illinois.
- Location
- 1201 North Alton, Lebanon, Illinois 62254
- CMS Provider Number
- 145897
- Inspections on file
- 34
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 6 (2 serious)
Citation history
Health deficiencies cited at Evercare Of Lebanon during CMS and state inspections, most recent first.
A resident with a history of elopement and cognitive impairment exited a secured memory care unit without staff intervention after an exit alarm was misattributed to a malfunctioning door. Staffing shortages and miscommunication delayed the response, resulting in the resident being missing for over two hours before being found unharmed in a nearby residential area.
A resident eloped from a locked memory care unit when only one CNA was present on the hall, as the other CNA was on break and the LPN was covering multiple areas. Staff interviews and observations revealed that alarms were not promptly responded to due to staffing shortages and communication issues, and a nurse was observed sleeping during a shift. These deficiencies affected the facility's ability to provide adequate care and supervision for all residents.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes that the environment was not maintained safely and supervision was lacking, but does not provide further specifics.
The facility did not provide the required RN coverage for at least eight consecutive hours per day, seven days a week, as only the DON was employed as an RN and no other RNs were scheduled or present. This deficiency affected all residents in the facility, which had a census of 75 to 78 residents.
The facility did not maintain RN coverage for at least eight consecutive hours daily, as required. Several dates were identified without an RN on duty, particularly on weekends. Staff interviews confirmed the shortage, and the Administrator acknowledged the issue, citing recruitment efforts and an RN's health concerns as contributing factors.
The facility failed to follow its Legionella Policy, with the Maintenance Director not performing required weekly water checks and lacking training. Additionally, a CNA did not adhere to hand hygiene protocols during incontinent care for a resident with multiple medical conditions, including COPD and bilateral amputations. These deficiencies in infection control practices posed a risk to all 54 residents.
The facility failed to feed residents with dignity, affecting four residents who were dependent on staff for eating assistance. A CNA was observed standing over a resident while feeding, and other residents were referred to as "feeders" within earshot, contrary to the facility's policy on maintaining dignity during meals.
The facility failed to implement and follow care plan interventions to prevent falls, resulting in multiple incidents. A resident with cognitive impairment experienced falls due to improper placement of assistive devices and incomplete 15-minute checks. Another resident, dependent on staff for mobility, attempted self-transfers without adequate assistance, leading to repeated falls. Additionally, a resident with osteoporosis and a recent fracture lacked fall precautions, and improper use of a mechanical lift was observed.
The facility failed to properly label and store medications for four residents, leading to deficiencies in medication administration. Medications were found unattended in residents' rooms, and an opened medication bottle lacked a date. Staff confirmed that medications should not be left at the bedside without a doctor's order, which was not present. The facility's policies require medications to be labeled with the date opened and not left unattended, but these standards were not followed.
The facility failed to provide adequate incontinent care for three residents, as observed by surveyors. Residents did not receive proper perineal care, including the application of barrier cream and the use of necessary equipment, as per their care plans and facility policy. Staff did not follow hand hygiene protocols, leading to incomplete and improper care.
The facility failed to ensure proper oxygen administration for three residents. One resident had undated oxygen tubing and humidifier bottles, contrary to facility policy. Another resident lacked a humidified water bottle on their oxygen concentrator, despite physician orders. A third resident had an empty, undated humidified water bottle attached to their concentrator. The facility's policy did not address dating oxygen supplies, contributing to these deficiencies.
The facility failed to maintain safe equipment conditions by not adhering to its policy for cleaning lint traps in the laundry area. Observations showed moderate lint accumulation, and staff admitted to not cleaning the traps as required. This poses a potential fire hazard, affecting all 54 residents.
The Facility failed to document the discharge of a resident and did not communicate necessary information to the receiving facility. The resident, who had multiple diagnoses and exhibited behavioral disturbances, was sent to the emergency room but was not accepted back after the bed hold expired. The medical record lacked necessary discharge documentation.
The Facility failed to follow discharge requirements for a resident with severe cognitive impairment and behavioral disturbances. After the resident was sent to the emergency room for physical aggression and sexually inappropriate behaviors, the Facility did not document a discharge plan or notify the resident and her representative, choosing not to readmit her after her bed hold expired.
The Facility failed to readmit a resident after hospitalization, despite having a bed available, due to the resident's expired bed hold and behavioral issues. The resident had severe cognitive impairment and exhibited inappropriate sexual behavior and aggression. The Facility did not comply with its Bed Hold Guarantee Policy or federal regulations.
Failure to Prevent Elopement from Secured Memory Unit
Penalty
Summary
A deficiency occurred when a resident with a known history of elopement and diagnoses including paranoid schizophrenia, cognitive impairment, and wandering behaviors exited a secured memory care unit without staff intervention. The resident was identified as an elopement risk, with documentation in the elopement binder and care plan noting previous incidents of leaving facilities and attempts to hide or leave unnoticed. On the evening of the incident, the resident exited through a locked door that required a code, which triggered an alarm. However, staff did not immediately recognize the alarm as indicating an exit from the men's unit, partly due to previous issues with a different door alarm and staffing shortages at the time. Only one CNA was present on the hall, as the other was on break, and the nurse was occupied with medication administration on another hall. The alarm was initially misattributed to a sticking door on the women's side, leading to a delay in response. Staff did not immediately check the source of the alarm, and a head count was not initiated until after the alarm had sounded and the resident had already left the building. The resident was unaccounted for during the head count, and a search was initiated. The resident was missing for over two hours, during which time local authorities, canine units, and a helicopter with infrared technology were involved in the search. The resident was eventually found in a residential area, having traversed steep and overgrown terrain in the dark. Interviews with staff revealed that the split staffing and miscommunication about the alarm contributed to the delay in identifying and responding to the elopement. The CNA present on the men's hall had hearing issues and did not immediately investigate the alarm, assuming it was related to the previously malfunctioning door. The nurse and other staff were not immediately aware that the resident had exited, and the search only began after the head count confirmed the resident was missing. The resident was ultimately found unharmed, but the lack of adequate supervision and delayed response allowed the resident to leave the facility unnoticed and unsupervised for an extended period.
Removal Plan
- R2 was moved to a room closer to the nurse's station.
- R2 was placed on 1:1 supervision with re-evaluation.
- R2's elopement risk was re-evaluated.
- A psych medication review was requested for R2.
- Administrator and Director of Nursing were in-serviced by the VP of Clinical Services.
- Administrator in-serviced the Intradisciplinary Team (IDT).
- Current staff were in-serviced on elopement policy and procedure.
- All residents in the facility had an elopement risk assessment completed.
- Elopement Binder was updated based on those risk assessments.
- Review of policy and procedure was completed to reflect current practice.
- All staff were in-serviced on elopement and procedures on steps to take if a resident is at risk.
- All facility staff were in-serviced for elopement and staffing.
- A QA tool was implemented along with audits of the 24-hour report for wandering/elopement risks.
- Audit for elopement risk assessments completed within admission.
- Audits to continue to ensure that elopement risk is documented.
- Root Cause Analysis completed for elopement.
Inadequate Staffing Leads to Resident Elopement and Lapses in Supervision
Penalty
Summary
The facility failed to provide an adequate number of nursing staff to meet the needs of all residents, as evidenced by an incident where a resident eloped from the male locked memory care unit. On the night of the elopement, staffing was insufficient, with only one CNA present on the relevant hall while the other CNA was on break, and the LPN was responsible for multiple areas. Staff interviews confirmed that the nurse was unaware of the staffing shortage at the time, and the CNA present had hearing issues and did not respond to the alarm, mistaking it for a recurring door issue. The facility's staffing policy requires sufficient licensed and unlicensed staff on each shift, but the actual staffing levels did not meet this standard during the incident. Observations also revealed that a nurse was found sleeping during a shift, and staff reported challenges in managing multiple halls and responding to alarms due to inadequate staffing. The administrator stated she had not observed staff sleeping during her visits, but the incident reports and staff interviews indicate lapses in supervision and response. The facility census documented 76 residents at the time, all potentially affected by the staffing deficiencies.
Failure to Maintain Safe Environment and Adequate 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, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required Registered Nurse (RN) coverage for at least eight consecutive hours per day, seven days a week, as mandated. According to interviews with the Administrator and the Director of Nursing (DON), the DON was the only RN employed and present in the building, and there were no other RNs scheduled or working during the reviewed period. The facility's nursing schedule and facility assessment confirmed that no other RN was present except for the DON, and during the survey period, no RN was observed in the facility, including the DON. The facility census was documented as 75 to 78 residents during this time.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, which is a requirement for maintaining the highest practical physical, mental, and psychosocial well-being of each resident. The Nursing Master Schedule revealed that there were several dates without an RN on duty, specifically on 11/10/24, 11/23/24, 11/24/24, 11/30/24, 12/1/24, 12/7/24, 12/8/24, 12/14/24, and 12/15/24. Interviews with staff, including a Certified Nursing Assistant (CNA) and the Administrator, confirmed the lack of RN coverage, particularly over the weekends. The Administrator acknowledged the shortage and mentioned ongoing efforts to recruit RNs, noting that one RN was unable to work due to health concerns. The facility's Nurse Staffing Policy emphasizes the importance of having sufficient licensed and unlicensed nursing staff on each shift to ensure resident well-being.
Infection Control Deficiencies in Legionella Management and Hand Hygiene
Penalty
Summary
The facility failed to operationalize its Legionella Policy and Procedure, as observed during a survey. The Maintenance Director, V17, stated that he runs water and flushes toilets monthly in empty rooms and checks the temperatures of hot water monthly, contrary to the policy which requires these actions weekly. Additionally, V17 admitted to never taking shower heads apart for cleaning and disinfection, as required every three months. The facility lacked a water flow diagram and had not identified areas with potential waterborne pathogen growth. Furthermore, neither V17 nor any facility staff had been trained on legionella procedures or policies, as confirmed by the Administrator, V1. The facility also failed to ensure proper hand hygiene practices, as observed with R5, a resident with multiple medical conditions including COPD and bilateral above-knee amputations. During incontinent care, a CNA, V9, was seen performing care without changing gloves or performing hand hygiene before, during, or after the procedure. This was contrary to the facility's Hand Hygiene and Perineal Cleansing Policies, which require hand washing after resident contact and glove changes. V9 admitted to only performing hand hygiene at the start of her shift and after resident interactions, which does not align with the facility's expectations. R5's care plan indicated a need for significant assistance with activities of daily living due to his medical conditions, including dependence on supplemental oxygen and frequent incontinence. The facility's failure to adhere to its infection control policies, both in terms of legionella prevention and hand hygiene, posed a risk to all 54 residents, as documented in the survey findings.
Failure to Feed Residents with Dignity
Penalty
Summary
The facility failed to feed residents in a dignified manner, affecting four residents who were reviewed for dignity. Resident R34, who was admitted with diagnoses including dementia with behavioral disturbances, major depressive disorder, and chronic post-traumatic stress disorder, was observed being fed by a CNA who stood over him. R34's Minimum Data Set (MDS) indicated severely impaired cognitive skills and dependence on staff for eating assistance. The care plan for R34, last revised in September 2024, documented that he is dependent on staff for activities of daily living, including eating. Additionally, residents R11, R14, and R17 were seated together in the dining room when CNAs referred to them as "feeders" within their earshot. All three residents were documented as severely cognitively impaired and dependent on staff for eating assistance. The facility's policy on assistance with meals, revised in July 2017, emphasized feeding residents with attention to safety, comfort, and dignity, specifically advising against standing over residents and using labels such as "feeders." However, these guidelines were not followed, leading to the deficiency.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and follow progressive care plan interventions to prevent falls for several residents, leading to multiple incidents of falls. One resident, who was moderately cognitively impaired and at high risk for falls, experienced several falls due to cognitive deficits and improper placement of assistive devices. Despite being on 15-minute checks as an intervention, documentation showed multiple instances where these checks were not completed as required. The administrator acknowledged the issue when presented with the documentation. Another resident, with a history of multiple falls and high fall risk, was observed attempting self-transfers without adequate staff assistance, despite being dependent on staff for mobility. The resident expressed frustration over the lack of assistance, and staff admitted to not always being present during transfers. This lack of supervision and assistance contributed to the resident's repeated falls. Additionally, a resident with a history of osteoporosis and a recent fracture was found without fall precautions in place, and their call light was not within reach. The resident's care plan included interventions to prevent falls, but these were not consistently implemented. The facility's policy on fall prevention and mechanical lift usage was not adhered to, as evidenced by improper use of the lift and lack of staff support during transfers, further compromising resident safety.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication labeling and storage for four residents, leading to deficiencies in medication administration. During observations, medications were found left unattended in residents' rooms, contrary to the facility's policy that requires medications to be administered directly and not left at the bedside. For instance, a resident was observed with a cup of medications on the nightstand, which had been administered earlier by an LPN. Another resident had inhalers left on the nightstand, and the LPN confirmed that inhalers should be kept in the medication cart. Additionally, a medication cart inspection revealed an opened bottle of escitalopram without a date indicating when it was opened, violating the facility's policy that requires dating medication containers upon opening. Interviews with staff, including the Administrator and Director of Nursing, confirmed that medications should not be left at the bedside unless there is a specific doctor's order, which was not present for the residents involved. The facility's policies on medication procurement and administration clearly state that medications must be labeled with the date opened and should not be left unattended. Despite these policies, the facility did not adhere to these standards, resulting in the observed deficiencies.
Inadequate Incontinent Care for Residents
Penalty
Summary
The facility failed to provide proper incontinent care for three residents, R5, R11, and R26, as observed by surveyors. R11, who is severely cognitively impaired and dependent on staff for activities of daily living, did not receive appropriate perineal care. During an observation, CNAs V14 and V15 did not cleanse R11's outer labia, failed to apply barrier cream as per the care plan, and did not use a washcloth, wash basin, and soap as required by facility policy. Similarly, R26, who is also severely cognitively impaired and requires substantial assistance, did not receive proper incontinent care. CNAs V14 and V10 failed to cleanse the outer labia and did not apply barrier cream as documented in R26's care plan. They also did not use the necessary equipment, such as a washcloth, soap, and wash basin, as per the facility's policy. R5, who has multiple diagnoses including COPD and bilateral above-knee amputations, was observed receiving incomplete incontinent care. CNA V9 did not cleanse R5's penis or scrotum and used the same towel for multiple areas without proper hand hygiene. The facility's hand hygiene policy and perineal cleansing policy were not followed, as V9 did not perform hand hygiene before and after resident contact, and the proper sequence of cleansing was not adhered to.
Failure to Ensure Proper Oxygen Administration
Penalty
Summary
The facility failed to ensure proper oxygen administration for three residents, as observed during a survey. For one resident, the oxygen cannula was connected to a humidifier bottle without a date, and the tubing was not dated, contrary to the facility's policy of changing and dating the tubing weekly. The resident's physician orders did not include instructions for changing the oxygen tubing, and despite the facility's policy, the tubing remained undated and in use over several days. Another resident, who was dependent on supplemental oxygen due to multiple health conditions, was observed without a humidified water bottle attached to their oxygen concentrator, despite physician orders and treatment records indicating that the tubing and humidifier should be changed weekly. Similarly, a third resident was found with an empty and undated humidified water bottle attached to their oxygen concentrator, and the nasal cannula was observed lying on the floor. The facility's policy did not address the dating of oxygen supplies, contributing to the oversight.
Failure to Maintain Safe Equipment Conditions in Laundry Area
Penalty
Summary
The facility failed to maintain equipment in a safe condition, specifically regarding the cleaning of lint traps in the laundry area. Observations revealed that the lint traps, each measuring 36 inches by 23 inches, had a moderate accumulation of lint, and the laundry staff member responsible for cleaning them stated she had never cleaned them and was unaware of when they were last cleaned. The Maintenance Director admitted to cleaning the lint traps only monthly, despite the facility's policy requiring daily cleaning. The Regional Maintenance Director confirmed that lint traps should be cleaned after every dryer cycle, highlighting a discrepancy between practice and policy. The facility's policy clearly outlines the necessity for daily cleaning of lint screens and monthly comprehensive cleaning by maintenance staff. However, the actual practice did not align with these guidelines, posing a potential fire hazard due to lint accumulation. The Administrator expected daily cleaning, but this was not being implemented. The report also references an article by a retired fire chief emphasizing the importance of regular lint trap cleaning to prevent fires, further underscoring the facility's failure to adhere to safety protocols. This deficiency has the potential to affect all 54 residents in the facility.
Failure to Document Discharge and Communicate Necessary Information
Penalty
Summary
The Facility failed to document the discharge of a resident (R2) in the medical record and did not communicate necessary information to the receiving facility. R2 was admitted with multiple diagnoses including hypertension, diabetes, chronic liver disease, anxiety, and chronic depression. The Minimum Data Set (MDS) indicated that R2 was severely cognitively impaired and exhibited behavioral disturbances such as verbal aggression and throwing items at staff. On a specific date, R2 was sent to the emergency room after exhibiting physically aggressive and sexually inappropriate behaviors. However, the medical record did not contain any documentation regarding the discharge, basis for discharge, physician documentation, or any other important information necessary for R2's care at the receiving facility. Interviews with the Administrator, Social Services Director, and Director of Nursing revealed that the Facility did not initiate an involuntary discharge for R2. Instead, they stated that R2's bed hold expired, and the resident was not accepted back after that. The Facility's Transfer and Discharge Policy and Procedure require documentation in the resident's clinical record, including the attending physician's documentation that the facility cannot provide for the resident's welfare or that the resident no longer requires the facility's services. This documentation was missing in R2's case.
Failure to Follow Discharge Requirements
Penalty
Summary
The Facility failed to follow discharge requirements for a resident (R2) who was admitted with diagnoses including hypertension, diabetes, chronic liver disease, anxiety, and chronic depression. R2 was documented as severely cognitively impaired with behavioral disturbances such as stripping clothes in public areas, verbal aggression, and throwing things at staff. On a specific date, R2 was sent to the emergency room after exhibiting physical aggression and sexually inappropriate behaviors. Following this incident, there was no documentation in R2's medical record regarding a plan for discharge, the basis for discharge, or advanced notification of discharge to R2 and her representative. The Facility's staff, including the Administrator, Social Services Director, and Director of Nursing, confirmed that R2 was not given an involuntary discharge notice and that her bed hold expired while she was in the hospital. The Facility chose not to readmit her. The Facility's Bed Hold Guarantee Policy and Transfer and Discharge Policy require that if a resident cannot return to the facility, the facility must comply with 42 CFR, Sec 483.15 (c) and notify the resident and their representative of the transfer and the reasons for it. This was not done in R2's case, leading to a deficiency in following proper discharge procedures.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The Facility failed to allow a resident (R2) to return after hospitalization, exceeding the bed-hold policy. R2, who was admitted with diagnoses including hypertension, diabetes, chronic liver disease, anxiety, and chronic depression, was severely cognitively impaired and exhibited behavioral disturbances such as verbal aggression, inappropriate sexual behavior, and physical aggression. Despite having a bed available, the Facility chose not to readmit R2 after the bed-hold period expired, citing R2's inappropriate behavior and aggression as reasons for their decision. The Facility's Bed Hold Guarantee Policy states that a Medicaid resident whose hospitalization exceeds the 10-day bed-hold period may return to their previous room if available or immediately upon the first availability of a bed in a semi-private room. However, the Facility did not comply with this policy or the federal regulation 42 CFR, Sec 483.15 (c), which requires compliance when a resident cannot return to the facility after a transfer with an expectation of return. Interviews with various staff members, including the Business Office Manager, Administrator, Social Services Director, Director of Nursing, and a Licensed Practical Nurse, confirmed that R2 was not readmitted due to her expired bed hold and behavioral issues. The Administrator admitted that there was a bed available for R2 but stated that they chose not to accept her back due to her inappropriate behavior and aggression. The Facility's Bed Census also documented that the room previously occupied by R2 was not occupied at the time of her potential readmission.
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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