Fairfield Senior Living & Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairfield, Illinois.
- Location
- 305 N.w. 11th Street, Fairfield, Illinois 62837
- CMS Provider Number
- 146000
- Inspections on file
- 36
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Fairfield Senior Living & Rehabilitation Llc during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a history of falls was found sitting on the floor by CNAs, but the RN on duty did not consider this a fall and failed to document or report the incident as required. The resident later developed severe pain, and an LPN ordered an x-ray that revealed a hip fracture. Facility policy requiring immediate assessment and notification for falls was not followed, and the resident's family was not informed until after the injury was discovered.
An LPN obtained supplies from a medication cart to administer insulin to a resident and then left the cart unlocked and unattended while entering the resident’s room, placing the cart out of visual control. At the time, the facility had multiple ambulatory residents and a total census of 47 residents. Facility policy required that all compartments containing drugs and biologicals, including medication carts, be locked when not in use and not left unattended if open or otherwise accessible.
Surveyors found that staff failed to verify and document proper sanitizer levels in the dish machine before washing breakfast dishes. A dietary aide and the dietary manager were unable to obtain a sanitizer reading using test strips while the dish machine was in use, and the sanitizer log for that day had no recorded level despite the manager’s statement that sanitizer checks were required before each meal’s dishes. Facility policy required preparation and daily testing of sanitizer solutions per manufacturer guidelines, but this was not carried out or documented, potentially affecting all 47 residents.
Surveyors found that the facility did not maintain effective pest control for flies and gnats, with insects observed around the kitchen dish machine area where wet towels, crumbs, and food debris were present, and gaps in the delivery door allowing pest entry. Several cognitively intact residents, including individuals with hemiplegia, dysphagia, depression, anxiety, Raynaud’s syndrome, glaucoma, and heart failure, reported persistent flies and gnats in their rooms, with insects seen on curtains, windows, sinks, and on a resident’s body, and residents resorting to fly swatters to manage the problem. The issue was identified as affecting the entire facility population of 47 residents.
Two alert and oriented residents were observed sitting in visibly soiled wheelchairs, with dried white substances, food crumbs, dust, and dirt on the cushions, seats, and outer areas near the self-propelled wheels. Both residents reported they were unaware of when their wheelchairs were last cleaned. When surveyors requested a wheelchair cleaning policy, the DON stated that only a wheelchair maintenance policy was available, and no specific cleaning policy could be located.
A resident with severe vascular dementia and documented nutritional risk had a physician order for a regular diet with fortified pudding at lunch, and the care plan included supplements per order. During an observed lunch meal service, the resident received a regular texture tray without the ordered fortified pudding, despite the diet card specifying it should be included. A dietary aide confirmed the omission after all trays were served. This failure occurred despite a facility policy requiring that each resident receive a diet that meets their nutritional and special dietary needs based on multidisciplinary assessment and a resident-centered nutrition plan.
A resident with osteoarthritis and mobility issues had a non-functional call light, which was not reported by staff until a surveyor's intervention. The resident expressed concerns about the night shift's response, and a family member reported delays in call light responses. The facility's policy on immediate reporting of call light issues was not followed.
A resident with multiple health conditions experienced a distressing mechanical lift transfer when a CNA, unable to find a second staff member, enlisted family members' help, violating facility policy. The lift leaned dangerously, requiring family intervention to complete the transfer safely. The incident was reported to the DON, but no incident report was filed.
The facility failed to provide adequate showers and timely incontinence care for five residents with various medical conditions, including COPD, Diabetes, and Dementia. Residents and family members reported issues such as being left soaked in urine for hours, not receiving the required number of showers, and long wait times for call lights. The Director of Nurses confirmed that care standards were not met, as policies on incontinence care and showering were not followed.
The facility failed to provide adequate nursing staff, affecting resident care on specific halls. Staffing schedules showed insufficient levels, with only one nurse and two CNAs on some shifts. Residents and staff reported long wait times for assistance and late medication administration. Frequent call-ins and absences worsened the issue, requiring administrative staff to cover shifts. Despite the DON's belief in meeting staffing requirements, evidence showed a pattern of understaffing, particularly during nights and weekends.
A resident with cognitive impairment sustained bruising and a hematoma due to improper handling during mechanical lift transfers. Despite multiple reports and observations of dried blood on the lift, the facility failed to document or investigate the injuries adequately, violating their policy on reporting injuries of unknown origin.
The facility failed to report and investigate potential abuse and neglect for two residents. One resident with cognitive impairment had unexplained bruising and a bleeding toenail, which were not documented or reported as injuries of unknown origin. Another resident was found soaked in urine, indicating possible neglect, but the incident was dismissed as a hygiene issue. The facility's policy for reporting suspected abuse or neglect was not followed, preventing appropriate investigation and response.
A resident with moderate cognitive impairment and multiple health issues was found with bruising and a hematoma under the right great toenail. Despite reports from hospice staff, the facility failed to document or investigate the injuries in a timely manner. The DON and other staff were aware of the injuries but did not report them to the administrator or initiate an investigation, violating the facility's policy.
The facility failed to provide timely incontinence care to two residents, leading to neglect. One resident, with severe cognitive impairment, was found repeatedly in soiled conditions, with hospice staff reporting the neglect to facility management. Another resident was discovered soaked in urine, with staff expressing concerns about neglect and inadequate staffing. Despite reports to management, the issues were not addressed, highlighting a significant deficiency in care.
A resident with severe cognitive impairment and identified as an elopement risk was not properly supervised, leading to their elopement and injury. The facility's wander guard system was not functioning, and the door locking mechanism was faulty, allowing the resident to exit without triggering an alarm. Staff interviews and maintenance records revealed a lack of oversight and preventive maintenance, contributing to the incident.
A resident with severe cognitive impairment and identified as an elopement risk managed to leave the facility unsupervised and was injured due to inadequate staffing. At the time, only one CNA and one LPN were on duty for 41 residents in the nonlocked unit, which was below the required staffing level. The facility lacked a formal staffing policy, relying instead on regulatory guidelines that were not met.
The facility failed to provide adequate staffing, resulting in delayed responses to call lights and insufficient incontinence care. A resident reported being left on a bedpan for over two hours, leading to skin excoriation. Other residents also experienced delays in care due to insufficient staffing, particularly during night shifts. Staff interviews confirmed that the facility often operates with fewer CNAs than needed, impacting the timeliness of care.
The facility failed to provide timely incontinence care for three residents, leading to deficiencies in care. One resident was left on a bedpan for over two hours, resulting in skin excoriation. Another resident reported delays in staff response to call lights, while a third was identified as being left in urine or feces for extended periods. Staffing issues were highlighted as a contributing factor, with staff indicating that the facility was often understaffed, affecting the timeliness of care.
The facility failed to provide additional nourishment as ordered for five residents, resulting in significant weight loss for two residents. Observations revealed that residents did not receive their prescribed nutritional supplements and fortified foods during meals and snack times, leading to deficiencies in their care.
The facility failed to provide adequate staffing, resulting in multiple instances of neglect and unmet resident needs. Residents were found with soiled linens, unclean rooms, and unmet personal hygiene needs. Staff confirmed frequent call-ins and the resulting strain on their ability to provide timely and adequate care.
The facility failed to follow the approved menu and did not accommodate the religious and cultural dietary needs of residents. Meals served were inconsistent with the documented menu, and portion sizes were incorrect. A resident with specific dietary requirements was served inappropriate food items, and the facility lacked a vegetarian or vegan menu. These issues affected all 67 residents.
The facility failed to maintain a sanitary environment for food preparation and storage, with observations of undated and unlabeled food items, dirty equipment, and unsanitary conditions in the kitchen. These issues have the potential to affect all 67 residents.
The facility failed to provide a clean, homelike environment for 10 residents. Observations revealed unclean rooms and bathrooms, with urine-soaked briefs and strong odors present. Interviews confirmed issues with staffing and cleanliness, and facility documentation highlighted ongoing concerns about housekeeping and trash collection.
The facility failed to provide scheduled showers for residents requiring assistance with activities of daily living. Multiple residents were observed with poor hygiene and reported not receiving showers as scheduled. Documentation confirmed missed showers, and staff shortages were cited as a contributing factor.
The facility failed to provide food at an appetizing temperature for four residents. One resident reported that food was always cold when eaten in her room, prompting her to eat in the dining room for warm meals. Another resident stated that her food was always cold when delivered to her room, sometimes arriving an hour late. Temperature checks on refused trays confirmed the residents' complaints, with food items measuring significantly below appetizing temperatures.
The facility failed to ensure newly admitted residents were offered the opportunity to formulate Advanced Directives. Three residents did not have their Advanced Directives documented in their EHRs, leading to confusion and delays in care during critical situations. The facility's policy on Advanced Directives was not followed.
The facility failed to obtain a PASRR level two screening for a resident with a newly diagnosed Severe Mental Illness. The resident was admitted with Schizoaffective disorder, and although the initial OBRA I screen did not indicate a mental illness, a later physician's order added the diagnosis. The Social Service Director acknowledged the oversight.
A resident with severe cognitive impairment and high fall risk fell and fractured their hip due to the facility's failure to implement planned fall interventions, including the use of a chair/bed pad alarm. The alarm was not in place at the time of the fall, contributing to the incident.
A resident with chronic pain conditions did not receive her scheduled doses of Percocet, leading to significant pain and loss of sleep. The nursing staff failed to reorder the medication in a timely manner, and the alternative medication was not offered until the following day. The resident experienced unbearable pain and discomfort for several days.
A resident with chronic pain conditions missed several doses of her prescribed Percocet due to the facility's failure to refill the medication on time. Despite the resident's clear need for pain management, the facility did not provide an alternative medication until the following day, causing significant discomfort and sleeplessness.
Failure to Document and Report Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to document and report a fall for one resident who was at risk for falls and had multiple medical conditions, including Parkinson's disease, dementia, and a history of unsteady gait. The resident was found sitting on the floor in his room, working on his wheelchair, by certified nurse assistants (CNAs) during a bed check. The CNAs notified the registered nurse (RN) on duty, who assessed the resident and noted no immediate complaints of pain or distress. However, the RN did not consider the incident a fall, did not complete a fall assessment or incident report, and did not notify the physician or the resident's family at that time, as required by facility policy. Subsequently, the resident began to complain of pain later in the morning, prompting the oncoming licensed practical nurse (LPN) to assess the resident and contact the physician for an x-ray. The x-ray revealed a subcapital right femoral neck fracture. The physician then ordered the resident to be sent to the hospital for evaluation and treatment. Interviews with staff revealed inconsistent accounts regarding the timing of the incident and the actions taken, with some staff stating the resident was not moved until after the RN's assessment, while others indicated the resident was assisted without immediate nurse notification. The resident's family was not informed of the fall until after the fracture was discovered. Facility policy required that any time a resident is found on the floor, it should be treated as a fall, with immediate assessment, documentation, and notification of the physician and family. The failure to recognize and report the incident as a fall resulted in a lack of timely documentation, assessment, and notification, contrary to established protocols. The deficiency was further compounded by the staff's misunderstanding of what constitutes a fall and the absence of a care plan addressing the resident's behavior of sitting on the floor.
Unlocked Medication Cart Left Unattended During Insulin Administration
Penalty
Summary
The facility failed to ensure medications were properly stored in locked compartments and maintained under appropriate security, as required by its Storage of Medications Policy and professional standards. During observation, an LPN was seen obtaining supplies from a medication cart to administer insulin to a resident identified as R10, then leaving the medication cart unlocked and out of her visual control while she entered the resident’s room to give the insulin. At that time, there were no residents or staff observed near the unlocked cart, but a facility list documented that eight residents were ambulatory, and the facility’s census showed a total of 47 residents. The facility’s written policy required that all compartments containing drugs and biologicals, including carts, be locked when not in use and that carts not be left unattended if open or otherwise potentially available to others. This deficiency was identified based on observation of the insulin administration process, interview with the DON, and review of the facility’s Storage of Medications Policy and resident census information.
Failure to Verify Dish Machine Sanitizer Levels Before Meal Service
Penalty
Summary
The facility failed to ensure the dish machine was effectively sanitizing dishes in accordance with professional standards and its own policy, creating a potential for cross contamination for all 47 residents. During an initial kitchen observation at 9:00 AM, the dish machine was in use for washing dishes when a dietary aide was asked to check the sanitizer level; the aide was unable to obtain a reading on the test strip. The dietary manager then obtained a new set of test strips but was also unable to obtain a sanitizer level reading. The dish machine sanitizer log for that day contained no recorded sanitizer level, and the dietary manager confirmed there was no documentation that the sanitizer level had been checked that morning prior to starting the breakfast dishes, despite stating that sanitizer levels were supposed to be checked three times daily before washing breakfast, lunch, and dinner dishes. The facility’s sanitizing solution policy required employees to prepare sanitizer solution per manufacturer guidelines and to test any dispensing system daily to ensure appropriate concentration, but this was not documented or verified on the morning in question. The Long Term Care Facility Application for Medicare and Medicaid documented that 47 residents resided in the facility at the time of the survey.
Failure to Maintain Effective Pest Control for Flies and Gnats
Penalty
Summary
The deficiency involves the facility’s failure to maintain effective pest control for flies and gnats in both the kitchen and resident areas. During an initial kitchen tour, surveyors observed gnats and flies near the dish machine area, specifically around the drain and garbage disposal, along with a wet towel under the garbage disposal and visible crumbs and food debris under the dish machine table. A dietary aide stated that gnats and flies become severe if the floor is not kept clean and dry and reported that bleach is sometimes poured down the drain to reduce the number of pests. Additionally, the delivery door outside the kitchen entrance had visible gaps at the bottom and where the double doors meet, allowing potential entry points for pests. Multiple residents reported and demonstrated ongoing issues with flies and gnats in their rooms. One cognitively intact resident who uses a wheelchair and has hemiplegia and chronic pain had flies observed on the privacy curtain and window, and later reported that numerous flies in the facility interfered with sleep, with flies crawling on his arm and leg during the interview. Another cognitively intact resident with ataxia, dysphagia, major depressive disorder, and anxiety was seen using a fly swatter in his room, where two dead flies were on the floor and gnats were observed flying around and crawling on the sink. A third cognitively intact resident with Raynaud’s syndrome, glaucoma, and heart failure reported that gnats and flies were bad throughout the facility and stated she had no traps in her room, only a fly swatter. These observations and interviews showed that the pest issue was facility-wide and had the potential to affect all 47 residents.
Failure to Maintain Clean Wheelchairs for Residents
Penalty
Summary
The facility failed to ensure residents’ wheelchairs were kept clean and free of dirt and debris, compromising the right to a safe, clean, comfortable, and homelike environment for two residents. One alert and oriented resident was observed in his room sitting in a wheelchair with a cushion and seat containing a dried white substance and several dried food crumbs, with dirty hand rims from self-propulsion and visible dust and dirt on the outside of the seat; the resident believed the white substance might be from spilled drinks and did not know when the chair was last cleaned. Another alert and oriented resident was observed in a common area sitting in a wheelchair with dust and dried food debris/crumbs on the seat and on the outside of the seat near the self-propelled wheels, and this resident also did not know when the wheelchair was last cleaned. When surveyors requested a wheelchair cleaning policy, the DON reported that only a maintenance policy regarding wheelchairs could be found, indicating there was no specific cleaning policy available at the time of the survey.
Failure to Provide Ordered Nutritional Supplement at Lunch
Penalty
Summary
The deficiency involves the facility’s failure to provide a prescribed nutritional supplement according to physician orders for one resident reviewed for dining. The resident was admitted with severe vascular dementia with agitation and had severe cognitive deficits documented on the MDS. The resident’s care plan identified that she was at nutritional risk for weight loss related to poor intake secondary to dementia, with an intervention specifying supplements or alternates per order. Current physician orders included a diet order for regular texture, regular liquid consistency, with fortified pudding to be added at lunch. During an observed lunch meal service in the dining room, the resident, who was alert and oriented only to herself, received a regular texture lunch tray. The diet card for this resident specified that the tray should contain fortified pudding at lunch, but the fortified pudding was not present on the tray. A dietary aide confirmed that all residents in the dining room had received their trays and acknowledged that this resident should have received fortified pudding. The facility’s Food and Nutrition Services policy stated that each resident is to be provided a diet that meets daily nutritional and special dietary needs, based on a multidisciplinary assessment and a resident-centered diet and nutrition plan, but the ordered fortified pudding supplement was not provided as required.
Resident Call Light Malfunction and Delayed Response
Penalty
Summary
The facility failed to ensure that a resident's call light was in working order, which was identified during a survey. The resident, who was admitted with diagnoses including weakness, unsteadiness on feet, and osteoarthritis in the right knee, was found to have a non-functional call light in her room. Despite being cognitively intact and requiring staff assistance for self-care activities, the resident was unaware that her call light was broken. During an interview, the resident expressed concern that the night shift staff did not respond to her call light. Upon testing the call light, it was observed that it did not light up, and a Certified Nurse Assistant (CNA) confirmed the malfunction after attempting to operate it. The CNA had not reported the issue to anyone before the surveyor's intervention. The Regional Clinical Nurse was informed and took immediate action to involve maintenance. The Regional Maintenance Director later identified a short in the cord, which was replaced. Additionally, a family member reported multiple instances of delayed response to the call light, with one instance taking 35 minutes for staff to respond. The facility's policy requires immediate reporting of call light issues to the Director of Nursing or Administrator, which was not followed in this case.
Unsafe Mechanical Lift Transfer Due to Inadequate Staffing
Penalty
Summary
The facility failed to provide a safe mechanical lift transfer for a resident, resulting in the resident becoming scared and anxious during the transfer. The resident, who has diagnoses including Chronic Obstructive Pulmonary Disorder, Diabetes Type 2, and Anxiety disorder, is totally dependent on staff for transfers. On the morning of the incident, a Certified Nursing Assistant (CNA) attempted to transfer the resident using a mechanical lift without the required assistance of a second staff member. The CNA was unable to find another staff member to assist and instead relied on the resident's family members to help with the transfer, which is against facility policy. During the transfer, the mechanical lift began to lean heavily to one side, causing the resident to hover over the wheelchair in a nearly laying down position. The family members had to intervene to safely lower the resident into the chair. The incident was later reported to the Director of Nurses, who confirmed that the facility policy requires two caregivers for mechanical lift transfers and that family members should not assist. However, no incident report was completed following the event.
Inadequate ADL Care and Incontinence Management
Penalty
Summary
The facility failed to provide adequate showers and timely assistance with incontinence care for five residents. These residents were identified as having various medical conditions such as Chronic Obstructive Pulmonary Disease, Diabetes Type 2, Morbid Obesity, Chronic Kidney Disease, Malignant Neoplasm of the Uterus, Major Depressive Disorder, Cerebral Palsy, Heart Failure, Hypertension, and Dementia. Each resident was documented as being totally dependent on staff for bathing and toileting, with some being always incontinent of bowel and bladder. Despite these needs, the facility did not meet the required care standards, as evidenced by the lack of showers and delayed incontinence care. Interviews with residents and their family members revealed consistent issues with care. One resident reported being left soaked in urine for hours, while a family member confirmed finding the resident in such a state during visits. Another resident stated they were not receiving the required number of showers per week, and a third resident mentioned long wait times for call lights to be answered, leading to extended periods of being wet. These accounts were corroborated by family members who expressed concerns about the care their loved ones were receiving. The Director of Nurses acknowledged that residents should receive two showers per week and that call lights should be answered within three minutes. However, the facility's policies on incontinence care and showering were not being followed, as residents were not being checked every two hours or provided with the necessary perineal care. Additionally, the Resident Council Meeting notes indicated that residents found it difficult to locate staff when assistance was needed, further highlighting the facility's staffing and care deficiencies.
Inadequate Staffing Leads to Delayed Care and Medication Administration
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure safe and timely care for all residents, particularly affecting those on the [NAME] and Daisy/Tulip halls. The deficiency was highlighted by a Resident Council Meeting note indicating difficulty in finding staff when assistance was needed. The staffing schedules revealed insufficient staffing levels, with only one nurse and two CNAs on certain shifts, and even fewer on others. Interviews with residents and staff confirmed that call lights often went unanswered for extended periods, medications were frequently passed late, and staff were often unavailable to assist with necessary tasks, such as transfers requiring mechanical lifts. Multiple staff members, including CNAs and nurses, reported frequent call-ins and last-minute absences, exacerbating the staffing shortages. Administrative staff often had to step in to cover shifts, indicating a systemic issue with staffing levels. Despite the Director of Nursing's belief that the facility met minimum staffing requirements, the evidence from staff and resident interviews, as well as documented schedules, demonstrated a consistent pattern of understaffing, particularly during night shifts and weekends. This led to delays in medication administration and inadequate resident care, as staff struggled to manage their duties with insufficient support.
Failure to Ensure Safe Transfers Resulting in Resident Injuries
Penalty
Summary
The facility failed to identify and evaluate potential hazards and implement interventions to ensure safe transfers via mechanical lifts for a resident, resulting in injuries. The resident, who had a history of unsteadiness, lack of coordination, and moderate cognitive impairment, sustained bruising to the tops of both feet and a hematoma under the nail of the right great toe. Despite multiple hospice visit notes documenting the injuries, the facility did not provide an incident report or documentation explaining the cause of the injuries. Interviews with staff revealed that the resident was transferred using a mechanical lift when not strong enough to stand, and it was suspected that the injuries were caused by staff hitting the resident's feet on the lift's bar. Observations confirmed the presence of a substance resembling dried blood on the mechanical lift, supporting the suspicion of improper handling during transfers. Despite these findings, the facility failed to document or investigate the injuries adequately. The facility's policy required reporting and investigating injuries of unknown origin, but this was not followed. The hospice nurse repeatedly requested an incident report, but the facility did not provide one, and the documentation in the resident's medical record was inconsistent and incomplete. The lack of proper documentation and investigation into the injuries highlights a deficiency in the facility's handling of accident hazards and resident safety.
Failure to Report and Investigate Potential Abuse and Neglect
Penalty
Summary
The facility failed to ensure timely reporting of potential abuse and neglect allegations for two residents, R1 and R4. R1, who had moderate cognitive impairment and multiple health issues, was found with unexplained bruising and a bleeding toenail. Despite repeated notifications from hospice staff about these injuries, the facility did not document or report them as injuries of unknown origin. The Director of Nursing (DON) acknowledged the injuries but did not report them to the Administrator or the State Agency, as required by the facility's policy. The facility's electronic medical record system flagged an incident, but it was incorrectly documented as an injury of known origin, preventing further investigation. R4, who was severely cognitively impaired, was found by CNAs to be soaked in urine, indicating possible neglect. The CNAs reported this to a nurse and later to the Assistant Director of Nursing (ADON), but the incident was dismissed as a hygiene issue rather than potential neglect. The CNAs had also indicated on abuse questionnaires that they were aware of potential abuse, but these concerns were not properly escalated to the Administrator. The ADON failed to report the CNAs' allegations to the Administrator, and the abuse questionnaires were not reviewed in a timely manner. The facility's policy requires immediate reporting of any suspected abuse or neglect to the Administrator, but this protocol was not followed in the cases of R1 and R4. The lack of timely reporting and documentation of these incidents prevented appropriate investigation and response, highlighting deficiencies in the facility's handling of potential abuse and neglect cases.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to initiate and complete a timely and thorough investigation of an injury of unknown origin for a resident with moderate cognitive impairment. The resident, who had a history of malignant neoplasm of the prostate, unsteadiness of feet, lack of coordination, abnormalities of gait and mobility, adult failure to thrive, and cerebrovascular disease, was found with bruising and a hematoma under the right great toenail. Despite multiple reports from hospice staff about the resident's injuries, the facility did not document or investigate the injuries in a timely manner. The hospice nurse reported bruising on the resident's feet to the Director of Nursing (DON) and other staff members on several occasions, but no incident report was completed. The hospice nurse repeatedly requested documentation of the injuries, but the facility staff failed to provide it. The DON and other staff members were aware of the injuries but did not report them to the administrator or initiate an investigation as required by the facility's policy. Interviews with facility staff revealed that the resident was dependent on care and had previously bumped their feet on a mechanical lift. However, no staff member could provide a clear explanation for the injuries. The facility's policy required immediate reporting and investigation of injuries of unknown origin, but this protocol was not followed, resulting in a deficiency in the facility's handling of the situation.
Neglect in Incontinence Care for Two Residents
Penalty
Summary
The facility failed to provide timely incontinence care to two residents, R1 and R4, leading to significant neglect. R1, who was admitted with diagnoses including malignant neoplasm of the prostate and cerebrovascular disease, was found on multiple occasions by hospice staff in a state of neglect. A hospice RN discovered R1's urinary catheter leaking, with the bed saturated in urine and a brown ring indicating prolonged exposure. Additionally, a hospice CNA found R1 soiled with dried feces and brown rings on incontinence pads, indicating a lack of timely care. Despite reporting these conditions to facility staff, including the Director of Nursing and Assistant Director of Nursing, the issues persisted, with hospice staff feeling compelled to make extra visits to ensure R1 received adequate care. R4, who was severely cognitively impaired, was also found neglected. A CNA discovered R4 sitting in a recliner soaked in urine, with brown lines of dried urine on clothing, indicating a lack of incontinence care. Despite reporting this to a nurse and later to the Assistant Director of Nursing, the incident was dismissed as a hygiene issue rather than neglect. The facility was reportedly short-staffed, which contributed to the inability to provide timely care. Staff members expressed concerns about neglect and the inability to complete necessary tasks due to staffing issues, further highlighting the facility's failure to meet the residents' needs.
Failure to Supervise Elopement Risk Resident
Penalty
Summary
The facility failed to adequately supervise a resident known to be at risk for elopement, resulting in the resident eloping from the facility and sustaining a head injury. The resident, who had severe cognitive impairment and was identified as an elopement risk, was not properly monitored, and the wander guard system intended to prevent such incidents was not functioning. On the night of the incident, the facility was short-staffed, and the resident was last seen in their wheelchair before being found outside the facility after falling down three steps. The resident's care plan had previously identified them as an elopement risk due to wandering and poor safety awareness. Despite this, the facility did not ensure that the wander guard system was operational, as there were no logs of checks on the system or the door locking mechanisms. The door through which the resident exited was supposed to be locked, but the locking mechanism was malfunctioning, allowing the resident to leave without triggering an alarm. Interviews with staff revealed that the wander guard alarm did not sound, and the door to the loading dock was not secure, allowing the resident to exit the building. The maintenance director confirmed that there were no records of the wander guard system or door locks being checked, indicating a lack of oversight and preventive maintenance. This oversight led to the resident's elopement and subsequent injury.
Inadequate Staffing Leads to Resident Elopement and Injury
Penalty
Summary
The facility failed to provide adequate staffing to supervise residents, resulting in an elopement incident involving a resident with severe cognitive impairment. The resident, who had a history of dementia and was identified as an elopement risk, managed to leave the facility unsupervised and was injured. At the time of the incident, the facility was short-staffed, with only one CNA and one LPN on duty for the nonlocked unit, which housed 41 residents. This staffing level was insufficient to meet the needs of the residents, as confirmed by the CNA on duty, who was unfamiliar with the night shift routine due to typically working other shifts. Interviews with facility staff, including the ADON and DON, revealed that the night shift should have been staffed with 4 CNAs and 2 nurses to adequately supervise and care for the residents. However, the facility's time records and daily census confirmed that the staffing levels were below this requirement on the night of the incident. The facility's Vice President of Operations acknowledged the lack of a formal staffing policy, indicating that the facility was expected to follow regulatory guidelines, which were not met in this instance.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, as evidenced by multiple instances of delayed response to call lights and insufficient incontinence care. Resident 1, who is cognitively intact and dependent on staff for toileting, reported that his call light was not functioning properly and that he experienced significant delays in receiving assistance. On one occasion, he was left on a bedpan for over two hours, leading him to contact the local police for help. Observations confirmed that Resident 1 had not received incontinence care for several hours, resulting in red and excoriated skin. Resident 2, also cognitively intact and dependent on staff for toileting, expressed concerns about the time it takes for staff to respond to call lights, noting that it sometimes exceeds 20 minutes. Although Resident 2 did not report being left in urine or feces due to delays, the frequent urination was a concern. Resident 5, who is always incontinent of bowel and bladder, similarly reported that it can take more than 30 minutes for staff to respond to call lights, attributing the delays to insufficient staffing. Staff interviews revealed that the facility often operates with fewer CNAs than needed, particularly during night shifts. Several CNAs and nurses acknowledged that the staffing levels were inadequate to meet the residents' needs, resulting in delayed call light responses and incomplete care tasks such as showers. The Director of Nursing and Assistant Director of Nursing were noted to occasionally stay late to assist, but this was not consistent, leaving the facility understaffed during critical times. Despite these issues, the facility's administration claimed to be unaware of any complaints regarding the timeliness of care.
Incontinence Care Deficiency Due to Staffing Issues
Penalty
Summary
The facility failed to provide timely incontinence care for three residents, leading to deficiencies in care. One resident, who was cognitively intact and dependent on staff for toileting, reported being left on a bedpan for over two hours, during which time he attempted to contact the facility multiple times without success. This resident's care plan did not include a focus area for incontinence care, which was acknowledged as an oversight by the Care Plan/MDS Coordinator. Observations confirmed that the resident had not received incontinence care for several hours, resulting in red and excoriated skin. Another resident, also cognitively intact and dependent on staff for toileting, expressed concerns about the time it took for staff to respond to call lights, although they did not report having to lay in urine or feces due to delays. This resident's care plan included a focus area for ADL self-care and mobility deficits, with an intervention for toilet hygiene, indicating a dependency on staff for assistance. A third resident, with a moderate cognitive deficit and requiring substantial assistance with toileting, was identified by a CNA as having been left in urine or feces for extended periods, particularly at shift changes. Staffing issues were highlighted by multiple staff members, who reported that the facility was often understaffed, affecting the timeliness of incontinence care and other resident needs. The facility's policy required incontinence checks approximately every two hours, but staff indicated that this was not consistently achieved due to staffing constraints.
Failure to Provide Nutritional Supplements and Fortified Foods
Penalty
Summary
The facility failed to provide additional nourishment as ordered in the form of nutritional supplements and fortified foods for five residents. This failure resulted in significant weight loss for two residents, with one experiencing a 17.5% weight loss in three months and another experiencing a 6.68% weight loss in one month. The deficiencies were observed through various instances where residents did not receive their prescribed nutritional supplements and fortified foods during meals and snack times. One resident, who had severe cognitive impairment and multiple diagnoses including dementia and COPD, did not receive fortified foods, nutritional supplements, or ice cream as ordered. Despite the care plan and physician orders specifying these nutritional interventions, the resident's weight dropped significantly over three months. Observations revealed that the resident was served regular mashed potatoes instead of fortified ones and did not receive the prescribed nutritional supplements during lunch and snack times. Another resident, with diagnoses including heart failure and diabetes, also experienced significant weight loss. This resident was observed waiting for a lunch tray for an extended period and eventually did not receive the prescribed nutritional supplement. The dietary manager acknowledged issues with the meal ticket printing system, which led to some residents not receiving their meals or supplements. The registered dietitian was unaware of these issues and confirmed that the resident should have received the nutritional supplement due to their weight loss.
Inadequate Staffing Leading to Neglect and Unmet Resident Needs
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, resulting in multiple instances of neglect and inadequate care. On several occasions, residents were found with soiled linens, unclean rooms, and personal hygiene needs unmet. For example, one resident had a half-eaten breakfast tray and soiled sheets left unattended for hours, while another resident reported not receiving a shower since admission and was found in a disheveled state with a strong odor of urine and body odor. These observations were verified by staff members who acknowledged the facility's staffing shortages and the impact on resident care. Another resident, who is dependent on staff for daily activities, was observed with food debris and trash in their room, and had not received a shower since admission. The resident expressed frustration over the lack of assistance and cleanliness, attributing it to the facility's insufficient staffing. Similarly, another resident, who requires substantial assistance, was found with oily hair, food-stained clothes, and reported not receiving scheduled showers. The facility's shower documentation confirmed missed showers on multiple occasions. The report also highlighted instances where residents' call lights went unanswered for extended periods, and meal trays were left in hallways for long durations due to staff shortages. Staff members, including CNAs and nurses, confirmed frequent call-ins and the resulting strain on their ability to provide timely and adequate care. The facility's internal documentation and interviews with staff further corroborated the ongoing issue of inadequate staffing and its detrimental effects on resident care and hygiene.
Failure to Follow Approved Menu and Accommodate Dietary Needs
Penalty
Summary
The facility failed to follow the approved menu and did not make a reasonable effort to provide menus in accordance with the religious and cultural needs of residents. On multiple occasions, the facility did not serve the meals as documented in the Diet Spreadsheet. For instance, on a specified Monday, the facility served fish instead of the planned beef and broccoli stir fry due to a lack of ingredients. Additionally, the portion sizes served were inconsistent with the menu, and essential components like vegetables were missing. The Dietary Manager acknowledged these discrepancies and admitted to not having recipes for certain substitutions, leading to uncertainty about the nutritional content of the meals served. A specific resident, identified as R45, who practices the Hindi culture and follows a vegan diet, was not provided with a menu that met her dietary needs. Despite having detailed care plans and physician orders specifying her dietary preferences and requirements, the staff was unsure about what to serve her. On one occasion, R45 was served fish, which contradicts her vegan diet, and was not given her ordered nutritional supplements. The Registered Dietician confirmed that there was no specific vegetarian or vegan menu available for R45, and the staff often resorted to serving her inappropriate food items like fruit loops. The Resident Council minutes also highlighted issues with portion control, indicating that this was a recurring problem affecting the entire facility. The report documents that 67 residents were potentially affected by these dietary deficiencies, as the facility did not consistently follow the approved menu or accommodate the specific dietary needs of its residents. The Registered Dietician and Dietary Manager both acknowledged the failures in meal preparation and serving, which contributed to the overall deficiency in meeting the nutritional needs of the residents.
Unsanitary Food Preparation and Storage
Penalty
Summary
The facility failed to prepare and serve food in a safe and sanitary environment, as evidenced by multiple observations of unsanitary conditions in the kitchen. During an initial tour of the kitchen, a large stand mixer was found with dried food splashes on its head. In the cooler, several food items, including a bowl of pudding, a container of sliced meat, an opened can of sweet potatoes, and a partial pan of lasagna, were undated and unlabeled. Additionally, various plastic portion cups, a fork, a plastic drinking cup, a plastic bag, and a pudding cup were found on the floor under the prep tables, along with crumbs under both prep tables, the stove, and the mixer. A portable stand fan with an accumulation of dirt on the front cage and blades was observed blowing on clean dishes across from the dish machine. The cook acknowledged that items in the cooler should be labeled and that the kitchen was messy. Despite the cook's acknowledgment, the unsanitary conditions persisted throughout the day, with the same items remaining on the floor and the dirty fan continuing to blow on clean dishes. These conditions have the potential to affect all 67 residents residing at the facility, as documented in the Resident List Report dated the same day.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, homelike environment for 10 of 38 residents reviewed. Observations over several days revealed that residents' rooms and bathrooms were not being cleaned properly. For instance, one resident's room had food debris and paper trash scattered on the floor, and the bathroom contained dark yellow odorous urine in the toilet bowl and urine-soaked adult briefs in the trash can. Similar conditions were noted in other residents' rooms, with urine-soaked briefs found on the floor and in trash cans, and strong urine odors present. Additionally, beds were not made from the night's sleep, and meal trays were left in hallways for extended periods of time, contributing to the unclean environment. Interviews with residents and staff confirmed the facility's issues with cleanliness and staffing. One resident mentioned that the facility is very short-staffed and not cleaned properly, while a staff member acknowledged frequent staff call-ins and the resulting impact on room cleaning schedules. The facility's own documentation also highlighted concerns about housekeeping not collecting trash on weekends and only spot-cleaning rooms. An ombudsman reported receiving multiple complaints from residents about the facility's cleanliness and the delayed removal of meal trays. These observations and interviews indicate a systemic issue with maintaining a clean and homelike environment for residents.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers for residents who require assistance with activities of daily living. Resident 113, who has hemiplegia and hemiparesis following a cerebral infarction, had not received a shower since being admitted to the facility. The resident was observed with greasy, dirty hair and a strong scent of urine and body odor. The Director of Nursing confirmed that the resident needed staff assistance for bathing and had only received one documented shower since admission. Resident 2, diagnosed with cerebral palsy, also did not receive showers as scheduled. The resident was observed with oily, disheveled hair, a moderate beard growth with food in it, and a strong scent of urine and body odor. The resident stated that he would like to take a shower every day but was lucky to get one per week. The facility's shower list indicated that the resident was to be showered twice a week, but records showed that he received significantly fewer showers than scheduled. Resident 11, who has multiple diagnoses including Parkinson's and morbid obesity, was also not provided with showers as scheduled. The resident was observed with oily hair and soiled clothes and reported that he was lucky to get a shower once a week. The facility's shower list indicated that the resident was to have showers twice a week, but documentation showed missed showers. Additionally, Resident 214, who requires assistance with transfers and showering, had not received a shower since being admitted to the facility. The resident stated that she had only been washed up by staff and had asked for a shower but was told they would get to her later, which never happened.
Failure to Provide Food at Appetizing Temperature
Penalty
Summary
The facility failed to provide food at an appetizing temperature for four residents. Resident 214, who has multiple diagnoses including End Stage Renal Disease and Type 2 Diabetes Mellitus, reported that food was always cold when eaten in her room, prompting her to eat in the dining room for warm meals. Resident 38, with diagnoses such as Chronic Obstructive Pulmonary Disease and Morbid Obesity, stated that her food was always cold when delivered to her room, sometimes arriving an hour late. She had to ask certified nurse assistants to warm her food. Resident 48 also reported that the food could be cold at times, and Resident 3 stated that the food was usually cold, submitting a complaint about it in the lunch dining room. Temperature checks on refused trays confirmed the residents' complaints. On one occasion, the fish was 81°F, the rice was 96°F, and the stuffing was 90.5°F, all of which tasted cold. On another occasion, the hamburger steak was 115°F, the scalloped potatoes were 112°F, and the broccoli was 103°F, all of which also tasted cold. The Registered Dietician stated that she would expect the food to be served at an appetizing temperature to the residents.
Failure to Ensure Advanced Directives for Newly Admitted Residents
Penalty
Summary
The facility failed to ensure newly admitted residents were offered the opportunity to formulate Advanced Directives. This deficiency was identified for three of five residents reviewed for Advanced Directives. Specifically, Resident 62's Advanced Directive was not available in the Electronic Health Record (EHR) when needed during a critical situation, leading to confusion and delay in care. The Director of Nursing (DON) acknowledged that the Advanced Directive was out for the doctor to sign and was not scanned into the EHR, making it inaccessible to staff during an emergency. Resident 62 was found unresponsive, and due to the absence of an Advanced Directive, Cardiopulmonary Resuscitation (CPR) was initiated, and the time of death was called by Emergency Medical Services (EMS) at 12:47 PM. The lack of an accessible Advanced Directive contributed to the delay in appropriate care decisions for Resident 62. Additionally, Residents 12 and 113 did not have their Advanced Directives documented in their EHRs. Both residents, who were cognitively intact, stated that the facility staff never discussed Advanced Directive preferences with them upon admission. The EHRs, Face Sheets, and Physician Order Sheets (POS) for both residents were reviewed and found to be missing any documentation of Advanced Directives. The Director of Nursing (DON) admitted that Resident 113's Advanced Directive might have been missed during admission and was in the process of contacting the previous facility for a copy. The facility's policy on Advanced Directives, which mandates that residents be asked about their Advanced Directives at the time of admission and that this information be documented in their medical records, was not followed in these cases.
Failure to Obtain PASRR Level Two Screening for Resident with Severe Mental Illness
Penalty
Summary
The facility failed to obtain a PASRR (Preadmission Screening and Resident Review) level two screening for a resident with a newly diagnosed Severe Mental Illness. The resident, identified as R11, was admitted with a diagnosis of Schizoaffective disorder. The initial OBRA I screen documentation did not indicate a reasonable basis to suspect a mental illness. However, a physician's order later added Schizoaffective Disorder to the resident's diagnosis list. The Social Service Director acknowledged that a new PASRR screen should have been completed when the new diagnosis was made but had not been done at the time of the survey.
Failure to Implement Fall Interventions Leads to Resident Injury
Penalty
Summary
The facility failed to implement planned fall interventions for a resident, resulting in a fall and a fractured right hip. The resident, who was admitted with Alzheimer's, chronic atrial fibrillation, weakness, and insomnia, was assessed as having severe cognitive impairment and required substantial assistance for transfers. Despite being identified as high risk for falls, the resident's care plan interventions, including the use of a chair/bed pad alarm, were not consistently implemented. On the day of the incident, the resident attempted to get up without assistance and fell, sustaining a hip fracture. Interviews with staff revealed that the chair/bed pad alarm, which was a critical intervention for preventing falls, was not in place at the time of the fall. The alarm was intended to alert staff when the resident attempted to get up, but it was not found in the resident's room during subsequent searches by staff members. The facility's post-fall investigation noted that the resident fell while trying to go to the bathroom, and the section of the report regarding the presence and function of the alarm was left blank. This oversight in ensuring the alarm was in place and functioning contributed to the resident's fall and subsequent injury, highlighting a lapse in the facility's adherence to its fall prevention policy.
Failure to Administer Scheduled Pain Medication
Penalty
Summary
The facility failed to administer regularly scheduled pain medication to a resident, resulting in significant pain and loss of sleep. The resident, who has a history of chronic pain conditions including chronic kidney disease, malignant neoplasm of the uterus, intervertebral disc degeneration, and osteoarthritis, did not receive her scheduled doses of Percocet on multiple occasions. Specifically, the resident missed doses on the evening of 2/5/2024, and throughout the day on 2/6/2024, leading to increased pain levels and discomfort. The resident reported unbearable pain in her shoulders, back, and knees, and stated that she did not get any sleep for three nights due to the missed medication doses. The issue began when the resident's Percocet medication ran out, and the nursing staff failed to reorder it in a timely manner. Despite being aware that the resident had only one dose left, the nurses did not promptly notify the primary physician or ensure that the medication was reordered. The primary nurse practitioner was informed on 2/5/2024 but mistakenly sent the prescription to the wrong pharmacy. The error was not corrected until 2/6/2024, and the alternative medication, hydrocodone, was not offered to the resident until later that day. The resident initially refused the alternative medication, stating that it was ineffective for her pain, but eventually agreed to take it after further explanation from the nursing staff. The facility's emergency medication kit did not contain Percocet, and the resident's pain medication was not delivered until 2/7/2024. During this period, the resident experienced significant pain and discomfort, which was documented in her progress notes and confirmed by interviews with the nursing staff and the resident herself. The facility's Director of Nursing acknowledged that the nurses are expected to refill medications in a timely manner and to offer alternative medications if the primary medication is unavailable. However, this protocol was not followed, leading to the resident's prolonged pain and suffering.
Failure to Refill Pain Medication Timely
Penalty
Summary
The facility failed to ensure that a resident's ordered pain medication was refilled in a timely manner, resulting in the resident missing several doses of her prescribed Percocet. The resident, who has a history of chronic kidney disease, malignant neoplasm of the uterus, intervertebral disc degeneration, and unspecified osteoarthritis, was admitted with a scheduled pain medication regimen. Despite the resident's cognitive intactness and clear documentation of her pain management needs, the facility did not refill her Percocet prescription on time, leading to missed doses on multiple occasions between 2/05/2024 and 2/07/2024. The issue began when the resident's last dose of Percocet was administered on 2/5/2024 at 1:00 PM. The resident informed the nurse that she was out of her pain medication, and the nurse attempted to get a new prescription signed by the primary nurse practitioner. However, the initial prescription lacked the necessary quantity amount and DEA number, causing a delay. The resident was not offered an alternative pain medication until the following day, despite experiencing significant pain and sleeplessness due to her arthritis and other conditions. The facility's Director of Nursing confirmed that the Percocet was not available in the emergency medication kit and that it is the nurses' responsibility to ensure timely refills. The resident's family and the ombudsman were also involved, expressing concerns about the missed doses and the resident's increased pain. The facility's failure to reorder the medication promptly and the subsequent delay in receiving the new prescription led to the resident missing five to six doses of her scheduled pain medication, causing her significant discomfort and distress.
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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