Glenview Terrace
Inspection history, citations, penalties and survey trends for this long-term care facility in Glenview, Illinois.
- Location
- 1511 Greenwood Road, Glenview, Illinois 60025
- CMS Provider Number
- 145268
- Inspections on file
- 28
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Glenview Terrace during CMS and state inspections, most recent first.
A resident on a regular diet reported that dietary staff would not provide pancakes or an extra meat item as an alternative to waffles at breakfast, stating that only white or wheat toast was allowed as a substitute. The Dietary Supervisor confirmed that the breakfast alternative menu did not include pancakes and that toast was the only alternative for waffles, with no meat substitution offered. This practice conflicted with the facility’s written food preference policy requiring alternatives when food is refused and with resident rights policies intended to support resident satisfaction and choice, resulting in a failure to fully honor the resident’s dietary preferences and dignity.
A resident with a colostomy and care plan requiring colostomy care every shift and as needed repeatedly requested assistance to have a filling colostomy bag emptied. An agency CNA declined to perform the task and did not promptly notify an RN or LPN, and the PM receptionist routed the resident’s calls to voicemail instead of overhead paging nursing staff or a supervisor. As a result, the resident ultimately called 911, and when staff entered with medications they were unaware of the colostomy care need, finding the bag leaking feces, contrary to the facility’s ostomy care policy.
The facility failed to maintain an environment free from abuse when one resident physically assaulted his roommate after staff briefly left the room to obtain requested items. An older adult with cognitive and mental health diagnoses was being assisted to bed by a CNA, who stepped out momentarily for pillowcases, leaving him alone with his roommate, an alert resident with multiple fractures. During this time, the first resident fell from his wheelchair, crawled to the roommate’s bed, and repeatedly struck the roommate’s legs with his fists. The CNA returned upon hearing the roommate cry out and found the aggressor on the roommate’s side of the room, holding onto him, confirming that the facility did not effectively prevent resident-to-resident physical abuse as required by its abuse policy.
A resident with a suprapubic catheter was found with a soaked brief, moderate serosanguineous drainage, and redness at the stoma site, without a required dressing or catheter securement. Staff failed to monitor, document, or notify the physician about the condition, and a nurse used a personal phone to photograph the site, violating privacy policies. Facility protocols for catheter care and skin breakdown were not followed.
The facility did not ensure that LAL mattresses were set to the correct weight for several high-risk residents, as staff either did not know the proper settings or failed to adjust them according to manufacturer guidelines. This resulted in mattresses being set too high or too low for residents with significant risk factors for skin breakdown, despite care plans and policies requiring individualized settings and limited linen layers. The deficiency was observed in three out of four residents reviewed for pressure injury prevention and treatment.
Two residents did not receive appropriate pain management: one non-verbal, cognitively impaired resident was assessed using an incorrect pain scale instead of the PAINAD tool, and another resident with chronic pain did not receive ordered narcotic pain medication for over five hours due to delays in reordering and lack of stock. These failures occurred despite facility policies requiring proper pain assessment and timely medication administration.
An LPN was observed pre-pouring medications for two residents and leaving them unattended in a medication cart, contrary to facility policy requiring immediate administration. Discrepancies were also found between the actual count and documentation of controlled medications, as the LPN failed to sign the controlled drug administration record after removing doses. The facility could not provide a specific policy prohibiting pre-pouring, despite existing procedures for medication administration and controlled drug counts.
An LPN failed to disinfect a blood pressure machine and cuff before and after use while taking a resident's blood pressure during medication administration. The equipment was placed on the medication cart and not cleaned between uses, contrary to facility policy requiring disinfection of reusable medical equipment between residents.
A resident with advanced dementia, Parkinsonism, and a history of falls, who required two-person assistance for mechanical lift transfers, was left with only one CNA during a transfer. While waiting for additional help, the resident had a sudden involuntary movement and fell, sustaining multiple fractures and head injuries. The facility's policy required two staff for such transfers, but this was not followed, resulting in serious harm.
The facility failed to protect two cognitively impaired residents from physical and verbal abuse by an agency CNA. The residents, both with severe cognitive impairment, were subjected to aggressive handling and yelling during care. The facility's inadequate screening and orientation of agency staff contributed to these incidents, resulting in Immediate Jeopardy.
The facility failed to follow its abuse policy, resulting in the verbal and physical abuse of two residents by an agency CNA. The incidents were not reported promptly, and the CNA did not receive adequate orientation or training on the facility's abuse policies and dementia care.
The facility failed to protect residents from abuse and did not follow its abuse policies and procedures. Two residents with severe cognitive impairments were affected, one allegedly assaulted by a staff member and the other found with multiple injuries. The investigation revealed inadequate orientation and training for agency staff, contributing to the incidents.
The facility failed to develop and implement comprehensive abuse care plans for two residents with severe cognitive impairment, despite assessments indicating they were at risk for abuse. Interviews with staff revealed confusion over responsibility for developing these care plans, leading to delays in their initiation.
Failure to Honor Resident Breakfast Preferences and Alternatives
Penalty
Summary
The facility failed to maintain a resident’s dignity and right to self-determination by not ensuring meaningful breakfast alternatives consistent with resident preferences were available and communicated. One resident (R2), on a general regular diet, reported that the dietary department would not allow residents to have pancakes as an alternative to waffles and would not provide an extra meat item in place of waffles, stating that the only alternative offered was white or wheat toast. The Dietary Supervisor confirmed that the breakfast alternative did not include pancakes and that the only alternative for waffles was white or wheat toast, with no meat alternative offered. This practice occurred despite the facility’s Food Preference Policy stating that if a resident refuses the food being served, the facility should offer alternatives consistent with the usual food items provided by the facility, and despite the Resident’s Rights policy requiring services that support residents’ physical and mental health and sense of satisfaction. The Executive Director and DON later stated that residents could have pancakes as an alternative and that all residents had the choice of a liberal diet and could ask for pancakes even if not listed on the alternative menu, indicating a discrepancy between facility leadership’s expectations and the actual options and information provided to residents by dietary staff.
Failure to Provide Timely Colostomy Care and Response to Resident Requests
Penalty
Summary
The facility failed to provide necessary colostomy care for a dependent resident who required assistance with emptying her colostomy bag. The resident, who had diagnoses including irritable bowel syndrome and an encounter for a colostomy, had a care plan dated 10/20/2023 that required colostomy care every shift and as needed. On the evening of 2/1/2026, the resident activated her call light around 8:00 p.m. and requested that an agency CNA empty her colostomy bag. The CNA stated she did not feel comfortable performing the task. The resident then asked the CNA to inform the nurse because the colostomy bag was filling up. After approximately 30 minutes, the resident again used the call light; the same CNA returned and reported she had asked other CNAs, but not the nurse, and said she would ask the nurse. The resident subsequently called the front desk multiple times requesting to speak with a supervisor. The AM receptionist stated that when residents call the front desk, she overhead pages the supervisor or nurse to the room. However, the PM receptionist reported that on the night in question, she transferred the resident’s calls to the voicemail of the unit manager and house supervisor and did not overhead page. The unit manager and DON both stated they expected the receptionist to overhead page and the CNA staff, including agency staff, to notify the nurse when there is a skill-related issue or when a resident requests to see the nurse. The executive director stated the resident should not have had to call 911 for assistance. When emergency services arrived, the agency nurse entered the room with medications and was unaware the resident needed colostomy care, at which point the resident’s colostomy bag was leaking feces. The facility’s colostomy care policy dated 6/30/2025 required that ostomy appliances be emptied every shift and as needed.
Failure to Prevent Resident-to-Resident Physical Abuse in Shared Room
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention policy and provide an environment free from abuse, resulting in one resident physically assaulting his roommate. Resident 1 (R1), an older adult with diagnoses including encounter for palliative care, cognitive communication deficit, anxiety disorder, and depression, was being assisted to bed by a CNA (V20) at approximately 10:00 PM. During this process, R1 requested two pillowcases. V20 left the room briefly to obtain the pillowcases, leaving R1 and his roommate, Resident 2 (R2), alone in the room. While R2 was asleep in bed, R1 fell from his wheelchair to the floor, crawled over to R2’s bed, and began hitting R2’s legs with his fists multiple times. R2, an older adult with a BIMS score of 15/15 and medical diagnoses including fractures of the first lumbar vertebra, right clavicle, and left humerus, reported that he felt a little pain and was more afraid than anything during the incident. When V20 re-entered the room, she heard R2 cry out and observed R1 on R2’s side of the room, holding on to R2. V20 immediately separated the two residents and notified the floor nurse (V22). The facility’s final investigation notes corroborated that V20 had stepped away briefly to obtain pillowcases at R1’s request and, upon returning, heard R2 say that R1 was grabbing him. This sequence of events demonstrates that the facility did not ensure an environment free from abuse as required by its Abuse and Neglect Policy, which states that professional care and services must be provided in an environment free from any type of abuse.
Failure to Monitor and Treat Suprapubic Catheter Site
Penalty
Summary
The facility failed to ensure ongoing monitoring and assessment of a resident with a suprapubic catheter, resulting in unaddressed drainage and skin impairment at the stoma site. During observation, the resident was found with a disposable brief soaked in serosanguineous drainage, no dressing on the suprapubic catheter site, and visible redness and irritation of the surrounding skin. The catheter was not secured to the abdomen as required. The resident reported that dressings were usually applied twice daily, but none was present after a recent shower. The assigned CNA was unaware of the missing dressing and had not yet provided morning care. Nursing staff, including an agency nurse and wound care nurse, were not informed of the absence of the dressing or the condition of the site until prompted by the surveyor. Documentation in the medical record did not accurately reflect the observed condition, as the wound care nurse documented intact skin with no redness or drainage, contrary to what was seen during the survey. The nurse also took a photo of the site using a personal cell phone, which was acknowledged as a violation of resident privacy. The nurse did not contact the physician for new treatment orders, instead applying a barrier cream not ordered for the suprapubic site. Facility policy required daily and as-needed dressing changes for suprapubic stoma sites with drainage, monitoring for redness or maceration, and securing the catheter to the abdomen. Policies also mandated prompt identification, documentation, and physician notification for skin breakdown. These protocols were not followed, as evidenced by the lack of dressing, improper documentation, failure to secure the catheter, and absence of physician notification for the observed drainage and skin impairment.
Failure to Ensure Correct Low Air Loss Mattress Settings for Pressure Injury Prevention
Penalty
Summary
The facility failed to ensure that low air loss (LAL) mattresses were set to the correct weight settings for residents at risk for developing pressure injuries. Multiple observations revealed that staff members, including agency LPNs and wound care team members, were either unaware of the appropriate mattress settings or did not verify them according to manufacturer guidelines. For example, one resident's LAL mattress was set for 110 lbs despite the resident weighing only 84 lbs, and another mattress was set at 150 lbs for a resident weighing 98 lbs. In both cases, staff had to be prompted to adjust the settings to more appropriate levels. Residents involved in these incidents were identified as high risk for skin impairment, with documented histories of pressure injuries, chronic wounds, and comorbidities such as diabetes, vascular disease, and limited mobility. Care plans and physician orders specified the use of specialized mattresses and detailed wound care regimens, but the observed mattress settings did not align with these requirements. Staff interviews confirmed that the settings should be based on resident weight, and that incorrect settings could compromise the effectiveness of the mattresses. Facility policy required limiting the number of linen layers on LAL mattresses and using the correct settings to manage comfort, positioning, and moisture for residents with stage 3 or 4 pressure sores. Despite these policies, the survey found that three out of four residents reviewed for pressure injury prevention and treatment had LAL mattresses set incorrectly, indicating a systemic failure to follow established protocols for pressure ulcer prevention and care.
Failure to Provide Appropriate Pain Assessment and Timely Pain Medication
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents. For one resident with multiple chronic wounds, advanced dementia, and on hospice care, staff used an inappropriate pain assessment tool. Despite the resident being non-verbal and cognitively impaired, nurses documented pain assessments using a numeric pain scale, which is designed for alert and oriented individuals. The appropriate tool, PAINAD, was only implemented after surveyor intervention, contrary to the facility's policy and the resident's needs. For another resident with a history of lupus, multiple fractures, and chronic pain, the facility failed to ensure the availability of ordered narcotic pain medication. The resident, who relies on scheduled and PRN pain medications, reported severe pain and was unable to participate fully in therapy due to uncontrolled pain. Nursing staff acknowledged that the narcotic medication was not reordered in a timely manner, resulting in a gap of over five hours without the medication. The medication was also unavailable in the facility's pyxis system, and staff were unable to provide an alternative during this period. Both deficiencies were confirmed through observation, interviews, and record review. The facility's own policies required appropriate pain assessment and timely administration of pain medication, but these were not followed. The failures affected two out of four residents reviewed for pain management in a sample of 35.
Failure to Accurately Document Controlled Medications and Prohibit Pre-Pouring
Penalty
Summary
The facility failed to ensure an accurate count of controlled medications and did not adhere to its policy prohibiting the pre-pouring of medications. During an observation of a medication cart with an LPN, pre-poured medications were found in a plastic medication cup inside both the top drawer and the controlled/narcotic drawer. The LPN stated that the medications were prepared for two residents but had not yet been administered, as she was interrupted by another resident's call light. The LPN acknowledged that medications should be administered immediately after preparation and that pre-pouring is not permitted. A review and count of controlled medications revealed discrepancies between the actual number of tablets present and the number documented on the controlled drug administration record for two residents. Specifically, the count for Tramadol 50mg and Alprazolam 0.25mg did not match the documentation, with the LPN admitting she forgot to sign the date, time, and amount on the controlled administration record after removing the medications. The facility was unable to provide a medication policy specifically prohibiting pre-pouring, though their existing policies require accurate controlled medication counts and adherence to medication pass procedures.
Failure to Disinfect Blood Pressure Equipment During Medication Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper infection control procedures during medication administration for a resident. The LPN took the resident's blood pressure using a portable BP machine and cuff without disinfecting the equipment before or after use. After obtaining the blood pressure reading, the LPN placed the BP machine on top of the medication cart and proceeded to prepare and administer oral medication to the resident, still without disinfecting the equipment. The LPN completed the medication pass and left the BP machine on the medication cart without cleaning it. When questioned about the lack of disinfection, the LPN acknowledged forgetting to disinfect both the BP machine and cuff before and after use. The facility's policy requires that reusable medical equipment be cleaned with an approved disinfectant between each resident use, a procedure that was not followed in this instance.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer Results in Serious Resident Injury
Penalty
Summary
A deficiency occurred when a resident with significant medical complexities, including dementia, Parkinsonism, a history of falls, and recent fractures, was not provided adequate supervision and assistance during a transfer. The resident was care planned as a high fall risk and required total assistance of two staff members with a mechanical lift for all transfers. Despite this, only one certified nursing assistant (CNA) was present in the room while preparing to transfer the resident from a wheelchair to the bed. The CNA was waiting for a second staff member but remained alone with the resident, who exhibited involuntary jerky movements associated with Parkinson's disease. During this period of inadequate supervision, the resident experienced a sudden movement and fell face down onto the floor, resulting in multiple serious injuries, including facial and skull fractures, a possible cervical spine fracture, and extensive bruising. Interviews with staff and other residents confirmed that the transfer was attempted without the required two-person assistance, and the facility's policy explicitly stated that two staff members must be present for mechanical lift transfers. The incident was witnessed by staff responding to the fall, and the resident was found on the floor with significant bleeding and injuries. The resident's medical records and care plan documented his high risk for falls and need for two-person assistance due to his physical and cognitive impairments. Staff interviews revealed that the CNA was aware of the requirement for two-person transfers but proceeded to prepare the resident alone while waiting for help. The lack of immediate supervision and failure to follow established transfer protocols directly led to the resident's fall and subsequent injuries.
Failure to Protect Cognitively Impaired Residents from Abuse
Penalty
Summary
The facility failed to protect cognitively impaired residents from physical and verbal abuse, specifically involving two residents, R1 and R2. Both residents were subjected to abuse by a Certified Nurse Aide (CNA) identified as V5. R1, a male resident with severe cognitive impairment and a history of delusional disorders and Alzheimer's disease, was verbally and physically abused by V5 during care. Video footage showed V5 yelling at and pushing R1, who was heard pleading for her to stop. Despite the presence of a camera in R1's room, V5 continued her aggressive behavior, which was later reported by R1's family member who had installed the camera. R1 was sent to the hospital for evaluation but returned with no visible injuries. R2, another male resident with severe cognitive impairment and Parkinson's disease, was also abused by V5. During care, V5 was seen on video footage yelling at and aggressively handling R2. R2 sustained multiple injuries, including a right frontal hematoma, left lateral periorbital ecchymosis, and a lower lip abrasion. V5 claimed that R2 became combative during care, causing her to sustain a scratch on her finger. However, the injuries observed on R2 were inconsistent with V5's explanation. R2 was sent to the hospital for further evaluation and treatment. The facility's failure to follow its abuse policy and properly screen and orient agency staff contributed to these incidents. V5, an agency CNA, was not adequately oriented or trained in dementia care and abuse prevention. The facility relied on the agency's background checks and did not conduct its own screening. Additionally, the facility's onboarding process for agency staff was insufficient, as evidenced by the incomplete orientation checklist for V5. These deficiencies resulted in Immediate Jeopardy, which was later removed, but noncompliance remained due to the need for further evaluation of the in-service training's effectiveness.
Failure to Follow Abuse Policy
Penalty
Summary
The facility failed to follow its abuse policy related to prevention, protection, screening, training, and reporting for two residents. One resident, an elderly male with severe cognitive impairment and a history of delusional disorders and dementia, was verbally and physically abused by an agency CNA. The incident was captured on video, showing the CNA yelling at and pushing the resident. The family member reported the incident to the Executive Director, who then suspended the CNA and notified the agency. The resident was sent to the hospital but returned with no visible injuries. The police were involved, but the abuse was only reported to them after the resident was sent to the hospital, leading to a delay in the investigation process. Another resident, also an elderly male with severe cognitive impairment and a history of dementia and Parkinson's disease, was found with multiple injuries, including scratches and bumps on the forehead and bleeding on the lips. The CNA involved claimed the resident was aggressive during care, but other staff members noted that the resident did not typically display aggressive behavior. The incident was reported to the Nurse Supervisor, who then called the Executive Director and the police. The CNA was supervised and removed from the schedule. The police report documented the incident as aggravated battery, but the resident was unable to recall the event due to cognitive impairment. The facility's failure to properly screen, train, and orient agency staff contributed to these incidents. The agency CNA involved in both incidents did not receive adequate orientation or training on the facility's abuse policies and dementia care. The facility relied on the agency to conduct background checks and provide training, but there were gaps in the verification process. The facility's abuse policy requires thorough screening, training, and reporting procedures, but these were not adequately followed, leading to the abuse of two vulnerable residents.
Failure to Protect Residents from Abuse and Inadequate Staff Orientation
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse and did not follow its own abuse policies and procedures. This deficiency affected two residents, both of whom had severe cognitive impairments and were at risk for abuse. One resident was allegedly assaulted by a staff member, resulting in a hospital visit, although no visible injuries were found. The other resident was found with multiple scratches and bruises but could not recall the incident due to cognitive impairment. The investigation revealed that the facility did not properly orient and screen agency staff, which contributed to the incidents. The agency CNA involved in the alleged abuse did not receive a proper orientation or training on the facility's policies and procedures. The onboarding checklist was not completed accurately, and the staff responsible for orientation denied providing it. Video footage confirmed that the orientation process was rushed and inadequate. Interviews with facility staff, including the Executive Director and Director of Nursing, highlighted inconsistencies in the orientation and training process for agency staff. The facility's policy on abuse and neglect was not followed, and there was a lack of supervision and proper onboarding for agency staff. This failure to adhere to established guidelines and procedures led to the incidents of abuse and the overall deficiency in care quality.
Failure to Develop and Implement Abuse Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for abuse for two residents, R1 and R2, who were reviewed for abuse. R1, an elderly resident with severe cognitive impairment and multiple diagnoses including Dementia and Alzheimer's Disease, was admitted on 02/19/2024. Despite being assessed as at risk for abuse/neglect on 04/18/2024, R1's care plan for abuse/neglect was not initiated until 04/29/2024, three days after an abuse allegation. Similarly, R2, another elderly resident with severe cognitive impairment and diagnoses including Dementia and Parkinson's Disease, was admitted on 02/14/2023. R2 was assessed as at risk for abuse/neglect on 02/28/2024, but the care plan was not initiated until 04/27/2024, one day after an abuse allegation. Interviews with facility staff, including the Director of Nursing (V3), Social Services Director (V21), and Special Care Unit Director (V10), revealed a lack of clarity and responsibility regarding the development of abuse care plans. V3 stated that all dementia residents should have abuse care plans upon admission, and V21 confirmed that it was their responsibility to develop these care plans. However, V10 believed it was the responsibility of social services to develop the initial abuse care plan. The facility's Care Plan Policy mandates that a baseline care plan be completed within 48 hours of admission and a comprehensive care plan within 7 days after the comprehensive assessment, but this was not adhered to for R1 and R2.
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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