Evervella Of Swansea
Inspection history, citations, penalties and survey trends for this long-term care facility in Swansea, Illinois.
- Location
- 100 Rosewood Village Drive, Swansea, Illinois 62220
- CMS Provider Number
- 145620
- Inspections on file
- 32
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Evervella Of Swansea during CMS and state inspections, most recent first.
The facility failed to respond to call lights in a timely manner, resulting in delayed assistance for residents needing toileting. A resident with multiple serious diagnoses, including heart failure, C. diff enterocolitis, gait abnormalities, and muscle weakness, reported that call light response times were long, worse at night and on weekends, and that a grievance she filed about this issue had not led to improvement. Another resident was observed with her call light on for about 25 minutes while CNAs passed meal trays before anyone responded, despite the facility’s policy and administrator’s statement that call lights should be answered promptly.
Two residents with mobility and toileting ADL deficits, but intact cognition, reported prolonged waits for assistance and nonfunctioning call lights, resulting in them being left in feces or urine and on bedpans for extended periods. One resident described call light responses taking up to an hour, with additional delays before a nurse arrived, and instances where staff turned off the call light and did not return. Another resident’s call light was confirmed not to work, leading her to yell for help at night for about 30 minutes despite hearing staff nearby. Resident council feedback noted call lights taking up to an hour to be answered, conflicting with facility policy requiring timely call light response and continuous accessibility.
A resident with fractures and Type 2 DM, who was cognitively intact and required partial to moderate assistance for toileting, reported that her bathroom call light had not worked for several days and demonstrated that activating the call light did not trigger the corridor signal. She stated that staff were supposed to check on her more frequently due to the nonfunctioning call system, but that night shift staff did not do so, causing her to yell for assistance. An LPN confirmed the call light was not working the prior day, the DON only became aware that morning, and the corporate maintenance supervisor acknowledged ongoing call light issues in multiple areas of the building, despite a facility policy requiring accessible call lights and prompt reporting and monitoring when defects occur.
Multiple residents with significant medical needs experienced prolonged wait times for staff to respond to call lights, resulting in discomfort, accidents, and unmet care needs. Interviews with residents and CNAs revealed that delays were common, especially during nights and weekends, and were attributed to staffing shortages and high care demands. Facility policy requires prompt responses, but both resident and staff accounts indicated this was not consistently achieved.
A resident with a history of falls and complex medical conditions experienced a fall and was not sent to the hospital for over two hours, resulting in a fractured ankle. Despite the resident's complaints of pain, the facility delayed medical intervention due to the POA's insistence on an in-house x-ray, which was unavailable overnight. The facility's failure to communicate effectively and adhere to its change of condition policy contributed to the delay.
The facility failed to maintain RN coverage for 8 consecutive hours daily, impacting 82 residents. No RN was on duty for two specific days, and staff acknowledged difficulties in hiring and retaining RNs, especially on weekends. The facility assessment and PBJ report highlighted ongoing staffing challenges and a lack of a staffing policy.
The facility failed to maintain an air gap for the ice machine, risking backflow contamination. The drainage hose was directly inserted into the drain without an air gap, potentially affecting all 82 residents as the ice is used for their drinks. The Dietary Manager was unaware of the backflow risk, violating the State Plumbing Code.
Two unlicensed staff members were hired as LPNs and allowed to administer medications under supervision without having passed their licensure exams. The facility lacked proper documentation and policies for Graduate Practice Nurses, leading to a violation of state regulations.
During a COVID outbreak, staff at the facility failed to follow CDC guidelines for PPE use. An LPN entered a COVID-positive resident's room wearing only an N95 mask, unaware of the need for full PPE, and later assisted in the dining room without changing PPE. A housekeeper also failed to wear eye protection while cleaning a COVID-positive resident's room. These actions contradict the facility's infection control policies and could impact all 82 residents.
A resident with severe cognitive impairment and a history of UTIs was observed receiving inadequate catheter care, with improper hygiene practices by a CNA. The resident's catheter drainage tubing was touching the floor, and contaminated wipes and gloves were used during the procedure. The facility's catheter care guidelines were not followed, contributing to the resident's ongoing UTI issues.
A resident with multiple health conditions experienced significant weight loss due to the facility's failure to follow physician orders for Marinol, which was on backorder. The facility did not notify the physician promptly, and the resident's care plan lacked nutritional interventions. Attempts to contact the medical director were unsuccessful, and confusion arose when a new order for Remeron was received, despite the resident already being prescribed it.
A facility failed to monitor and discontinue unnecessary psychotropic medications for a resident with dementia and major depressive disorder. Despite recommendations to discontinue PRN Haldol, the order remained active beyond the 14-day limit. The resident received multiple psychotropic medications without adequate documentation of necessity or effectiveness. Inconsistent monitoring and documentation of the resident's behaviors and medication effects were observed, contrary to the facility's policy on psychotropic drug use.
A hospice resident with Dementia and Parkinsonism did not receive appropriate care during a five-day Respite stay, resulting in significant behaviors and a leg injury. The facility failed to administer prescribed anxiety medications, leading to the resident's restlessness and injury. The resident was also found with multiple bruises, a significant leg wound, and dried stool upon discharge, indicating inadequate care and cleanliness.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The deficiency involves the facility’s failure to respond to resident call lights in a timely manner, as required by its call light policy. One resident, who uses a wheelchair, reported that she filed a grievance because it takes too long for staff to answer her call light and meet her needs. She stated that response times vary depending on which staff are working, that agency staff are the worst, and that delays are worse at night and on weekends. She reported having diarrhea and expressed concern that when she needs to use the bathroom, staff may not arrive in time, causing her to have an accident. She also stated that there had been no improvement in call light response times since she filed the grievance. Record review showed this resident has multiple diagnoses, including heart failure, malignant neoplasm of the bladder, enterocolitis due to Clostridium difficile, muscle wasting, abnormalities of gait and mobility, and muscle weakness, and requires supervision/touch assistance with toileting and partial/moderate assistance with transfers. Her care plan documents Clostridium difficile, and a grievance dated several days earlier documented her complaint about long call light wait times. During observation on another date, a different resident was seen with her call light on, stating she had turned it on to use the bathroom; the call light remained on for approximately 25 minutes while CNAs were passing meal trays before it was answered. The Acting Administrator/Regional Director of Operations stated that call lights should be answered as soon as possible, and the facility’s undated Call Light Policy states that resident call lights will be answered in a timely manner.
Failure to Ensure Functioning Call Lights and Timely Responses
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had functioning call lights and timely responses to call light use, resulting in residents being left in soiled conditions and on bedpans for extended periods. One resident with hypertension, prediabetes, and post-polio syndrome, who was cognitively intact and required substantial/maximal assistance for toileting, reported being incontinent twice and left sitting in feces for over two hours on both occasions after being told staff were too busy serving supper. This resident also reported being left on a bedpan for more than an hour on more than one occasion, experiencing call light response times of up to an hour, and additional delays of up to another hour before a nurse arrived. The resident stated that staff sometimes entered, turned off the call light, and did not return. Another cognitively intact resident with type 2 diabetes and fractures of the left tibia and fibula, who required partial to moderate assistance for toileting, reported that her call light had not been working for 3–4 days. Observation confirmed that when she pressed the call light button, the corridor light did not illuminate. The resident stated that while day shift staff checked on her more frequently due to the nonfunctioning call light, night shift staff did not, and she had to yell for help during the night, including one occasion when she hollered for about 30 minutes before anyone came, despite hearing staff talking nearby. She reported being left in her own urine for an extended period in an undignified manner. Staff interviews showed inconsistent awareness of how long the call light had been nonfunctional, and resident council feedback documented complaints over the past 90 days that call lights could take up to an hour to be answered, contrary to the facility’s written policy requiring timely response and continuous availability of call lights to residents able to use them.
Failure to Maintain Functional Call Light System for Resident Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to maintain a working call light system in a resident’s bathroom and bathing area. One resident with diagnoses including Type 2 diabetes and fractures of the left tibia and fibula was cognitively intact and required partial to moderate assistance for toileting, with a care plan noting an ADL self-care performance deficit related to right leg fractures. During an interview, the resident reported that her call light had not been working for 3–4 days and demonstrated that pressing the call light button did not activate the corridor light. The resident stated that, due to the nonfunctioning call light and the absence of a Maintenance Supervisor, staff were supposed to check on her more frequently, and that while day shift staff checked on her often, night shift staff did not, resulting in her having to yell for help during the night. Staff interviews and maintenance information further described the extent and duration of the call light problem. An LPN reported that the resident’s call light was not working on the previous day and that staff were checking on the resident at least hourly. The DON stated she became aware that morning that the resident’s call light was not working and believed it had stopped working that day. The Corporate Maintenance Supervisor acknowledged awareness that the resident’s call light was not working, was unsure how long it had been out, and reported having replaced a battery in part of the unit two days earlier. He also stated there had been issues with call lights in other areas of the building not working the prior week and that some call lights in empty rooms were currently not working. The facility’s undated Call Light Policy required that all residents able to use a call light have the system available and accessible at all times, that call bell system defects be promptly reported to Maintenance, and that hourly room checks occur until the system is repaired.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to answer call lights in a timely manner for all six residents reviewed for timely assistance. Multiple residents reported extended wait times for staff response after activating their call lights, with some instances exceeding an hour. Residents described situations where they experienced pain, discomfort, or soiled themselves due to the delay in receiving assistance, particularly with toileting and transfers. Several residents also observed staff walking past rooms with active call lights without stopping to help or acknowledge the request. Residents interviewed had significant medical conditions, including fractures, diabetes, chronic kidney disease, heart failure, and impaired mobility, requiring varying levels of assistance for activities of daily living. Despite care plans indicating the need for prompt assistance and the use of call lights, residents consistently reported delays, especially during night shifts or weekends. Some residents stated they had to wait for extended periods before being assisted, leading to accidents and prolonged discomfort. Certified Nurse Aides (CNAs) interviewed confirmed that staffing levels often resulted in delays, particularly when multiple residents required two-person assistance. CNAs reported that it was not uncommon for residents to wait 20 to 45 minutes, or longer, depending on the care needed and the number of residents waiting. Resident council minutes also documented complaints about insufficient CNA assistance and lack of staff presence after meals. The facility's policy requires timely and courteous responses to call lights, but this expectation was not met according to both resident and staff accounts.
Delayed Medical Intervention for Resident After Fall
Penalty
Summary
The facility failed to seek timely medical intervention for a resident, identified as R39, who experienced a fall and was not sent to the hospital for over two hours, resulting in a fracture of her left ankle. R39 had a complex medical history, including Alzheimer's disease, dementia, osteoarthritis, and a history of falls, which placed her at increased risk for fractures. On the night of the incident, R39 fell out of bed, and despite her complaints of pain and visible injury, the facility delayed sending her to the emergency room due to the Power of Attorney's (POA) insistence on obtaining a STAT x-ray in-house, which was not available overnight. The nursing staff initially assessed R39 and noted a small lump on her left leg, with the resident expressing significant pain. The POA was contacted and requested an in-house x-ray, refusing to send R39 to the emergency room. The facility's nurse practitioner was not informed that STAT x-rays were unavailable overnight, which contributed to the delay in medical intervention. Despite R39's continued complaints of pain and her request to be taken to the hospital, the facility adhered to the POA's instructions until the Director of Nursing was notified and decided to send R39 to the emergency room. Upon arrival at the hospital, R39 was diagnosed with a closed fracture of the distal end of the fibula. The delay in seeking appropriate medical care was a significant oversight, as the facility's policy required notifying the physician and the resident's representative of any significant change in the resident's condition. The facility's failure to act promptly and communicate effectively with the nurse practitioner and the POA resulted in a prolonged period of pain and discomfort for R39.
Deficiency in RN Staffing Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, which is a requirement for the care of the 82 residents living in the facility. This deficiency was identified through a review of schedules and interviews with facility staff. Specifically, there was no RN coverage documented for the dates of 7/13/2024 and 7/14/2024. The Assistant Director of Nursing acknowledged the struggle to maintain RN coverage, particularly on weekends, and the Administrator admitted to the absence of an RN on the specified dates, citing difficulties in hiring and retaining staff. The facility's assessment highlighted a significant need for RNs to stabilize the nursing department, yet there was no staffing policy in place. The Payroll-Based Journal (PBJ) Report for the second quarter of 2024 also indicated concerns regarding RN coverage, contributing to a one-star rating for that fiscal quarter. Interviews with the Director of Nursing confirmed the absence of a staffing policy, further underscoring the facility's challenges in meeting the required RN staffing levels.
Ice Machine Lacks Required Air Gap
Penalty
Summary
The facility failed to maintain an air gap for the ice machine in the kitchen, which is a requirement to prevent potential backflow contamination. During an observation, it was noted that the white drainage hose from the ice machine was directly inserted into the drain hole without an air gap. This setup poses a risk of backflow from the sewage drain into the ice machine, potentially affecting the safety of the ice used for residents' drinks during meal services. The Dietary Manager acknowledged the issue upon observation, indicating a lack of awareness regarding the potential for backflow. The facility's failure to comply with the State Plumbing Code, which mandates an air gap for ice storage bins to prevent backflow, was documented. This deficiency has the potential to impact all 82 residents living in the facility, as the ice from this machine is used for their drinks.
Unlicensed Staff Administering Medications
Penalty
Summary
The facility failed to ensure that staff members hired as Licensed Practical Nurses (LPNs) had passed their required licensure exam before allowing them to work in the capacity of a license-pending graduate practice nurse. Two individuals, identified as V10 and V23, were hired for LPN positions without confirmation of a valid LPN license from the Illinois Department of Financial and Professional Regulation. Despite being unlicensed, they were allowed to administer medications to residents under the supervision of other nurses, which is not permitted by regulations. The Director of Nursing (DON) and the Administrator were unaware that V10 and V23 had not taken or scheduled their licensure exams. The DON admitted to allowing them to pass medications under supervision, believing it was permissible. Both V10 and V23 were observed wearing identification badges labeling them as LPNs, despite not having taken their licensure exams. They were also documented in employee files as LPNs, and were paid LPN wages, although they had not completed the necessary steps to obtain licensure. The facility did not have a job description or policy for the position of a Graduate Practice Nurse (GPN), and the Administrator relied on regulations without a clear understanding of them. The Assistant Administrator confirmed that background checks were conducted, but there was no documentation of completed LPN schooling for V10 and V23. The facility's actions were in violation of the Illinois General Assembly Public Act, which requires individuals to pass the licensure exam and meet other criteria before being employed as license-pending practical nurses.
Failure to Follow PPE Protocols During COVID Outbreak
Penalty
Summary
The facility failed to adhere to CDC Infection Control Guidelines during a COVID outbreak, as observed in multiple instances involving staff not wearing the appropriate Personal Protective Equipment (PPE). On one occasion, an LPN entered a resident's room, who was on droplet precautions due to a positive COVID test, wearing only an N95 mask without a gown or eye protection. The LPN was unaware of the resident's isolation status and subsequently assisted with breakfast in the main dining room without changing PPE. This oversight was acknowledged by the LPN, who admitted to not noticing the isolation sign on the resident's door. In another instance, a housekeeper was observed cleaning a COVID-positive resident's room while wearing a gown, gloves, and an N95 mask, but without eye protection. The housekeeper realized the omission after noticing the isolation sign on the resident's door, which indicated the need for droplet and contact precautions. The facility's policies, which were provided by the Administrator, outline the requirement for full PPE, including face shields or goggles, when dealing with residents on droplet precautions. These lapses in following established infection control protocols have the potential to affect all 82 residents in the facility.
Inadequate Catheter Care Leading to Infection Risk
Penalty
Summary
The facility failed to provide appropriate care for an indwelling urinary catheter for a resident, leading to potential infection risks. During an observation, the resident was found with a catheter drainage tubing touching the floor, and the drainage bag was improperly stored in a privacy bag. A Certified Nursing Assistant (CNA) was observed performing catheter care without maintaining proper hygiene standards. The CNA used contaminated wipes and gloves, failed to maintain a clean/dirty field, and did not change gloves appropriately during the procedure. The resident, who has a diagnosis of urinary tract infection (UTI) and urine retention, was documented to have severe cognitive impairment and was dependent on toileting with an indwelling urinary catheter. The resident's care plan indicated a potential for UTIs due to the catheter use. The resident had a history of UTIs and sepsis, with multiple instances of cloudy urine and abnormal urinalysis results. The resident's medical records showed repeated hospital admissions and treatments for UTIs, including antibiotic therapy. The Director of Nurses (DON) stated that the facility uses a catheter competency guideline that requires staff to perform hand hygiene, use one wipe per swipe, and change gloves twice during catheter care. However, the observed practice did not adhere to these guidelines, as evidenced by the improper handling of wipes and gloves during the catheter care procedure. The facility's Foley Catheter Care Policy emphasizes the importance of using proper procedures to prevent UTIs, which was not followed in this instance.
Failure to Follow Physician Orders and Notify Physician
Penalty
Summary
The facility failed to ensure that physician orders were followed and that the physician was notified when orders could not be carried out for a resident diagnosed with multiple conditions, including rhabdomyolysis, anemia, and chronic kidney disease. The resident, who was moderately impaired for cognition, had a physician order for Marinol 2.5 mg to be administered twice daily to address appetite issues. However, the medication was on backorder, and the pharmacy was unsure of its availability date. Despite this, the facility did not notify the physician promptly about the inability to administer the prescribed medication. The resident experienced significant weight loss, triggering concerns from the dietary team. The resident's care plan did not address weight loss or nutrition, and the resident was noted to have poor meal intake and refusal of supplements. Although a new order for Remeron was received to replace Marinol, the resident was already prescribed Remeron, leading to further confusion. Attempts to contact the medical director were made, but no response was received. The facility's medication administration policy emphasizes administering medications per a standardized schedule, considering residents' preferences and quality of life, but this was not adhered to in this case.
Failure to Monitor and Discontinue Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to monitor medications properly, resulting in a resident receiving unnecessary medications. The resident, identified as R67, has moderately impaired cognitive skills and multiple diagnoses, including unspecified dementia and major depressive disorder. Despite recommendations from a consultant pharmacist to discontinue the PRN order for Haldol, the order remained active beyond the 14-day limit set by CMS guidelines. The resident was also receiving multiple psychotropic medications, including Buspirone, Quetiapine, Sertraline, Haloperidol, and Lorazepam, without adequate documentation of their necessity or effectiveness. Observations and interviews with staff revealed inconsistencies in the monitoring and documentation of the resident's behaviors and medication effects. The Behavior/Intervention Monthly Flow Record showed incomplete tracking of the resident's behaviors, with only sporadic documentation of restlessness and redirection. Hospice Plan of Care notes indicated varying levels of confusion, restlessness, and somnolence, but there was no clear evidence of the medications' benefits or the resident's improvement. The facility's policy on psychotropic drug orders emphasizes the need for appropriate use based on documented resident needs, avoiding unnecessary drugs, and ensuring informed consent for dosage changes. However, the facility did not adhere to these guidelines, as evidenced by the continued use of PRN Haldol without proper justification and the lack of comprehensive monitoring of the resident's condition and medication effects.
Failure to Provide Proper Care for Hospice Resident
Penalty
Summary
The facility failed to properly care for a hospice resident with Dementia and Parkinsonism who was admitted for a five-day Respite stay. The resident, who was dependent on staff for all Activities of Daily Living (ADLs) and mobility, did not receive appropriate care, including the administration of prescribed anxiety medications. This failure resulted in the resident experiencing significant behaviors and obtaining a leg injury. The resident's daughter reported that the facility did not administer the resident's anxiety medications, which were crucial for managing his restlessness and anxiety. Additionally, the resident was found to have multiple areas of bruising and a significant leg wound upon discharge, which was not adequately communicated to the family by the facility staff. The resident's care plan and Minimum Data Set (MDS) were not completed due to the short stay, and the facility's staff failed to follow best practices in managing the resident's condition. The resident's leg injury was initially described as a scratch, but it was later found to be much more extensive, with areas of blood and serosanguineous fluid. The facility's investigation revealed that the resident's leg had been rubbing against the bedrails, causing the injury. Despite the resident's high risk for skin impairments, the facility did not take adequate measures to prevent the injury or provide appropriate wound care. The facility's staff also failed to ensure the resident's cleanliness and proper nutrition during the stay. The resident was found with dried stool on him upon discharge, and only two out of the six nutritional supplement drinks provided were used. The facility's investigation confirmed that the resident's care was unacceptable, leading to disciplinary actions against the involved staff members. The Director of Nursing (DON) and Administrator acknowledged the deficiencies in care and the failure to meet the family's expectations for the resident's care.
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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