Highland Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Highland, Illinois.
- Location
- 1450 26th Street, Highland, Illinois 62249
- CMS Provider Number
- 145508
- Inspections on file
- 42
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Highland Health Care Center during CMS and state inspections, most recent first.
Two residents with cognitive and mental health conditions were left in urine-soaked bedding for hours due to staff failure to provide timely incontinence care and inadequate documentation of care refusals. Both experienced significant emotional distress, including feelings of humiliation and shame, as a result of being neglected.
Two residents dependent on staff for ADLs did not receive timely incontinence care, resulting in prolonged periods in soiled briefs and bedding. In both cases, CNAs failed to provide care, did not document refusals or interventions, and did not communicate residents' needs during shift changes. Facility policies requiring regular incontinence care and documentation were not followed.
A resident with severe cognitive impairment and a history of exit-seeking behaviors was not consistently identified as at risk for elopement, resulting in multiple unsupervised exits from the facility. Staff lacked a formal system to track or communicate which residents were at risk, and there was confusion and insufficient documentation regarding elopement incidents. This failure to systematically assess, document, and monitor residents with wandering tendencies led to the resident leaving the facility without supervision on more than one occasion.
A resident with dementia and PTSD, identified as at risk for abuse, was groped on the buttocks by another resident in a common area, causing distress and embarrassment. The incident was reported by the resident and family to staff, confirmed through interviews, and led to a medical evaluation. The facility's failure to prevent this incident resulted in psychosocial harm.
A resident with cognitive impairment and a history of fractures did not receive adequate pain management following a fall that resulted in a serious injury. Despite high pain levels recorded in the MAR, pain assessments were not completed, and pain medications were not administered for several days. The facility's failure to adhere to its pain management policy was confirmed by interviews with the DON and the physician.
The facility failed to properly store, label, and dispose of medications for several residents, as observed during an inspection of medication carts. Issues included unlabeled insulin pens, expired medications, and improper storage of refrigerated items. The DON confirmed that these practices did not align with the facility's Medication Storage Policy.
The facility failed to prevent inappropriate antibiotic use for four residents, prescribing antibiotics without necessary susceptibility reports. Residents with chronic kidney disease were given Ciprofloxacin and Bactrim, despite resistance or lack of evidence for effectiveness. The DON noted challenges in delaying prescriptions until culture results were available, contrary to the facility's Antibiotic Stewardship Policy.
The facility did not meet the required minimum square footage per resident bed for 13 residents. Seven rooms provided only 77.1 square feet per bed, while three others provided 74 square feet per bed. The DON stated that room and bed sizes are considered during room assignments to ensure safety and a clutter-free environment. No resident complaints or infection control issues were reported.
A resident with severe cognitive impairment and multiple medical conditions was not assisted with activities of daily living, including oral and hygiene care, leading to poor dental hygiene, dry mouth, cracked lips, and excoriated skin. The resident, dependent on a G-tube for nutrition, was transferred to the ICU with sepsis after the facility failed to address a clogged G-tube in a timely manner. Family and staff expressed concerns about the care provided.
A resident with severe cognitive impairment and G-tube dependence experienced a delay in care when their G-tube became clogged, preventing nutrition and hydration. Despite attempts to unclog the tube, the resident was not transferred to the ED until nearly four hours after the recommendation, arriving in critical condition with severe dehydration and hypernatremia. The facility's policy for acute changes in condition was not followed, contributing to the delay in treatment.
A resident with severe cognitive impairment and multiple medical conditions experienced a failure in gastrostomy tube care at a facility. The resident's G-tube became clogged, preventing nutrition and hydration, and despite attempts to unclog it, the resident was transferred to the hospital in a severely dehydrated state. The facility failed to follow up on a gastroenterology referral for G-tube replacement, leading to the use of a urinary catheter as a temporary solution, which was not properly managed.
The facility failed to maintain a clean and homelike environment, as residents reported infrequent linen changes and persistent unpleasant odors. Observations confirmed strong urine and bowel movement odors in bathrooms, and cluttered hallways with various equipment. The facility lacked a specific policy for changing bed sheets, relying on standard practices that were not effectively implemented.
Failure to Provide Timely Incontinence Care Results in Resident Neglect
Penalty
Summary
The facility failed to provide timely and adequate incontinence care for two residents, resulting in both being left saturated in urine for extended periods. One resident with paranoid schizophrenia and anxiety, who required one-person assistance with toileting, reported being left in urine all day without staff assistance, leading to feelings of humiliation and distress. Staff interviews revealed inconsistent documentation and communication regarding the resident's care needs and refusals, with one CNA admitting she did not know the resident was incontinent and failed to report alleged refusals of care. The resident was ultimately found by night shift staff to be soaked in urine, with saturated bedding and visible emotional distress. Another resident with dementia and anxiety, who was care planned for bladder incontinence and required regular checks and assistance, was also found lying in bed without clothing or a brief, saturated in urine. The resident expressed feelings of disgust and humiliation due to being left in soiled conditions for hours. Staff interviews indicated that the resident was known to be resistant to care and sometimes removed soiled items herself, but there was no documentation of care refusals or interventions attempted during the relevant shift. Day shift staff did not provide incontinence care, citing the resident's combative behavior and a lack of report on her status. Facility leadership confirmed that staff are expected to check and change incontinent residents every two hours and document any refusals of care, with further interventions required for continued refusals. However, in both cases, there was a lack of documentation, communication, and timely intervention, resulting in neglect as defined by regulatory standards. Both residents experienced psychosocial harm, including feelings of shame, humiliation, and emotional distress, as a direct result of being left in their own incontinence for prolonged periods.
Failure to Provide Timely Incontinence Care and Document Refusals
Penalty
Summary
The facility failed to provide adequate and timely incontinence care for two residents who were dependent on staff for activities of daily living. One resident with diagnoses including paranoid schizophrenia and anxiety reported being left in a saturated brief for an entire day shift, with no incontinence care provided by the assigned CNA. The resident stated he did not refuse care, and this was corroborated by the night shift CNA, who found the resident and his bedding soaked with urine and provided immediate care. The day shift CNA admitted she did not know the resident was incontinent and did not receive a report about his needs, leading to a lack of care throughout her shift. She later reported to the ADON that the resident refused care, but this was not documented during the shift, and no interventions or escalation were attempted at the time. Another resident with dementia and anxiety, who was known to be resistant to care, was found in bed without clothes or an incontinence brief, lying on saturated sheets and pads. The resident stated she removed her soiled clothing and brief due to being wet with urine. The night shift CNA reported that the resident refused care and threw soiled items at her, but there was no documentation of the refusal or of any interventions attempted to provide incontinence care overnight. The day shift CNA did not provide care in the morning, stating she did not want to wake the resident and was unaware of the resident's condition or lack of clothing. When care was finally provided, the resident was cooperative and received incontinence care and clean linens. Facility policies required CNAs to provide incontinence care every two hours and as needed, and to document refusals of care, including interventions attempted and notification of the charge nurse and provider. In both cases, staff failed to follow these policies, resulting in residents remaining in soiled conditions for extended periods without appropriate documentation or escalation. There was also a lack of communication during shift changes, leading to gaps in care and failure to meet residents' needs.
Failure to Systematically Assess and Monitor Resident with Exit-Seeking Behaviors Leads to Elopement
Penalty
Summary
The facility failed to implement a systematic approach to assess and monitor a resident with known unsafe wandering and exit-seeking behaviors, resulting in multiple elopement incidents. One resident with diagnoses of dementia, anxiety disorder, and depression, who was severely cognitively impaired and required substantial assistance, was not consistently identified as at risk for elopement in assessments, despite documented exit-seeking behaviors and previous elopement attempts. The care plan noted interventions such as redirection and 15-minute checks, but there was a lack of consistent documentation and follow-through, and the resident was able to leave the facility unsupervised on more than one occasion. Staff interviews revealed that there was no centralized or accessible list or binder of residents at risk for elopement, and many staff members were unaware of which residents were at risk or what interventions were in place. Several staff, including CNAs, LPNs, and RNs, stated that they relied on shift reports or visible Wander Guard devices to identify at-risk residents, but there was no formal system for tracking or communicating this information. Additionally, staff were not always aware of the resident's medical history or cognitive status, and there was confusion and lack of documentation regarding elopement incidents, with some staff and administrators denying that elopements had occurred or failing to complete incident reports as required by facility policy. Observations and interviews with staff, residents, and local police confirmed that the resident was able to exit the facility through both the front and fire exit doors without staff supervision, and in one instance, was found by police outside the facility. The lack of a systematic approach to assessment, documentation, and monitoring of residents with exit-seeking behaviors, as well as the absence of clear communication and staff awareness, directly contributed to the resident's ability to elope and the facility's failure to prevent these incidents.
Removal Plan
- Care plan reviewed to ensure appropriate interventions addressing exit-seeking behaviors.
- Elopement risk assessment reviewed for accuracy and completeness.
- Elopement assessments for all residents were reviewed and updated for accuracy as needed.
- Care plans for residents identified as at risk for elopement were reviewed and revised with appropriate interventions.
- Behavior tracking was initiated for all residents identified as at risk for elopement or exit-seeking behaviors.
- Staff education on elopement policy and procedures, recognition of exit-seeking behaviors, accurate and timely documentation requirements, and location/use of the facility's Elopement Binder.
- Licensed nursing staff received additional targeted training on documenting elopement attempts and exit-seeking behaviors.
- Facility will ensure staff members are educated prior to working their next shift if unable to be reached initially.
- Elopement Policy and Documentation Policy regarding exit-seeking behaviors were reviewed and approved by Chief Nursing Officer and Chief Operating Officer.
- DON or designee will review the 24-hour report and behavior tracking logs to identify and address exit-seeking behaviors.
- DON or designee will review all new admissions and readmissions to ensure elopement assessments are accurate and care plans reflect appropriate interventions.
- Administrator or designee will provide in-services on elopement policy, identification of exit-seeking behaviors, and implementation of appropriate interventions.
- Administrator or designee will conduct monitoring of three residents identified as at risk for elopement to ensure elopement assessments are completed, wandering/exit-seeking behaviors are documented and addressed with interventions, and care plans are updated as needed.
- Results of all monitoring activities will be reviewed during QAPI meetings led by the Administrator.
- Additional education and corrective measures will be implemented as necessary until sustained compliance is achieved.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident sexual abuse involving a cognitively impaired resident with a history of trauma, including PTSD and dementia. The resident's care plan identified a potential for abuse and noted that being grabbed or observing others being grabbed were known trauma triggers. Despite these documented risks, another resident approached from behind and grabbed the resident's buttocks with both hands while both were clothed. The incident occurred in a common area and was witnessed by the resident's family, who reported it to staff. The resident expressed distress, embarrassment, and pain as a result of the incident, which occurred in front of others and triggered his trauma. Multiple staff interviews and witness statements confirmed that the incident was reported to nursing staff and administration. The resident described the event as being groped and squeezed on the buttocks, and he reported feeling terrible and embarrassed. The resident's family corroborated his account and expressed concern about the documentation of the incident by outside medical providers. The resident was sent for medical evaluation, where no physical injuries were found, and the police were contacted. There was no evidence of prior inappropriate sexual contact between the involved residents, but one resident had a history of grabbing others, though not previously in a sexual manner. The facility's abuse policy prohibits all forms of abuse and requires measures to prevent such occurrences. However, the incident demonstrated a failure to protect a vulnerable resident from sexual abuse by another resident, resulting in psychosocial harm. The event was not immediately witnessed by staff, but was promptly reported by the resident and his family, and subsequently investigated by facility administration and outside agencies.
Failure to Provide Adequate Pain Management After Resident Fall
Penalty
Summary
The facility failed to provide adequate pain management for a resident who experienced a fall resulting in a serious injury. The resident, who was cognitively impaired and required assistance for activities, had a documented history of fractures and potential for pain due to conditions like unstable angina and COPD. Despite these conditions, the resident did not receive pain management for 24 hours following a fall on November 16, 2024. The fall investigation noted no immediate signs of trauma, but an X-ray later revealed an impacted subcapital fracture of the femoral neck. The resident's pain was recorded as high as 10 on the day of the fall, yet no pain medications were administered on November 16, 17, or 18, despite the availability of physician orders for pain relief medications like Norco and Tramadol. The resident's Medication Administration Record (MAR) indicated that pain assessments were not completed from November 16 to 21, and pain medications were not administered even when the resident's pain levels were documented. The resident was eventually given Tylenol on November 22 for a lower pain level, which was effective. Interviews with the Director of Nursing and the physician confirmed the expectation for pain management, highlighting the facility's failure to adhere to its pain management policy, which emphasizes prompt and accurate pain assessment and encourages self-reporting of pain by residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store, label, and dispose of medications for four residents, as observed during an inspection of medication carts on two different halls. On the B Hall, a registered nurse identified several issues, including an insulin pen labeled with a date but not discarded after 30 days, an unopened vial of Epogen that required refrigeration, an unlabeled half tablet of magnesium, and an opened carton of thickened lemon water that was past its labeled date. On the F Hall, another registered nurse found a sealed, unopened eye drop solution that required refrigeration, an insulin pen not labeled with a resident's name, and another insulin pen that was opened and not labeled with any resident's name. Additionally, there were bottles of Pro-Heal and multivitamins that were either not dated upon opening or past their best-by dates. The Director of Nursing confirmed that insulin pens should be labeled with resident names, dated upon opening, and discarded within 30 days. Expired items should be thrown away, and manufacturer's instructions for medication storage should be followed. The facility's Medication Storage Policy mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner, with proper labeling and disposal of discontinued, outdated, or deteriorated drugs. The policy also requires that medications be administered before their expiration date and that those requiring refrigeration be stored appropriately.
Inappropriate Antibiotic Use in LTC Facility
Penalty
Summary
The facility failed to maintain a system to prevent unnecessary or inappropriate antibiotic use for four residents. Resident 16 was prescribed Ciprofloxacin for a urinary tract infection (UTI) without a susceptibility report to confirm the bacteria's resistance or susceptibility to the antibiotic. Similarly, Resident 25 was also given Ciprofloxacin for a UTI, again without a susceptibility report to guide the antibiotic choice. Both residents had chronic kidney disease, which could complicate their treatment. Resident 45 was prescribed Cephalexin for a UTI, but the urine culture did not document a bacteria specimen or susceptibility report, indicating a lack of evidence to support the antibiotic choice. Resident 48 was given Bactrim for a bladder infection, despite the susceptibility report showing that the bacteria, Escherichia coli, was resistant to Bactrim. This indicates a failure to adjust the treatment based on the culture results. The Director of Nursing (DON) acknowledged difficulty in getting doctors to wait for culture results before prescribing antibiotics. The facility's Antibiotic Stewardship Policy aims to promote appropriate antibiotic use, but the events described show a failure to adhere to this policy, as antibiotics were prescribed without proper evidence of their necessity or effectiveness.
Facility Fails to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident bed in multiple resident bedrooms for 13 out of 80 residents. Specifically, seven resident bedrooms were found to provide only 77.1 square feet per resident bed, with each room measuring 15 feet 2 inches by 10 feet 2 inches. These rooms, numbered 105, 106, 107, 117, 118, and 119, are two-bed rooms certified for Medicaid/Medicare. Additionally, three other resident bedrooms provided only 74 square feet per resident bed, with room dimensions of 15 feet 3 inches by 21 feet, and included wardrobes measuring 23 inches by 63 inches and 24 inches by 94 inches. These rooms, numbered 225, 227, and 228, are also certified for Medicaid/Medicare. The Director of Nursing (DON) stated that the facility considers room size and bed size when assigning rooms to residents upon admission, ensuring a safe and clutter-free environment. Despite the undersized rooms, there were no complaints from residents regarding room size, nor were there any infection control concerns related to the room size.
Failure to Assist Resident with ADLs and Hygiene
Penalty
Summary
The facility failed to assist a resident, identified as R2, with activities of daily living, specifically oral and hygiene care. R2, who has severe cognitive impairment and is dependent on others for daily care, was found to have poor dental hygiene, dry mouth, cracked lips, and caked dried vaginal secretions with a foul smell and excoriated skin. These conditions were observed when R2 was transferred to the emergency department due to a clogged gastrostomy tube, which prevented her from receiving nutrition and fluids. R2's medical history includes osteomyelitis, protein calorie malnutrition, non-traumatic extradural hemorrhage, aphasia, Parkinson's disease, a stage 3 pressure ulcer, peripheral vascular disease, dysphagia, seizures, neurocognitive disorder with Lewy bodies, dystonia, hypernatremia, major depressive disorder, and hypertension. The resident was non-verbal, bed-bound, and dependent on a G-tube for nutrition. The facility's failure to maintain R2's hygiene and address the G-tube blockage in a timely manner resulted in her being transferred to the ICU with a diagnosis of sepsis. Interviews with facility staff and R2's family revealed concerns about the care provided. The facility's administrator and director of nursing acknowledged the family's dissatisfaction with R2's condition and care. The emergency department nurse noted R2's poor condition upon arrival, including severe dehydration and a strong odor in her mouth and perineal area. R2's son expressed that R2, a former nurse, would have been embarrassed by her lack of cleanliness and the odors present when she was sent to the hospital.
Failure to Provide Timely Care for G-Tube Dependent Resident
Penalty
Summary
The facility failed to provide timely care and treatment for a resident, identified as R2, who was dependent on a gastrostomy tube (G-tube) for nutrition and hydration. R2 had a complex medical history, including severe cognitive impairment, dysphagia, and a stage 3 pressure ulcer, among other conditions. On the day of the incident, the G-tube was found to be clogged, preventing the administration of necessary nutrition and fluids. Despite attempts by the nursing staff to unclog the tube using various methods, they were unsuccessful, and the resident was unable to eat or drink by mouth. The primary clinician recommended transferring R2 to the emergency department (ED) at 11:20 AM due to the inability to provide nutrition and fluids through the G-tube. However, there was a significant delay, as R2 did not arrive at the ED until 3:13 PM, nearly four hours later. Upon arrival at the ED, R2 was found to be severely dehydrated, tachycardic, and hypotensive, with a high lactic acid level and severe hypernatremia, indicating a critical condition. The ED notes also revealed that a urinary catheter had been used in place of the G-tube for some time, which frequently clogged, and there was no follow-up with the gastroenterologist to replace it with an actual G-tube. Interviews with the facility's nursing staff indicated that R2 had not received any nutrition since the night before the incident, and there was a lack of immediate action to address the clogged tube. The facility's Acute Change of Condition Policy requires prompt identification and treatment of residents with acute changes, but this was not adhered to in R2's case, leading to a delay in necessary medical intervention.
Failure in Gastrostomy Tube Care Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide appropriate gastrostomy tube care for a resident, identified as R2, who was dependent on tube feeding due to severe dysphagia and other complex medical conditions. R2's medical history included osteomyelitis, protein-calorie malnutrition, Parkinson's disease, and severe cognitive impairment, among others. The resident's care plan indicated a need for tube feeding due to dysphagia, and a physician's order was placed for a gastroenterology referral for G-tube replacement. However, there was no documentation that the referral or appointment was made, leading to a significant delay in addressing the resident's needs. On a particular day, R2's G-tube became clogged, preventing the administration of nutrition and fluids. Despite attempts by nursing staff to unclog the tube using various methods, they were unsuccessful. The resident was unable to eat or drink by mouth and was eventually transferred to the emergency department. Upon arrival at the hospital, R2 was found to be severely dehydrated, tachycardic, and hypotensive, with a high lactic acid level indicating septic shock. The hospital records revealed that R2 had previously been seen for a dislodged G-tube, and a urinary catheter had been used temporarily in place of the G-tube, but proper follow-up with the gastroenterologist was never completed. Interviews with facility staff and the resident's family highlighted a lack of communication and follow-up regarding the G-tube replacement. The facility's Director of Nursing and other staff members were unaware of any scheduled follow-up appointments with the gastroenterologist. The resident's son was not informed about the temporary use of a urinary catheter as a G-tube. The facility's failure to ensure timely and appropriate medical care for R2's G-tube issues resulted in the resident's severe dehydration and subsequent hospitalization.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for several residents, as evidenced by observations and resident interviews. One resident reported having to request sheet changes weekly and described the hallways as cluttered, resembling an obstacle course. Another resident complained about persistent unpleasant odors, likening the smell to a bathroom, and noted that bed sheets were changed only once a month. Observations confirmed strong urine odors in the shower area and bowel movement odors in another bathroom, where a smear of stool was found on the floor. Additionally, various equipment and carts cluttered multiple hallways, contributing to the unkempt environment. A resident's grievance documented concerns about bathroom cleanliness, and resident council meeting minutes highlighted issues with the frequency of linen changes. The facility administrator acknowledged the absence of a specific policy for changing bed sheets, stating that the standard practice was to change them on shower days and as needed. Despite the administrator's expectations for a clean and odor-free facility, the daily cleaning procedures policy was not effectively implemented, as evidenced by the persistent odors and clutter observed during the survey.
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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