Heritage Health-hoopeston
Inspection history, citations, penalties and survey trends for this long-term care facility in Hoopeston, Illinois.
- Location
- 423 North Dixie Highway, Hoopeston, Illinois 60942
- CMS Provider Number
- 145470
- Inspections on file
- 26
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Heritage Health-hoopeston during CMS and state inspections, most recent first.
The facility failed to protect residents from physical abuse when two severely cognitively impaired, wheelchair-dependent residents with documented behavioral symptoms began arguing in a hallway and one struck the other on the arm. Both residents required substantial to maximum assistance with ADLs and had multiple psychiatric and medical diagnoses. A witness observed the altercation, and the Administrator confirmed the incident, demonstrating a failure to uphold the facility’s abuse prohibition policy and to prevent resident-to-resident physical abuse.
A resident with dementia, psychosis, severe cognitive impairment, and recurrent behavioral symptoms hit another resident on the arm during an argument in a hallway, an event witnessed by a third resident. Despite this incident of physical abuse and the resident’s documented behavioral history and high ADL needs, the care plan did not include any problem or interventions addressing the abuse or the hitting incident, and was not revised in a timely manner as required by facility policy.
Two cognitively intact residents reported receiving towels and washcloths with frayed edges and holes, and observations confirmed the presence of worn linens in the clean linen cart. The Housekeeping Supervisor acknowledged that staff were not consistently discarding damaged linens, resulting in residents being provided with substandard items.
The facility failed to report an injury of unknown origin and changes in medication orders for two residents. A resident with moderate cognitive impairment had a medication change that was not communicated to their family. Another resident with severe cognitive impairment had a bruise that was not reported to their family or physician until days later. The facility's policies on reporting changes and injuries were not followed.
The facility failed to report abuse allegations and injuries of unknown origin for three residents. One resident's bruise was reported late, another's family reported a nurse's alleged yelling, and a third resident's claim of being hit was not documented. These incidents were not reported to the state agency as required, indicating a breakdown in reporting procedures.
The facility failed to investigate abuse allegations for three residents, including one with severe cognitive impairment who reported being squeezed by staff, another whose family reported a nurse yelling, and a third who claimed to be hit by another resident. These incidents were not documented or investigated, and no staff were placed on leave.
The facility failed to implement fall interventions, document falls, and perform safe transfers for three residents. A resident with cognitive impairment fell while being assisted into a recliner, and the fall was not documented in the medical record. Another resident, requiring substantial assistance, experienced multiple falls due to improper transfer procedures and lack of thorough investigation. A third resident, at risk for falls, had several unwitnessed falls, with missing documentation and interventions not being followed.
The facility failed to label refrigerated chopped onions and tomatoes with dates and did not monitor cooking temperatures, risking food safety for all 72 residents. The Dietary Manager admitted these items would have been served without the surveyor's intervention, and temperature logs showed missing records for several meals over multiple weeks.
The facility failed to document orders, consents, or assessments for restraints used on four residents. A body pillow was used as a restraint for two residents without proper documentation. Another resident used a breakaway lap cushion without an initial assessment, and a fourth resident used a soft lap cushion without documented consent. The facility's staff acknowledged these deficiencies.
The facility failed to administer medications correctly for three residents, resulting in a 16% medication error rate. A resident received an incorrect dose of Metamucil, while two others were given insulin without following proper timing and priming procedures, contrary to manufacturer's instructions.
The facility failed to properly label and store medications for eight residents, leading to deficiencies in medication management. Insulin pens and eye drops were not labeled with full names or opened dates, and some were used past their beyond use dates. The DON confirmed that medications should be labeled correctly and expired or discontinued medications should be returned to the pharmacy.
A facility failed to conduct a Level II PASRR for a resident with PTSD, despite the diagnosis being recorded. The resident was cognitively intact, and the facility's administrator was unaware of the requirement to obtain a Level II PASRR when a serious mental illness is identified. The facility lacked a specific policy for obtaining a Level II PASRR.
The facility did not provide necessary shaving assistance to two residents who are dependent on staff for personal hygiene. One resident, unable to use his hands, was observed with significant beard growth and expressed a desire to be clean-shaven. Another resident, cognitively intact and requiring shaving assistance, was also unshaven over several days. Both residents expressed dissatisfaction with the lack of daily shaving, and a nurse confirmed the expectation for residents to be shaved during morning care.
A resident with multiple diagnoses, including Dementia and knee contractures, was improperly transferred using a sit-to-stand mechanical lift. The CNA and students did not position the resident's knees against the knee pad or use the leg strap, causing the resident to slide in the sling with elbows raised. The facility's Director of Nursing confirmed the correct procedure was not followed.
A facility failed to provide trauma-informed care for a resident with PTSD, as their care plan lacked documentation of triggers and interventions. The resident preferred a dark room to stay calm, but the Assistant DON was unaware of the PTSD's cause or triggers. The facility had no Social Service Director since January, and the resident's PTSD was not addressed with a consultant.
A registered nurse failed to perform hand hygiene before and after administering insulin and eye drops to two residents, contrary to the facility's Medication Administration policy. The nurse confirmed the omission, and the Director of Nursing stated that hand hygiene should occur between each resident during medication pass.
Failure to Prevent Resident-to-Resident Physical Abuse During Hallway Argument
Penalty
Summary
The facility failed to protect residents from physical abuse when one resident struck another during an argument. The facility’s Abuse Prohibition policy, revised on 8/25/25, affirms that all residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, and exploitation. Despite this policy, an incident occurred in which two residents who were sitting in the hallway talking began to argue, and one resident hit the other on the arm. A witness reported seeing the resident raise a hand and smack the other resident on the arm after becoming upset during the disagreement. The residents involved both had significant cognitive and functional impairments documented in their medical records and MDS assessments. One resident had diagnoses including fibromyalgia, dementia without behavioral disturbances, and psychosis, was severely cognitively impaired, exhibited physical/verbal behavioral symptoms one to three times a week, used a wheelchair for mobility, and required substantial to maximum assistance with all ADLs. The other resident had diagnoses including lumbar spinal stenosis without neurogenic claudication and delusional disorders, was also severely cognitively impaired, exhibited physical/verbal behavioral symptoms one to three times a week, used a wheelchair, and required substantial to maximum assistance with ADLs. The incident in which one resident hit the other on the arm, as confirmed by a witness and the Administrator, represents a failure to uphold the facility’s abuse prohibition policy and to protect residents from physical abuse by another resident.
Failure to Revise Care Plan After Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan following an incident of resident-to-resident physical abuse. A facility-reported incident investigation documents that one resident hit another resident on the arm in the hallway while they were talking and arguing, and a third resident witnessed the event. The resident who struck the other has medical diagnoses including fibromyalgia, dementia without behavioral disturbances, and psychosis. Their MDS shows severe cognitive impairment, physical/verbal behavioral symptoms occurring one to three times per week, wheelchair use for mobility, and a need for substantial to maximum assistance with all ADLs. Despite this incident of physical abuse, the resident’s care plan, last reviewed on 1/27/26, did not include any problems or interventions addressing the abuse or the hitting of the other resident. There was no documentation on the care plan related to the incident that occurred on 12/6/25. During interview and care plan review, the RN ADON confirmed that there was no information about the incident on the care plan and acknowledged that issues arising from incidents are to be addressed on the care plan as soon as possible. The Administrator also stated awareness that the care plan had not been revised until 2/4/26, although facility policy requires revising care plans as soon as possible after an event.
Failure to Provide Clean, Intact Linens for Residents
Penalty
Summary
The facility failed to maintain a homelike environment by not ensuring that linens provided to residents were in good condition. Two cognitively intact residents reported receiving towels and washcloths that were worn, with frayed edges and holes. One resident displayed a towel with frayed edges and two washcloths with fraying on every side, expressing confusion as to why staff continued to provide such items instead of replacing them with linens in good shape. Another resident showed a washcloth with a large hole and frayed edges, noting that he had seen worse and expected better quality in the facility. Observations confirmed the presence of frayed washcloths in the clean linen cart. The Housekeeping Supervisor stated that laundry is outsourced and that staff are responsible for discarding worn linens, but acknowledged that this was not being consistently done.
Failure to Report Injury and Medication Changes
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the physician and resident representative, as well as changes in medication orders to the resident representative for two residents. One resident, identified as R1, had a moderate cognitive impairment and experienced a change in medication when Plavix was discontinued. The Assistant Director of Nursing (ADON) attempted to contact the resident's family but failed to document the notification. The facility's policy requires that resident representatives be informed of changes in treatment, which was not adhered to in this case. Another resident, R2, with severe cognitive impairment, had a bruise that was not reported to the family or physician until three days after it was discovered. The bruise was noted to be aging, indicating it was not fresh, and was considered an injury of unknown origin. The Director of Nursing confirmed that the bruise should have been reported immediately. The Licensed Practical Nurse (LPN) involved did not report the bruise to anyone and admitted to not having training on identifying and reporting such injuries. The facility's policy mandates that injuries of unknown origin be reported to the resident's physician and family, which was not followed in this instance.
Failure to Report Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of abuse and injuries of unknown origin in a timely manner for three residents. The facility's policy requires immediate reporting of such incidents to the administrator and the state surveying agency. However, the facility's abuse tracking log did not document any allegations involving the residents in question. For one resident, a bruise was discovered but not reported to management or the state agency until four days later, despite the facility's policy requiring immediate reporting. Another resident's family reported an incident where a nurse allegedly yelled at the resident while changing the television channel. Although the family member later apologized, the incident was not reported to the state surveying agency as required. The facility's administrator was unaware of the allegation, indicating a breakdown in communication and reporting procedures. A third resident reported being hit by another resident, but this was not documented in the facility's abuse log or reported to the state surveying agency. The facility's administrator confirmed that this incident should have been reported, highlighting a failure to adhere to the facility's abuse reporting policy. These deficiencies demonstrate a lack of compliance with established procedures for reporting abuse and injuries of unknown origin, potentially compromising resident safety.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of abuse and implement protective measures for three residents. One resident, who has severe cognitive impairment, frequently complained of being squeezed by unidentified staff during care. Despite these complaints being reported to management, the facility's abuse log did not document any allegations involving this resident, and no investigation was conducted. The Director of Nursing was aware of the accusations and had implemented a two-staff care protocol, but the Administrator was not informed of the specific allegations, and the accused staff member was not placed on leave. Another resident's family reported an incident where a nurse allegedly yelled at the resident while changing the television channel. The family member reported this to the Administrator and a corporate official, but the incident was not considered an abuse allegation by the Director of Nursing, who believed the issue was resolved after the family member apologized. Consequently, the incident was not investigated, and the nurse was not placed on leave. A third resident, also with severe cognitive impairment, reported being hit by another resident. A CNA reported this to the Administrator, but the Administrator stated that nothing had been reported, and the incident was not documented in the facility's abuse log. As a result, the allegation was not investigated, indicating a failure in the facility's abuse reporting and investigation processes.
Failure to Implement Fall Interventions and Document Falls
Penalty
Summary
The facility failed to implement fall interventions, document falls in medical records, perform safe transfers, and thoroughly investigate falls for three residents. Resident 1, who has moderate cognitive impairment and is dependent on staff for transfers, experienced a fall while being assisted into a recliner with a sit-to-stand lift. The fall was not documented in the resident's medical record, and the Assistant Director of Nursing confirmed that falls should be documented in a nursing note. Resident 2, with severe cognitive impairment and requiring substantial assistance for transfers, experienced multiple falls. One fall occurred when a CNA assisted the resident into a chair without using a gait belt or having a second staff member present, despite the resident's care plan requiring two staff for transfers. Another fall was unwitnessed, and the investigation lacked staff statements or interviews to determine when the resident was last observed or toileted. Resident 6, who has severe cognitive impairment and is at risk for falls, experienced several unwitnessed falls. The care plan included an intervention for a nonskid mat, but it was not present in the resident's wheelchair. The fall investigations did not include staff interviews or documentation of when the resident was last observed or provided toileting assistance. The Assistant Director of Nursing confirmed the lack of documentation and awareness of the nonskid mat intervention.
Food Safety Protocols Not Followed
Penalty
Summary
The facility failed to adhere to proper food labeling and temperature monitoring protocols, which are essential for ensuring food safety. During an inspection, it was observed that chopped onions and tomatoes were stored in the refrigerator without any date labels. The Dietary Manager acknowledged that these items should have been dated when they were chopped and stored, and admitted that they would have been served had the issue not been identified. This oversight in labeling could lead to the growth of bacteria, posing a risk to the health of all 72 residents in the facility. Additionally, the facility did not consistently monitor or document cooking temperatures, as evidenced by missing temperature records for several meals over multiple weeks. The Food Temperature Logs for various weeks showed no recorded temperatures for several meal services, indicating a lack of compliance with the facility's own procedures. The Dietary Manager confirmed that cooking times are supposed to be monitored to ensure thorough cooking, but this was not being done, further increasing the risk of foodborne illness among residents.
Improper Use of Restraints Without Documentation
Penalty
Summary
The facility failed to adhere to its Restraint Program Policy and Procedure, resulting in the use of restraints without proper orders, consents, or assessments for four residents. Resident R52, who is severely cognitively impaired, was observed with a body pillow used as a restraint without any documented order, consent, or assessment. The Assistant Director of Nursing confirmed that the body pillow could be considered a restraint and acknowledged the lack of necessary documentation. Similarly, Resident R219, who is confused and not interviewable, was found with a body pillow used to prevent them from getting out of bed. Staff confirmed the use of the pillow as a restraint, yet there was no consent, assessment, or order documented in the resident's medical record. The Assistant Director of Nursing acknowledged the improper use of the body pillow and the absence of required documentation. Resident R47, who is severely cognitively impaired, was using a breakaway lap cushion as a restraint without an initial assessment documented. The Director of Nursing admitted that the initial assessment was missed. Additionally, Resident R55, diagnosed with dementia and other conditions, was using a soft lap cushion as a restraint without documented consent. The Director of Nursing confirmed the lack of consent documentation for the restraint change from a hook and loop closure belt to a soft lap cushion.
Medication Administration Errors and Non-Compliance with Manufacturer Instructions
Penalty
Summary
The facility failed to administer medications as ordered and in accordance with manufacturer's instructions for three residents, resulting in a medication error rate of 16%. For one resident, a registered nurse administered an incorrect dose of Metamucil, providing only 1/2 teaspoon instead of the prescribed 12 grams, as confirmed by the nurse and the medication label. Another resident was administered Humalog insulin without priming the pen, and the insulin was given over 30 minutes before the resident received their meal, contrary to the manufacturer's instructions that it should be administered within 15 minutes before a meal. Additionally, a third resident received Admelog insulin 40 minutes before their meal, which is outside the recommended administration window of within 15 minutes before a meal. The facility's medication administration policy requires following physician's orders and comparing the medication label with the MAR, which was not adhered to in these cases. The failure to prime the insulin pen and the timing of insulin administration could lead to incorrect dosing, as noted in the manufacturer's instructions.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for eight residents, leading to deficiencies in medication management. During an inspection, it was observed that several insulin pens and eye drops were not labeled with the residents' full names or opened dates, and some medications were used past their beyond use dates. For instance, a Lispro insulin pen for one resident was labeled with an opened date that exceeded the beyond use date, while another resident's Basaglar insulin pen lacked an opened date. Additionally, a Novolog insulin pen was labeled only with a resident's nickname and no opened date. The Registered Nurse verified these labeling issues and acknowledged the incorrect assumption about the insulin's usability period. Further inspection revealed that an eye drop bottle was labeled with an opened date that surpassed the discard date, and another resident's eye drops were still in the cart despite the resident no longer residing in the facility. Insulin pens for two residents were only labeled with first names, and another resident's insulin pen was not labeled with an opened date, even though the medication was discontinued. The Director of Nursing confirmed that medications should be labeled with full names and opened dates, and expired or discontinued medications should be returned to the pharmacy. The facility's pharmacy guide and policy manual also outlined these requirements, emphasizing the importance of adhering to beyond use dates and proper labeling to maintain medication efficacy and safety.
Failure to Obtain Level II PASRR for Resident with PTSD
Penalty
Summary
The facility failed to obtain a Level II Preadmission Screening and Resident Review (PASRR) for a resident diagnosed with Post-traumatic Stress Disorder (PTSD). The resident, identified as R57, was found to have an active diagnosis of PTSD and was cognitively intact according to the Minimum Data Set (MDS) dated [DATE]. Despite this diagnosis being recorded on 6/30/23, there was no evidence in the medical record that a Level II PASRR screening was conducted. During an interview on 6/5/24, the facility's administrator, V1, admitted to being unaware of the requirement to obtain a Level II PASRR when a serious mental illness diagnosis is identified, if not indicated by the Level I PASRR. Additionally, it was confirmed that while the facility's Care Plan Procedure policy includes PASRR recommendations in the initial Care Plan, there is no specific policy regarding when to obtain a Level II PASRR.
Failure to Provide Shaving Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene care, specifically shaving, for two dependent residents, R12 and R17, who require assistance with activities of daily living. R17, who is dependent for all activities of daily living, was observed with significant beard growth on multiple occasions, despite expressing a preference for being clean-shaven and an inability to use his hands. Similarly, R12, who is cognitively intact and requires assistance with shaving as per his care plan, was also observed with unshaven facial hair over several days. Both residents expressed dissatisfaction with not being shaved daily, and a Registered Nurse acknowledged the expectation for residents to be shaved during morning care.
Improper Use of Mechanical Lift During Resident Transfer
Penalty
Summary
The facility failed to perform a safe sit-to-stand mechanical lift transfer for a resident diagnosed with Dementia, Contracture of both knees, Muscle Weakness, Muscle Wasting, Abnormal Posture, Obesity, Anxiety, and Depression. During the transfer, the resident's knees were not positioned against the knee pad, and the leg strap was not used, causing the resident's elbows to raise towards the ceiling in a 'chicken wing' position. The resident's legs remained bent, and she began sliding down in the sling, indicating an improper transfer technique. The incident was observed by a Certified Nursing Assistant (CNA) and two CNA students, who did not follow the correct procedure as outlined in the mechanical lift's instruction manual. The Director of Nursing confirmed that competency training is conducted for staff on all mechanical lifts, and the resident's knees should be against the knee pad, with elbows at the resident's side. The Occupational Therapy Assistant assumed the resident could straighten her legs enough to be safe on the lift, but acknowledged that the resident's knees should be against the knee pad and arms should not be raised.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with Post-traumatic Stress Disorder (PTSD), as required by their policy. The policy mandates that residents who are trauma survivors receive culturally competent, trauma-informed care, with efforts to eliminate or mitigate triggers that could cause retraumatization. However, the facility did not identify potential triggers or implement resident-centered trauma-based interventions for the resident with PTSD. The resident's care plan, revised in April 2024, did not document the events leading to the PTSD or potential triggers, nor did it include any specific interventions for managing the PTSD. During an observation, the resident was found lying in a dark room, which she stated helped her stay calm. The Assistant Director of Nursing admitted to not knowing the cause of the resident's PTSD or what triggers it, and acknowledged that the PTSD was not addressed in the care plan. The facility had been without a Social Service Director since January, and the duties were shared among staff with the help of a consultant, but the resident's PTSD had not been addressed with the consultant. This lack of attention to the resident's PTSD needs represents a deficiency in the facility's care practices.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to adhere to its Medication Administration policy, which requires hand hygiene before and after medication administration. During an observation, a registered nurse did not perform hand hygiene before or after administering insulin to one resident and eye drops to another. The nurse applied gloves, administered Admelog insulin to a resident's abdomen, removed the gloves, and then proceeded to administer Timolol Maleate eye drops to another resident without performing hand hygiene in between. The nurse confirmed the omission of hand hygiene during the medication pass. The Director of Nursing stated that nurses are expected to perform hand hygiene or use hand sanitizer between each resident during medication administration. This expectation was not met in the observed instances, leading to a deficiency in infection prevention and control practices.
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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