Helia Healthcare Of Olney
Inspection history, citations, penalties and survey trends for this long-term care facility in Olney, Illinois.
- Location
- 410 East Mack, Olney, Illinois 62450
- CMS Provider Number
- 145388
- Inspections on file
- 27
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Helia Healthcare Of Olney during CMS and state inspections, most recent first.
A dependent, medically complex resident who required extensive assistance and mechanical lift transfers was repositioned in a recliner by two CNAs who lifted under the resident’s arms and grabbed the waist/pants without using a gait belt, contrary to facility safe patient handling and gait belt policies. During this maneuver, several loud pops were heard from the resident’s left arm and the resident immediately reported that the arm was broken; subsequent x‑ray confirmed an acute proximal humerus fracture suspected to be pathological. The initial RN notified of the event did not assess the resident or report the incident at shift change, leaving the resident without timely nursing evaluation. Later assessment documented pain with movement and decreased ROM, and family and staff reported the resident experienced severe pain through the night and next morning, while only acetaminophen was initially available and nurses described difficulty obtaining ordered opioid analgesia from the pharmacy and on‑call MDs. The attending MD later stated that, given the resident’s weakened condition and lack of gait belt use, the repositioning most likely caused the fracture and that the facility could have provided better care.
A resident with multiple chronic conditions sustained an acute left humerus fracture when two CNAs lifted the resident in a recliner by the arms without a gait belt, resulting in audible pops and immediate complaints that the arm was broken. The CNA reported the incident to an RN, who failed to assess the resident or notify the oncoming nurse. Later, another RN assessed the resident, noted significant pain with movement, obtained an x-ray order, and administered PRN acetaminophen, while a family member reported the resident was in horrible pain and that requests for stronger pain medication were met with comments about the difficulty of obtaining narcotics. Overnight, pain assessments were incomplete or undocumented, and pain was charted as zero despite guarding and reported pain. The next morning, another RN documented pain at 10/10, gave acetaminophen with little effect, and obtained an order for hydrocodone-acetaminophen, but due to delays in pharmacy access and e-prescribing, the narcotic was not administered for several hours, during which the resident continued to experience severe pain, contrary to the facility’s pain assessment and management policy.
A resident with multiple chronic conditions sustained a left humerus fracture during repositioning and subsequently experienced severe pain. Staff had only PRN acetaminophen ordered and available that night, did not obtain stronger analgesia from the pharmacy or e‑kit, and the resident remained in significant pain until the next day when hydrocodone‑acetaminophen was finally accessed from the e‑kit after delay. The resident’s scheduled evening and morning medications were not available due to late pharmacy delivery, and staff did not request STAT delivery or use the e‑kit for commonly used drugs. An RN documented several morning medications as administered on the eMAR even though they were not given, later stating the system would not allow correction, and leadership and the pharmacist acknowledged ongoing problems obtaining narcotics and new‑resident medications despite policies for 24/7 emergency pharmacy service and e‑kit use.
Two residents with behavioral health diagnoses were involved in a physical altercation, during which one resident struck another multiple times with a closed fist, and the other resident responded by grabbing the first resident's arm. Staff separated the residents and assessed them for injuries, finding none. The incident was reported to the administrator, physician, and authorities, and was documented in the medical records. The event occurred despite existing behavioral care plans and interventions intended to prevent such incidents.
A medication cart was left unlocked and unattended with its keys on top and out of visual control by an RN during medication pass, while confused, ambulatory residents were present. Facility policy requires medication carts to be locked and keys to remain with licensed staff, but this was not followed, allowing unauthorized access to medications.
A resident with cognitive impairments and multiple medical conditions sustained a burn from spilling hot coffee on her thigh. The facility failed to consistently monitor coffee temperatures, with logs showing gaps and inconsistencies. The coffee was served without a lid, and the resident accidentally spilled it while talking to another resident. The incident was partly attributed to the resident's medication, which caused drowsiness, and highlighted a lack of safety measures for handling hot beverages.
The facility failed to ensure dishware was sanitized appropriately, potentially affecting all 66 residents. A dietary aide used swimming pool test strips to check the dish machine sanitizer, which read very high. The dietary manager, new to the position, found the correct test strips, revealing a sanitizer level below the required 50 ppm. The manager admitted to not considering alternative sanitization methods.
The facility failed to provide correct food portions as per the approved menu for four residents. During lunch service on two separate days, the cook served significantly smaller portions than specified in the facility's recipes and menus. The dietary manager confirmed that all residents should receive the portion sizes listed on the menu or recipe unless otherwise directed by the registered dietitian or physician, which was not adhered to in these instances.
The facility failed to provide nutritional supplements as ordered for two residents. One resident with a complex medical history did not receive her prescribed nutritional shake during lunch, and the Dietary Manager confirmed the facility had run out of shakes. Another resident with severe protein-calorie malnutrition also did not receive her prescribed nutritional health shake, and the cook confirmed insufficient supply. This highlights a lapse in adherence to dietary protocols.
Improper Repositioning Without Gait Belt Causes Humerus Fracture and Poor Pain Control
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer and reposition a dependent resident in accordance with its own safe patient handling and gait belt policies. The resident had multiple serious diagnoses, including COPD, diabetes, CHF, small cell B lymphoma, and hypertension, and was assessed on admission as not independent in transfers or ambulation, not predictable or cooperative, unable to bear weight, and requiring a full-body mechanical lift for all transfers. A functional abilities assessment documented that sit-to-stand was not attempted due to medical or safety concerns and that bed mobility required substantial/maximal assistance. Nursing documentation described the resident as a “heavy 2 assist,” very weak, and incontinent, with an indwelling catheter and a stage 2 pressure sore. On the day of the incident, family requested that staff pull the resident up in his recliner because he was sliding down. Two CNAs (V3 and V4) stood on either side of the recliner and, without using a gait belt, hooked their arms under the resident’s armpits and used their other hands to grab the resident’s waist/pants to lift and pull him up in the chair. During this maneuver, multiple witnesses, including family and staff, reported hearing three loud pops from the resident’s left arm, after which the resident stated that his arm was broken. The resident then had minimal movement below the elbow and was unable to move the arm above the elbow without serious pain. The facility’s Safe Patient Handling Policy required use of lift equipment and/or assist devices for residents who were totally dependent or required extensive assistance, and the DON stated that repositioning in a situation such as this required use of a gait belt. The Gait Belt Use Policy required gait belts when staff transfer weight-bearing residents or assist with walking, and the therapy director stated that current recommendations for a similar resident would be repositioning with a gait belt rather than lifting under the arms. Following the incident, there were additional failures in timely assessment and pain management. CNA V3 immediately reported the event to the RN on duty (V5), who stated she would assess the resident after finishing a medication pass but then forgot, did not assess the resident, and did not report the incident to the oncoming nurse. V3 continued to check the arm every 10 minutes for swelling or bruising, but no nurse assessment occurred before shift change. The oncoming RN (V6) was informed by V3 about the popping noise and the resident’s pain and then assessed the resident, noting pain with movement and decreased range of motion but no swelling or bruising. A portable x-ray was ordered and later showed an acute proximal left humerus fracture suspected to be pathological. Family and staff reported that the resident experienced severe pain that evening and into the next morning, with family describing “horrible pain,” moaning, and screaming with repositioning. Initially, only Tylenol was administered despite reports of severe pain, and both night and day shift nurses (V7 and V8) described difficulty obtaining narcotic pain medication from the pharmacy and on-call physicians. The primary care physician later stated that, in the resident’s weakened state and without a gait belt, the repositioning most likely caused the fracture and that the facility could have done a better job of taking care of the resident.
Failure to Promptly Assess and Adequately Manage Severe Pain After Arm Fracture
Penalty
Summary
The deficiency involves the facility’s failure to promptly assess and adequately manage severe pain for a resident who sustained an acute left humerus fracture. The resident was a recent admission with multiple serious diagnoses, including COPD, Type 2 diabetes, CHF, small cell B lymphoma, hypertension, prostate cancer, and lymphoma. On the afternoon of admission, two CNAs repositioned the resident in a recliner by placing their arms under the resident’s armpits and lifting without a gait belt. During this maneuver, three loud pops were heard from the resident’s left arm, and the resident immediately stated that the arm was broken. A family member present confirmed hearing a loud crack and reported that the resident said, “You broke my arm.” The CNA promptly reported the incident to the RN on duty (V5), who stated she would assess the resident after completing a medication pass but then forgot, did not assess the resident, and did not report the incident to the oncoming nurse. Later that evening, the oncoming RN (V6) was informed by the CNA that there had been a popping noise from the resident’s arm during repositioning and that the resident was in pain. V6 assessed the resident and noted that the left arm was not bruised or swollen and was not painful if immobile, but there was significant pain with movement and decreased range of motion. V6 contacted the on-call physician (V9), who ordered a portable x-ray, and administered two Tylenol tablets around 7:00 p.m. per an existing PRN order. The family member reported that as the evening progressed, the resident was in “horrible pain,” moaning and screaming out when repositioned, and that Tylenol was not given until sometime around 9:00 p.m. The family member also stated that when she requested stronger pain medication, V6 responded that obtaining a narcotic order at that time of day was “a whole big thing.” The x-ray later confirmed an acute, likely pathological, fracture of the proximal shaft of the left humerus. Overnight, the night-shift RN (V7) recalled that the resident was guarding the arm and did not want it moved, but did not recall performing a pain scale or the specific severity of the pain, and was unsure if Tylenol was administered during her shift. The MAR documented that Tylenol was given at 9:29 p.m. and again at 6:35 a.m., with no numeric pain ratings recorded and only qualitative notes that it was effective or slightly effective. The facility’s records also showed a standing order for pain assessment every shift, with pain documented as zero on the evening and night shifts, despite reports of significant pain with movement and family observations of severe pain. On the following morning, the day-shift RN (V8) assessed the resident and documented a pain level of 10/10. Tylenol was administered around 6:30 a.m. with little effect, and V8 contacted the primary care physician (V10), who ordered hydrocodone-acetaminophen PRN. Due to limitations in e-prescribing and pharmacy access, the narcotic was not administered until after 10:30 a.m., during which time the resident continued to experience severe pain. Staff interviews indicated that nurses perceived obtaining narcotic pain medications, especially at night and for new residents, as difficult, and this contributed to delays in escalating pain management beyond Tylenol. The facility’s own Pain Prevention and Treatment Policy required that each resident be assessed for pain using an appropriate pain rating scale upon admission and at least quarterly, and that after completion of the assessment, residents receive interventions to reduce or alleviate pain, including pharmacological interventions with a physician’s order. The resident’s MDS pain assessment documented that in the last five days the resident rarely or not at all experienced pain, and that the worst pain over the last five days was rated as 4, which did not reflect the documented 10/10 pain level and severe pain behaviors described after the fracture. The MAR lacked numeric pain ratings associated with PRN pain medication administration and showed a pain score of zero on shifts when the resident was reported to have significant pain with movement. These actions and inactions—including failure to promptly assess the injury when first reported, failure to consistently and accurately assess and document pain using a numeric scale, and delays in obtaining and administering stronger pain medication—resulted in the resident experiencing severe pain for approximately four hours after sustaining the fractured left humerus.
Failure to Provide Timely Pain Control, Routine Medications, and Accurate MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide timely routine and emergency medications and to accurately document medication administration for a resident with multiple serious diagnoses, including COPD, Type 2 diabetes, CHF, small cell B lymphoma, and hypertension. The resident was admitted with numerous scheduled medications (Eliquis, Lasix, metoprolol, potassium chloride, magnesium oxide, folic acid, vitamin D3, inhaled/nebulized respiratory medications, and others) and PRN Tylenol for pain. On the evening of admission, the resident’s evening medications were not administered because they were unavailable due to delayed pharmacy delivery, and the MAR documented that no scheduled evening medications were given for that reason. The facility did not utilize the emergency medication kit or request a STAT delivery from the pharmacy, despite the pharmacy’s later statement that most commonly used medications and controlled substances were available in the e-kit and that a STAT delivery could have been guaranteed within four hours if requested. During repositioning in a recliner around dinner time, two CNAs lifted the resident without a gait belt, and a popping sound was heard from the resident’s left arm, after which the resident complained of pain and stated his arm was broken. Nursing assessment later that evening documented minimal movement below the elbow, inability to move the arm above the elbow without serious pain, and decreased range of motion, and an on‑call physician ordered a portable x‑ray, which showed a pathological transverse fracture of the left humerus. The only pain medication available and ordered that evening was PRN Tylenol, which was administered around 9:29 p.m. and provided some relief, but the family reported the resident was in horrible pain, moaning, and screaming out with repositioning. Staff did not obtain or attempt to obtain narcotic pain medication from the pharmacy or the e-kit that night, despite the on‑call physician later stating he could have provided an order and that an e‑script could have been used to access narcotics from the e‑kit. The following morning, the resident continued to experience severe pain rated 10/10. The RN on duty administered Tylenol around 6:30 a.m., which was documented as only slightly effective, and contacted the primary care physician, who ordered hydrocodone‑acetaminophen PRN for pain and directed that Eliquis be held pending goals‑of‑care clarification. However, due to the physician not being in his office to e‑script immediately, the facility did not obtain the narcotic from the e‑kit until after 10:20–10:29 a.m., and the resident remained in severe pain until that time. Additionally, the RN documented that several morning medications (Eliquis, magnesium oxide, vitamin D3, folic acid, and Lasix) were charted as given on the electronic MAR but were in fact not administered due to family questions and pharmacy delivery delays; the nurse stated there was no way to uncheck medications once marked as given in the eMAR. The DON and pharmacist confirmed ongoing problems with obtaining narcotics and new‑resident medications from the contracted pharmacy, and the pharmacist confirmed that the facility did not call for e‑kit codes or request STAT delivery for this resident’s medications, despite policy stating that emergency pharmacy service and e‑kit access are available 24/7 and that medications must be administered and documented in accordance with prescriber orders.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an altercation between two residents. One resident, who had diagnoses including dementia with mood disturbances, heart failure, anxiety disorder, and Parkinsonism, and who had a moderate cognitive deficit, was involved in a physical altercation with another resident diagnosed with neuroleptic-induced parkinsonism, bipolar disorder, and schizophrenia, who was cognitively intact. The incident occurred when the second resident, while in her wheelchair, made contact with the first resident using a closed fist to the side and arm. The first resident then responded by making contact with the second resident's arm. Both residents were separated by staff and assessed for injuries, with no marks, bruising, or redness noted. The care plans for both residents documented behavioral symptoms and previous incidents, including inappropriate comments, threats, and prior altercations. Interventions in the care plans included attempts to keep the residents separated and monitoring for behavioral issues. Despite these interventions, the altercation occurred, and staff responded by separating the residents and assessing them for injuries. The incident was reported to the administrator, physician, and other relevant parties, and documentation was made in the residents' medical records. Interviews with staff indicated that the altercation was witnessed by a CNA, who reported it to an LPN, and subsequently to the administrator. The administrator did not witness the event but was informed by staff. The incident was also reported to the police and the state survey agency. The facility's abuse prevention policy defines abuse as the willful infliction of injury or intimidation resulting in physical harm, pain, or mental anguish, and requires immediate action when such incidents occur.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart was observed left unlocked and unattended on two separate occasions while a registered nurse was passing medications. During these times, the cart keys were left on top of the cart and out of the nurse's visual control. These incidents occurred in the presence of residents and staff, with four confused and ambulatory residents identified as having access to the unsecured medication cart. The facility's policies require that medication carts be kept locked and that keys remain in the possession of the nurse administering medications. Only licensed nursing personnel or those lawfully authorized are permitted to access medication storage areas. The Director of Nursing confirmed that the cart should have been locked and the keys kept by the nurse. The residents involved were documented as confused and ambulatory, increasing the risk of unauthorized access to medications.
Resident Burned by Hot Coffee Due to Inadequate Temperature Monitoring
Penalty
Summary
The facility failed to adequately monitor and control the temperature of coffee served to residents, leading to an incident where a resident sustained a burn. The resident, who has a history of neuroleptic induced parkinsonism, bipolar disorder, schizophrenia, and other medical conditions, spilled coffee on her inner thigh, resulting in a blister. At the time of the incident, the resident was moderately cognitively impaired, as indicated by a BIMS score of 10. The coffee was served without a lid, and the resident was in the dining room when she accidentally spilled the coffee while attempting to talk to another resident. The facility's coffee temperature logs showed inconsistencies, with no temperatures recorded for a week and documented temperatures ranging from 185 to 130 degrees Fahrenheit. The Dietary Manager admitted to confusion and staffing issues that led to the lack of temperature monitoring during that period. The coffee was initially brewed at 205 degrees Fahrenheit and allowed to cool before being served, but the exact temperature at the time of the incident was not verified. The Registered Nurse present during the incident confirmed that the resident dropped the coffee cup, leading to the burn. The Director of Nursing and the Administrator acknowledged that the incident was partly due to the resident's medication, which caused drowsiness. The facility had not previously identified the need for coffee lids or other assistive devices for residents consuming hot beverages. The incident highlighted a gap in the facility's procedures for ensuring the safety of residents when handling hot liquids, particularly for those with cognitive impairments or other risk factors.
Improper Dishware Sanitization
Penalty
Summary
The facility failed to ensure dishware was sanitized appropriately, potentially affecting all 66 residents. On 05/05/24, a dietary aide used swimming pool test strips to check the dish machine sanitizer, which read very high. The dietary manager, who had been in the position for about two months, acknowledged the incorrect test strips and found the appropriate chlorine test strips, which indicated a sanitizer level of approximately 10 ppm, below the required 50 ppm. The dietary manager admitted to not considering alternative sanitization methods and was still learning the role. On 05/06/24, the dietary manager tested the dish machine sanitizer again, and the chlorine test strip indicated an appropriate range of 100 ppm. The facility's policy from 01/2012 requires employees to use appropriate test strips to check sanitizer concentration. The daily census report documented 66 residents residing at the facility, all of whom were potentially affected by the improperly sanitized dishware.
Failure to Provide Correct Food Portions as Per Approved Menu
Penalty
Summary
The facility failed to provide food portions as directed by the approved menu for four residents. Specifically, during lunch service on two separate days, the cook served portions of ground chicken tenders, mashed potatoes, ground Swedish meatballs, pureed chicken, pureed egg noodles, and pureed bread that were significantly smaller than the amounts specified in the facility's recipes and menus. For example, residents were served 2.875 ounces of ground chicken tenders instead of the required 4.75 ounces, and 1.125 ounces of mashed potatoes instead of 3.75 ounces. These discrepancies were observed for residents with various medical conditions, including cerebral ischemia, dementia, type 2 diabetes, chronic kidney disease, protein-calorie malnutrition, and other serious health issues, who had specific dietary orders that were not followed correctly. The dietary manager confirmed that all residents should receive the portion sizes listed on the menu or recipe unless otherwise directed by the registered dietitian or physician, which was not adhered to in these instances. The report highlights that the facility's policy on menus and food preparation, which mandates that meals be prepared according to the approved menu and corresponding recipes, was not followed. This failure was observed through direct inspection and interviews, revealing that the residents did not receive the appropriate portion sizes as per their dietary requirements. The dietary manager acknowledged the discrepancy, stating that all residents should receive the supplements and dietary orders as prescribed, which was not the case during the observed meal services. This deficiency affected the nutritional intake of the residents, potentially impacting their health and well-being.
Failure to Provide Nutritional Supplements as Ordered
Penalty
Summary
The facility failed to provide nutritional supplements as ordered for two residents, R45 and R56, out of a sample of 40 residents reviewed for nutrition. R45, who has a complex medical history including cerebral ischemia, dementia, and type 2 diabetes mellitus, was observed not receiving her prescribed nutritional shake during lunch. The Dietary Manager (V10) confirmed that the facility had run out of nutritional shakes and acknowledged that nutritional ice creams should have been provided as a substitute. The facility's policy on weight management emphasizes the importance of following physician orders and providing necessary nutritional supplements, which was not adhered to in this case. Similarly, R56, who suffers from severe protein-calorie malnutrition, dysphagia, and other significant health issues, did not receive her prescribed nutritional health shake during lunch. Despite being on a puree diet with supplements, R56 was only served a glass of water and a flavored drink mix. The cook (V13) confirmed that the facility had insufficient nutritional health shakes to meet the needs of all residents with such orders. This failure to provide essential nutritional supplements as ordered highlights a significant lapse in the facility's adherence to dietary and nutritional protocols.
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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