Jacksonville Skld Nur & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Jacksonville, Illinois.
- Location
- 1517 West Walnut Street, Jacksonville, Illinois 62650
- CMS Provider Number
- 145273
- Inspections on file
- 36
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Jacksonville Skld Nur & Rehab during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including ESRD, prior lumbar issues, essential tremor, and a left BKA, who used a manual wheelchair and was assessed as high fall risk, was transported to an appointment in the facility’s small van. During the return trip, the wheelchair tipped backwards in the van while the resident was strapped in and the wheelchair brakes were locked, causing the resident to strike the back of the head and upper back on the van floor and complain of headache and back pain. Staff and the resident reported that the wheelchair had been secured, and the van’s strap system included a red lever that, if contacted, could loosen the straps. Subsequent imaging documented an acute L1 compression fracture, demonstrating that the facility failed to ensure the wheelchair was safely and securely positioned during transport as required by its transportation policy.
A resident with severe cognitive impairment and a history of behavioral symptoms became agitated due to a delusional belief and physically struck another cognitively impaired resident on the cheek. Staff intervened immediately, and no injuries were found, but the incident showed a failure to prevent resident-to-resident abuse as required by facility policy.
Staff failed to perform hand hygiene and use gloves appropriately during meal service and direct care, including handling food without sanitizing hands and not following enhanced barrier precautions. A nurse also did not change gloves or perform hand hygiene while administering IV antibiotics to a resident with a midline IV, and reused an alcohol wipe during the procedure, contrary to facility policy.
A resident with multiple risk factors for skin breakdown developed a facility-acquired, unstageable pressure ulcer that was not identified until it had progressed significantly. Despite care plan interventions and facility policy requiring regular skin assessments and prompt reporting, the pressure ulcer was only discovered during a wound dressing change, with the wound nurse acknowledging it should have been found earlier.
A resident with severe cognitive impairment and a history of falls was found on the floor with an injury after required bed bolsters, intended to prevent falls, were not properly secured as outlined in the care plan. The bolsters were found loose and not clipped to the bed at the time of the incident.
A resident with severe cognitive impairment and high fall risk experienced a fall resulting in injuries due to the facility's failure to implement necessary interventions. The resident was not wearing nonskid footwear, and alarms were not in place at the time of the fall. Staff interviews revealed confusion about the resident's fall prevention measures, and the facility lacked a specific fall prevention policy. The root cause analysis identified bladder spasms and medication changes as contributing factors.
The facility failed to maintain properly inflated air mattresses for three residents, resulting in safety hazards and an unwitnessed fall. A resident with severe cognitive impairment fell from bed due to mattress deflation, sustaining a laceration and skin tears. Other residents reported frequent deflation issues, and staff acknowledged recurring problems with air mattresses. The facility lacked a policy or maintenance program for air mattresses, contributing to the deficiency.
A resident with cognitive deficits and a history of falls fell and sustained a head laceration while being assisted by a CNA. The CNA momentarily removed support to adjust a stuck bed remote, leading to the fall. Staff noted the resident's need for constant supervision and physical support due to safety awareness issues. The facility lacked a documented Fall Prevention policy.
The facility failed to prevent potential food contamination, affecting all 83 residents. Staff were observed handling food with bare hands, not restraining hair properly, and neglecting hand hygiene. A CNA fed a resident with bare hands, while the Director of Nurses and another CNA handled sandwiches without gloves. The Dietary Aide scratched her head and face without washing hands during meal prep. These actions violated the facility's policies on hand washing, staff attire, and meal assistance.
The facility failed to provide necessary oxygen to two residents, resulting in one resident becoming cyanotic with a dangerously low oxygen saturation level. Staff interviews revealed a lack of communication and protocol for switching residents from portable oxygen tanks to concentrators, and the facility's oxygen administration procedure was not followed.
The facility failed to properly store and label Tuberculin and Insulin vials, affecting all 83 residents. Open and partially used vials were found without open dates, contrary to the facility's Medication Storage policy.
The facility failed to properly dispose of soiled linens and perform hand hygiene between glove changes for four residents during incontinent care. Staff did not follow the facility's infection prevention and control program, leading to multiple instances of improper hand hygiene and handling of soiled items.
The facility failed to provide timely and complete incontinent care for five residents, including proper hand hygiene and glove changes. Observations confirmed that staff did not perform hand hygiene or change gloves appropriately while providing care, and residents were left in soiled conditions multiple times. The care provided was incomplete, with areas not being properly cleaned or dried, leading to potential skin integrity issues.
A resident with multiple diagnoses and a risk for falls experienced inadequate lighting in her room for over a month, despite informing the maintenance staff. The room remained dark, affecting the resident's comfort and safety, and the facility's policy on providing adequate lighting was not followed.
Wheelchair Not Properly Secured During Van Transport Leading to Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s wheelchair was properly secured during transport in the facility’s van, resulting in the wheelchair tipping over. The resident involved had multiple medical diagnoses, including Type 2 diabetes mellitus, end stage renal disease, peripheral vascular disease, lumbar intervertebral disc degeneration, prior L1 vertebral fracture, low back pain, essential tremor, and a left below-knee amputation. The resident was cognitively intact, used a manual wheelchair for locomotion, did not ambulate, and was assessed as a high fall risk with care plans identifying risk for falls related to her diagnoses and medications. On the day of the incident, the resident was transported to an appointment in the facility’s small van. Upon returning, her wheelchair tipped backwards in the van while she was strapped in with the wheelchair brakes engaged. The resident reported that she was strapped in properly and that the driver did not accelerate or brake abruptly when the wheelchair tipped. Staff interviews confirmed that the resident’s wheelchair brakes were locked and that she was secured in the van at the time of the incident. The Maintenance Director and the transport CNA indicated that the van’s wheelchair securement system uses straps with a red lever that, if pressed or contacted (for example, by a resident’s foot), could loosen the straps securing the wheelchair. After the wheelchair tipped, the resident hit the back of her head and upper back on the floor of the van. Nursing documentation and staff interviews describe a small hematoma to the back of the resident’s head, complaints of headache and lower back pain, and the resident’s refusal of immediate hospital evaluation and x‑rays. The facility initiated in‑house assessment and monitoring, and subsequent imaging, including a CT scan of the lumbar spine, later documented an acute L1 compression fracture along with degenerative disc disease and facet arthrosis. The facility’s transportation policy states that it is the facility’s responsibility to ensure any resident transported by facility vehicle has a safe and secure transport, which was not achieved in this incident when the wheelchair tipped while the resident was secured in the van.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents with severe cognitive impairment and dementia. One resident, who had a history of accusatory statements, verbal aggression, and misperceptions related to Alzheimer's disease, became agitated after observing another resident speaking with a female peer. Due to her cognitive impairment and delusional belief that the other resident was her deceased husband cheating on her, she attempted to strike him on the cheek, making contact with her fingertips. Staff immediately intervened and separated the residents, and both were assessed with no injuries noted. Interviews with staff and documentation confirmed that both residents involved were confused and cognitively impaired. The incident occurred in a common area near the nurse's stations, where the aggressor approached and made contact with the other resident's cheek. The facility's abuse policy prohibits all forms of abuse, neglect, and mistreatment, but the event demonstrated a failure to prevent physical abuse between residents, as required by regulation.
Failure to Follow Hand Hygiene and Infection Control Protocols
Penalty
Summary
Multiple staff members failed to follow proper hand hygiene and infection control protocols during meal service and while providing direct care. During meal distribution, staff including a CNA, Activity Director, and Activity Assistant did not sanitize their hands or don gloves before handling food or serving meal trays to residents. In one instance, a CNA removed a sandwich from its bag with bare hands and handed it to a resident without performing hand hygiene. Additionally, staff did not perform hand hygiene before donning gloves when entering a resident's room under enhanced barrier precautions, despite posted signage instructing them to do so. A Registered Nurse, while administering IV antibiotics to a resident with a midline IV access for a urinary tract infection, failed to change gloves or perform hand hygiene between tasks, and reused an alcohol wipe during the procedure. The facility's own hand hygiene policy requires hand hygiene before and after handling invasive devices and after contact with objects in the resident's immediate vicinity. These lapses were observed across multiple staff and residents, and were confirmed by staff interviews and review of facility policies.
Failure to Timely Identify Facility-Acquired Pressure Ulcer
Penalty
Summary
The facility failed to identify a pressure ulcer in one resident who was at high risk for skin breakdown due to cognitive deficits, decreased sensation, diabetes mellitus, neuropathy, incontinence, and edema. During a wound dressing change, the wound nurse observed an unstageable pressure ulcer on the resident's sacrum, characterized by slough and eschar, absence of granulation tissue, and a red peri-wound area with foul-smelling drainage. The wound was determined to be facility-acquired, and the wound nurse acknowledged that the pressure sore should have been detected before reaching an unstageable stage. Review of the resident's care plan indicated interventions for monitoring skin integrity and prompt physician notification of skin breakdown, but the new pressure ulcer was not identified until it had progressed significantly. Facility policy requires regular observation, measurement, and documentation of pressure areas, as well as immediate reporting of skin conditions by certified nursing assistants. Despite these protocols, the pressure ulcer was not identified in a timely manner, resulting in a facility-acquired, unstageable wound.
Failure to Implement Fall Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement a required intervention to prevent falls for a resident with severe cognitive impairment and a history of falls and fracture. The resident's care plan identified the use of bolsters clipped to the bed as an intervention for positioning and fall prevention. However, on the date of the incident, the resident was found on the floor beside the bed with a 3 cm scratch to the left cheek, and it was documented that the bolsters were not clipped to the bed but were instead loose and laying on the bed. The facility's policy required the interdisciplinary team to investigate and implement appropriate interventions, but the intervention of securing the bolsters was not followed, contributing to the resident's fall.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent a fall for a resident identified as R2, who was at high risk for falls. On the morning of 3/6/2025, R2 was observed sitting in a recliner with a pad alarm in place and a call light within reach. However, on 2/19/2025, R2 experienced a fall that resulted in injuries, including a laceration to the chin and a fracture of the right mandibular condyle. Interviews with staff revealed that R2 did not have his alarms on, nor was he wearing nonskid footwear at the time of the fall. Additionally, there was confusion among staff regarding whether R2's pad alarm was in place during the night of the incident. R2's medical history included severe cognitive impairment, a high risk for falls, and diagnoses such as Neurocognitive Disorder with Lewy Bodies and a wedge compression fracture. The care plan for R2, dated prior to the fall, included interventions such as fall mats, a low bed, and personal alarms. However, these interventions were not effectively implemented or communicated to the staff, as evidenced by the lack of alarms and appropriate footwear at the time of the fall. The root cause analysis conducted after the fall identified bladder spasms and the urge to void as contributing factors, exacerbated by the discontinuation of medications during a recent hospitalization. The facility's policy required a thorough investigation of accidents and incidents, including identifying the root cause and implementing appropriate interventions. Despite this policy, the facility did not have a specific fall prevention policy in place, and the lack of consistent implementation and communication of fall prevention measures contributed to the incident. The assistant administrator confirmed the absence of a fall prevention policy, highlighting a gap in the facility's approach to managing fall risks for residents like R2.
Air Mattress Deflation Leads to Resident Fall and Safety Concerns
Penalty
Summary
The facility failed to ensure the proper inflation of air mattresses for three residents, leading to safety hazards and an unwitnessed fall. Resident R2, who has severe cognitive impairment and is at risk for falls, was found on the floor with a laceration and multiple skin tears after her air mattress deflated. The incident report identified the root cause as air mattress deflation, and it was noted that the mattress had been reset and bolsters added. Interviews with staff revealed that the deflation of air mattresses was a recurring issue, often due to unplugged CPR plugs or pinched tubing when the bed was raised too high. Resident R4, who has moderate cognitive impairment, reported frequent issues with her mattress deflating, stating that nothing was done about it. Similarly, Resident R5, who is cognitively intact, also reported that his mattress deflates often, making it uncomfortable. The facility's administrator acknowledged the problem with deflating mattresses and mentioned that they had started purchasing a different brand, but issues persisted. The facility did not have a policy regarding air mattresses or perform assessments for residents using air loss mattresses. The air mattress manual provided by the facility indicated that proper patient assessment, monitoring, equipment use, and maintenance are required to reduce entrapment risk. It also included guidelines for cleaning the air filter cotton every three months. However, the Maintenance Director stated that there was no maintenance or preventative program for the air mattresses, and issues were often addressed through a work order system. The lack of a structured maintenance program and the recurring deflation issues contributed to the deficiency in ensuring a safe environment for the residents.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate safety and supervision for a resident, identified as R3, who was at risk for falls due to cognitive deficits and a history of falls. R3's care plan indicated a need for assistance with activities of daily living and specified that R3 required one-person physical assistance for bed mobility and dressing. On the day of the incident, a CNA was assisting R3 with getting dressed while R3 was sitting on the side of the bed with the bed elevated. The CNA momentarily removed her support from R3 to adjust a stuck bed remote, during which time R3 fell forward, resulting in a laceration to the forehead that required sutures. Interviews with staff revealed that R3 was dependent on staff for care and could not sit on the side of the bed independently. Staff members emphasized the need to be directly in front of R3 and maintain physical contact due to R3's tendency to reach out and pick at things randomly. The incident report and staff statements confirmed that the CNA had raised the bed too high, causing R3's feet to be off the floor, which contributed to the fall. The facility did not have a documented Fall Prevention policy, which may have contributed to the lack of adequate supervision and safety measures for R3.
Food Handling and Hygiene Deficiencies
Penalty
Summary
The facility failed to handle food in a manner that prevents potential contamination, affecting all 83 residents. During breakfast, a Certified Nurse Aide (CNA) was observed feeding a resident with her bare hands, repeatedly handling toast without gloves. In the kitchen, a Dietary Aide and a Corporate Dietary Supervisor were seen with improperly restrained hair, and the Dietary Aide was observed scratching her head and face without washing her hands before continuing meal preparation. Additionally, the Director of Nurses was seen handling residents' sandwiches with bare hands, tearing and altering the food before serving it to the residents. Further observations included a CNA assisting a resident with lunch by handling a grilled cheese sandwich with bare hands, dipping it into soup, and feeding it to the resident. The facility's policies on hand washing, staff attire, and meal assistance were not adhered to, as evidenced by the lack of proper hand hygiene and hair restraint among staff members. The facility's administrator acknowledged that all kitchen staff should wear hair nets, wash hands when necessary, and avoid touching residents' food with bare hands.
Failure to Provide Necessary Oxygen to Residents
Penalty
Summary
The facility failed to provide necessary oxygen to two residents who required it, resulting in one resident becoming cyanotic with a dangerously low oxygen saturation level. Resident 26, who had multiple diagnoses including COPD and dependence on supplemental oxygen, was found with an empty portable oxygen tank on two separate occasions. On the first occasion, the resident's oxygen saturation was 88% and improved after being connected to an oxygen concentrator. On the second occasion, the resident was found with an oxygen saturation of 51%, and her condition improved only after the oxygen concentrator was used. Staff interviews revealed that there was a lack of communication and protocol regarding the switching of residents from portable oxygen tanks to concentrators upon returning to their rooms. The Director of Nursing and other staff members acknowledged the issue and indicated that there was no existing policy for transporting residents on oxygen. Additionally, the facility's oxygen administration procedure policy was not followed, as evidenced by the empty tanks and lack of humidifiers. Resident 56 also experienced issues with oxygen administration. The resident's daughter reported that the oxygen tank was frequently empty, and she had to replace it herself during visits. The facility's failure to ensure that oxygen tanks were filled and functioning properly, as well as the lack of adherence to the oxygen administration procedure, contributed to the deficiencies observed by the surveyors.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to properly store and label medications, specifically Tuberculin and Insulin vials, which has the potential to affect all 83 residents. During an inspection of the 100-Hall Medication Storage Room, an open and partially used multi-dose vial of Tuberculin was found without an open date. Additionally, the Medicare medication cart contained several open and partially used multi-dose vials of Lantus, Gargling, and Humalog, all without open dates. Licensed Practical Nurse (LPN) V6 confirmed that the Tuberculin is a stock medication used for all residents and should have an open date to track its expiration. V6 also stated that insulin pens should have the resident's name and open date once in use, as the expiration date decreases once opened. Registered Nurse (RN) V25 corroborated that a new Tuberculin multi-dose vial should have an open date or expiration date placed on it, and once opened, its use-by date shortens to 30 days. V25 also confirmed that insulin pens should be labeled with the open date or expiration date once removed from the box. The facility's Medication Storage policy mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner, and that drug containers with missing or incorrect labels should be returned to the pharmacy for proper labeling. The policy also requires that medications be administered before the manufacturer's expiration date.
Failure to Follow Infection Control Practices
Penalty
Summary
The facility failed to properly dispose of soiled linens and perform hand hygiene between glove changes for four residents during incontinent care. For instance, a CNA did not sanitize hands before donning new gloves while providing care to a resident who is frequently incontinent of urine. Another CNA, while assisting a resident with multiple diagnoses including Brown-Sequard Syndrome and morbid obesity, failed to perform hand hygiene before and after changing gloves during the resident's cleaning process. This resident was dependent on staff for all ADLs and was always incontinent of both bowel and bladder. In another instance, two CNAs did not perform hand hygiene before donning gloves while providing care to a resident with severe cognitive impairment and multiple diagnoses including dysphagia and chronic kidney disease. The CNAs also failed to perform hand hygiene after removing gloves and before leaving the room. Additionally, a CNA was observed throwing soiled washcloths and pads on the floor while providing care to a resident who was incontinent of urine and bowel, and did not perform hand hygiene after handling the soiled items. The facility's policies on perineal care and hand hygiene were not followed, as staff did not perform hand hygiene before and after direct contact with residents, after removing gloves, or after handling soiled linens. These actions are contrary to the facility's infection prevention and control program, which emphasizes hand hygiene as the primary means to prevent the spread of infections. The failure to adhere to these policies was observed in multiple instances involving different residents and staff members, indicating a systemic issue in the facility's infection control practices.
Inadequate Incontinent Care and Hand Hygiene
Penalty
Summary
The facility failed to provide timely and complete incontinent care for five residents, including proper hand hygiene and glove changes. Resident R48, who has multiple diagnoses including Brown-Sequard Syndrome and Hemiplegia, reported being left in a saturated brief for extended periods, particularly during mealtimes. Observations confirmed that staff did not perform hand hygiene or change gloves appropriately while providing care, and R48 was left in soiled conditions multiple times, including during meals and therapy sessions. The care provided was incomplete, with areas not being properly cleaned or dried, leading to potential skin integrity issues. Resident R55, who has severe cognitive impairment and multiple diagnoses including CHF and chronic kidney disease, was also subjected to inadequate care. Staff failed to perform hand hygiene before and after donning gloves, did not dry cleaned areas, and did not cleanse all necessary areas during incontinence care. Similar issues were observed with Resident R37, who is cognitively intact but dependent on staff for toileting. The care provided was incomplete, with staff failing to cleanse all areas of incontinence and not performing hand hygiene. Resident R180, who requires assistance with ADLs due to weakness and decreased mobility, also received inadequate care. Staff did not clean all areas of incontinence and failed to dry the cleansed areas. Additionally, Resident R23, who is frequently incontinent of urine, was not properly rinsed or dried after being cleaned with soapy water. The facility's policies and procedures for perineal care and incontinence care were not followed, leading to multiple instances of inadequate care and potential risks for the residents involved.
Failure to Provide Adequate Lighting for Resident
Penalty
Summary
The facility failed to provide adequate lighting for a resident, leading to a deficiency in accommodating the resident's needs and preferences. The resident, who has multiple diagnoses including Polyneuropathy, Morbid obesity, and Major Depressive disorder, prefers to spend most of her time in her room. Despite being cognitively intact, the resident is dependent on staff for various activities of daily living and is at risk for falls. The resident's care plan specifically mentions the need for adequate lighting to mitigate fall risks. However, observations revealed that the resident's room was very dark, and the over-bed lights were burnt out. The resident reported that she had informed the maintenance staff about the issue a month prior, but the lights had not been fixed due to delays in obtaining parts and the maintenance staff's busy schedule. Further observations and interviews confirmed the inadequate lighting in the resident's room. A wound nurse attending to the resident also noted the poor lighting conditions, indicating the need for additional light sources to perform wound care. The Maintenance Director acknowledged the issue and mentioned that he was in the process of switching to LED bulbs but had not yet completed the task. Despite having received the necessary parts a week prior, the maintenance staff had not prioritized the replacement of the burnt-out bulbs. The facility's policy on providing a homelike environment with adequate lighting was not adhered to, resulting in the deficiency.
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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