La Bella Of Sterling
Inspection history, citations, penalties and survey trends for this long-term care facility in Sterling, Illinois.
- Location
- 3601 Sixteenth Avenue, Sterling, Illinois 61081
- CMS Provider Number
- 14E579
- Inspections on file
- 20
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at La Bella Of Sterling during CMS and state inspections, most recent first.
Multiple areas of the facility, including resident rooms, common spaces, and shower rooms, were found to be significantly colder than required, with temperatures as low as 50°F. Residents and staff reported discomfort and wore extra clothing indoors, while maintenance staff cited ongoing issues with old heating units and drafts. Leadership was not promptly informed of the extent of the cold conditions, and the facility's policy to maintain temperatures between 71-81°F was not met.
A resident with multiple medical conditions but no cognitive impairment sustained second-degree burns to the hand and forearm after returning unsupervised to a fire pit during an outdoor activity. Staff were occupied with other tasks and did not maintain supervision of the fire area, leading to the incident. The facility did not have a policy for supervision during outdoor activities.
The facility failed to ensure its activity program was directed by a qualified professional, affecting all residents. The Activity Director, who also serves as Social Services and a CNA, had been in the role for two months and worked every other weekend. During her absence, residents received activity packets. The Regional Director of Operations confirmed that the Activity Director lacked necessary certifications.
The facility failed to ensure the dishwasher sanitation solution was checked at the recommended level, affecting all 43 residents. A cook and a dietary aide used incorrect test strips for the hypochlorite solution, leading to inaccurate readings. The correct strips were later found under the dishwasher, and when used, showed the correct concentration. However, the log book showed inconsistent records, and the dietary manager confirmed the switch from quaternary ammonia to hypochlorite a month ago.
The facility failed to provide adequate behavioral health services for residents with mental illness, affecting four individuals. Residents expressed dissatisfaction with the lack of on-site counseling and in-person psychiatric care, relying instead on limited telehealth services. The facility's social services staff lack the necessary background to address residents' mental health needs, resulting in unmet care requirements.
The facility failed to provide necessary social services to residents with significant mental health needs. One resident expressed boredom and lack of counseling, another had unmet dental and vision needs, a third lacked in-person therapy, and a fourth had not met a psychiatrist in person. The social services staff was inexperienced and inadequately trained.
The facility failed to document consents for two residents who received the PCV 20 vaccine and declinations for two residents who refused it. The Corporate Regional Director of Operations confirmed the absence of necessary documentation in the residents' EMRs, contrary to the facility's policy requiring signed consent forms and documentation of refusals or contraindications.
A resident's room was found with missing sections of the wall and an ant infestation, which had not been addressed despite the resident notifying staff. The Maintenance Supervisor admitted to being aware of the issue but cited limited resources and time as reasons for the delay in repairs. The facility lacked a policy on building maintenance.
The facility failed to provide adequate activities for two residents, leading to dissatisfaction with the age-inappropriate and limited options available. One resident expressed a desire for more group activities and access to newspapers, while another noted staffing shortages prevented outdoor activities. Observations confirmed a lack of organized activities, contrary to the facility's policy.
A facility failed to provide appropriate mental health services for a resident with PTSD and other mental health diagnoses. The resident, who identifies as non-binary or male, did not receive recommended rehabilitative services, structured environments, or psychotherapy. The care plan was incomplete, lacking specific triggers and preferences. Staff were not informed of the resident's preferred pronouns, leading to misgendering. The facility lacked a policy on psych services and did not provide evidence of services received.
The facility failed to administer medications as ordered and properly account for controlled substances, affecting three residents. One resident missed their evening medication due to lack of staff reminder, while another had discrepancies in their narcotic count documentation. A third resident did not receive cogentin due to delayed prior authorization, leading to refusal of haldol. These issues highlight deficiencies in medication administration and documentation practices.
The facility failed to address pharmacy recommendations for three residents, leading to deficiencies in medication regimen reviews. One resident did not have required lab tests completed, another had a medication dosage adjustment unaddressed, and a third had a recommendation to discontinue a medication left incomplete. The DON found a backlog of unaddressed pharmacy forms.
The facility failed to address a gradual dose reduction for a resident on buspirone and did not ensure a stop date for a PRN anti-anxiety medication for another resident. The DON and MDS Coordinator did not follow up on the dose reduction, and the PRN order lacked the required 14-day stop date.
A resident missed five doses of apixaban due to an empty medication card sent by the previous facility and a delay in processing insurance information. The resident, admitted with acute embolism and thrombosis, received their first dose three days after admission, contrary to the facility's policy to prevent significant medication errors.
The facility failed to ensure RN staffing data was accurately entered in the PBJ system, affecting all 42 residents. The Administrator indicated uncertainty about the issue, suggesting it might be due to the corporate office pulling punch codes from the time clock, which outside agency staff do not use, or how the time clock codes the nurses. The person responsible for reporting the PBJ data only works weekends and did not respond to an email inquiry. The PBJ Staffing Data Report for a specified period showed no RN hours and failed to have licensed nursing coverage 24 hours a day, despite the nursing schedule indicating otherwise, demonstrating inaccurate reporting.
The facility failed to administer medications according to manufacturer's directions, monitor residents during medication administration, and provide ordered medications. An LPN did not provide a resident's prescribed medication due to unavailability, did not monitor another resident who threw away a pill, and did not instruct a resident to rinse after using an inhaler. Additionally, the LPN did not follow proper procedures for administering insulin to another resident.
Failure to Maintain Comfortable Temperatures Throughout Facility
Penalty
Summary
The facility failed to maintain comfortable temperatures throughout the building, resulting in multiple areas being significantly colder than the required range. During an initial tour, surveyors observed that the west hallway, group and activity room, nursing station, and main dining area were very cold. Temperature readings taken with the facility's infrared gun showed several locations with wall temperatures as low as 50.0°F to 57.2°F, including resident rooms, common areas, and shower rooms. Residents and staff reported that the building had been cold over the weekend, with some residents wearing jackets indoors and staff layering clothing to stay warm. One resident room's heating unit had not been working properly for about a week, and maintenance staff acknowledged ongoing issues with old heating units and drafts from exhaust fans. Staff interviews revealed that although the cold conditions were noticed by both residents and staff, there was a lack of timely communication to facility leadership. The administrator and DON were not made aware of the extent of the cold temperatures until after the weekend, despite staff and residents experiencing discomfort. The maintenance log indicated that heating issues in at least one resident room had been reported two weeks prior, but the problem persisted. The facility's policy requires immediate action to maintain temperatures between 71-81°F, which was not achieved in several areas during the survey.
Lack of Supervision During Outdoor Fire Activity Results in Resident Burn Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to a resident during an outdoor activity involving a fire pit. The resident, who had diagnoses including major depressive disorder, anxiety disorder, COPD, schizoaffective disorder, and tremor but no cognitive impairment, was participating in a marshmallow roasting activity. Staff members were assigned to supervise different areas, but after assisting the resident with roasting a marshmallow, the dietary manager left the resident to assist others. The resident then returned to the fire pit alone, attempted to throw a napkin into what appeared to be an extinguished fire, and the napkin ignited while stuck to her hand, resulting in burns to her left hand and forearm. Other staff present were occupied with setting up a piñata and were not supervising the fire area at the time of the incident. The incident resulted in the resident sustaining second-degree burns, requiring immediate first aid and subsequent evaluation at a local emergency room. Interviews with staff revealed that supervision around the fire was not maintained after the initial activity, and there was confusion regarding who was responsible for monitoring the residents near the fire pit. The facility was unable to provide a policy regarding supervision of residents during outdoor activities.
Unqualified Activity Director in Facility
Penalty
Summary
The facility failed to ensure that its activity program was directed by a qualified professional, which has the potential to affect all residents residing in the facility. The facility's Resident Census and Condition form dated March 10, 2025, indicated a census of 43 residents. On March 11, 2025, the Activity Director, who also serves as Social Services and a CNA, stated that she had been in the role for about two months and worked every other weekend. During her absence, residents were provided with activity packets containing crosswords, sudoku puzzles, and coloring pages. However, it was revealed by the Regional Director of Operations that the Activity Director did not possess any activity director certifications.
Dishwasher Sanitation Solution Not Checked Properly
Penalty
Summary
The facility failed to ensure the dishwasher sanitation solution was checked at the recommended level prior to use, affecting all 43 residents. During an observation, a cook (V7) and a dietary aide (V8) were involved in testing the dishwasher's sanitation level. Initially, quaternary ammonia test strips were used, which turned yellow, indicating an incorrect concentration. Upon realizing the sanitizing solution bucket was nearly empty, V7 replaced it with a full bucket and retested, but the strips still showed an incorrect concentration. It was then discovered that the strips used were not appropriate for the hypochlorite solution currently in use. Further investigation revealed that the correct test strips for hypochlorite were found scattered under the dishwasher. When these strips were used, the concentration registered at 50 ppm, which is the correct level according to the facility's policy. However, the log book showed that V8 had recorded a concentration of 100 ppm earlier, which was inconsistent with the findings. The dietary manager (V6) confirmed that the sanitation level should be 100 ppm and acknowledged the switch from quaternary ammonia to hypochlorite a month ago. The facility's policy requires that the chemical solutions be maintained at the correct concentration and checked at least once per shift, which was not adhered to in this instance.
Inadequate Behavioral Health Services for Residents
Penalty
Summary
The facility failed to provide necessary behavioral health care services for residents with mental illness diagnoses, affecting four residents in the sample. Resident 32, diagnosed with major depressive disorder, PTSD, and schizophrenia, expressed dissatisfaction with the lack of on-site counseling services and reported feelings of boredom and depression. The facility's activity director, who recently assumed the role of social services, lacks a behavioral health background and is unsure of the specific services needed by the residents. The resident's care plan includes interventions for depression and self-harm risk but lacks effective implementation of behavioral health services. Resident 41, with diagnoses including major depressive disorder, bipolar disorder, and PTSD, also reported inadequate mental health services at the facility. He was under the impression that he would receive more intensive psychiatric care and has had to find his own therapy. The facility's social services staff, who are new to their roles, are not equipped to provide the necessary psych services, and the resident's care plan does not adequately address his mental health needs. The facility previously had behavioral health aides and an in-person psychiatrist, but these services are no longer available, leaving residents without sufficient support. Residents 22 and 26, both with severe mental health diagnoses, also reported dissatisfaction with the facility's psychiatric services, which are limited to telehealth visits. Both residents expressed a preference for in-person psychiatric care, which the facility does not currently provide. The lack of comprehensive behavioral health services and the absence of a qualified social services staff have resulted in unmet needs for these residents, contributing to their ongoing mental health challenges.
Failure to Provide Adequate Social Services for Residents
Penalty
Summary
The facility failed to provide medically related social services to four residents, each with significant mental health diagnoses, as observed during the survey. One resident, a male with major depressive disorder and PTSD, expressed dissatisfaction with the lack of on-site counseling and life skills activities, feeling bored and uninformed about his discharge plan. Another resident, also with major depressive disorder and other mental health issues, was found with broken glasses and unmet dental needs, feeling overwhelmed due to the absence of counseling support and inadequate social service documentation. A third resident, identifying as male and with a history of suicidal ideation, reported a lack of in-person therapy and group support for trauma and wellness, despite having been recently hospitalized for mental health issues. The fourth resident, with a history of substance abuse and mental health disorders, had not met with a psychiatrist in person, only through telehealth, and expressed a preference for face-to-face interactions. The facility's social services were inadequately staffed, with the current staff lacking the necessary training and experience to meet the residents' needs.
Failure to Document Pneumonia Vaccine Consents and Declinations
Penalty
Summary
The facility failed to ensure proper consent or declination documentation for pneumonia vaccinations for four residents. Specifically, two residents received the PCV 20 vaccine without documented consent in their electronic medical records (EMRs), and two other residents who declined the vaccine did not have their declinations documented. This deficiency was confirmed by the Corporate Regional Director of Operations, who acknowledged the absence of the necessary consents or declinations in the residents' EMRs. The facility's policy requires that a consent form be signed prior to immunization and that any refusal or medical contraindication be documented in the clinical record.
Failure to Maintain a Homelike Environment in Resident's Room
Penalty
Summary
The facility failed to maintain a resident's room in a comfortable and homelike environment, as observed during a survey. A resident was found in her room with a section of the baseboard wall missing, leaving an open hole approximately one foot in size, and another section with wood exposed and several ants present. The resident reported that she had informed the staff about the issue, but no repairs had been made, and ants were a year-round problem. The Maintenance Supervisor acknowledged the need for repairs, stating that the facility had been neglected over the years and he was the only maintenance staff available, which limited his ability to address the issue promptly. The facility did not provide a policy regarding the maintenance of the building.
Inadequate Activity Program for Residents
Penalty
Summary
The facility failed to provide activities that meet the physical, mental, and psychosocial well-being of two residents, R22 and R26. R22, who has diagnoses including bipolar disorder and major depressive disorder, expressed dissatisfaction with the activities offered, describing them as age-inappropriate and lacking in variety. He noted a preference for activities such as dining out, reading newspapers, and participating in group activities, which were not being provided. R22 also mentioned that the facility no longer receives newspapers regularly, which was an activity he valued. R26, who has diagnoses including major depressive disorder and generalized anxiety disorder, also reported dissatisfaction with the current activity offerings. He noted that the previous activity director had quit, and the new director, who also serves as the social services person, was not providing adequate activities. R26 expressed a desire to go outside more frequently and listen to music, but stated that staffing shortages prevented this. Observations confirmed a lack of organized activities, with no staff directing activities and residents left to wander the halls or engage in minimal activities like card games. The facility's policy requires activities to be based on residents' assessments and preferences, which was not being met in these cases.
Failure to Provide Resident-Centered Mental Health Services
Penalty
Summary
The facility failed to implement and provide resident-centered mental health services for a resident diagnosed with PTSD, major depressive disorder, schizoaffective disorder, borderline personality disorder, and suicidal ideations. The resident, who identifies as non-binary or male, was admitted to the facility with a PASRR II recommendation for rehabilitative services, structured environments, and psychotherapy. However, the facility did not provide these services, and the resident reported having only one telehealth session with a psychiatric nurse practitioner, preferring in-person therapy sessions. The resident expressed dissatisfaction with the lack of trauma, wellness, life skills, or behavior management groups at the facility. The resident also reported that staff were not informed of their preferred pronouns and name, leading to misgendering and inappropriate interactions. The care plan for the resident was incomplete, lacking specific triggers, PTSD information, and preferences for being addressed, as well as activities that the resident enjoys, such as journaling and reward-based tasks. Interviews with facility staff revealed a lack of awareness and training regarding the resident's needs and preferences. The activity director/social services staff lacked a behavioral health background and was unsure of the psych services required by the resident. The facility previously had behavioral health aides and an in-person psychiatrist, but these services were no longer available. The facility did not provide evidence of the psych services the resident was receiving, nor did it have a policy regarding psych services, behavior management, or PTSD.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered as ordered and controlled medications were properly accounted for, affecting three residents. One resident missed their evening medication because they were not reminded by staff, and the nurse refused to administer the medication outside the scheduled time. The resident's Medication Administration Record (M.A.R.) confirmed that the medications were not administered as ordered. Another resident's Controlled Substance Form showed discrepancies in the narcotic count, with two doses of hydrocodone not signed out or accounted for. The nurse failed to document the administration of these doses, leading to uncertainty about whether the resident received the medication. Additionally, a third resident did not receive their prescribed cogentin due to a delay in obtaining prior authorization, which led to the resident refusing to take their haldol without it. The facility's attempts to secure the authorization were delayed, impacting the resident's medication regimen.
Failure to Address Pharmacy Recommendations for Residents
Penalty
Summary
The facility failed to address pharmacy recommendations for three residents, leading to deficiencies in medication regimen reviews. For one resident, R18, the pharmacy recommended obtaining specific lab tests, including CBC, BMP, hepatic panel, GGT, ammonia, and A1C, which were not available in the medical record. The Director of Nursing confirmed that these labs were not done, and the MDS/Care Plan Coordinator was unaware of the reason for this oversight. Another resident, R35, had a pharmacy recommendation to increase the dosage of levothyroxine due to a high TSH level and to follow up with a TSH concentration test. This recommendation was not addressed by the resident's physician, and the resident continued to receive the lower dosage. Additionally, for resident R33, a recommendation to discontinue hydroxyzine PRN for anxiety was not completed, as the form was left blank. The Director of Nursing, who had recently joined the facility, found a backlog of unaddressed pharmacy recommendation forms, including the one for R33.
Failure to Address Gradual Dose Reduction and PRN Stop Date
Penalty
Summary
The facility failed to address a gradual dose reduction for a resident diagnosed with multiple mental health disorders, including schizoaffective disorder, bipolar disorder, and generalized anxiety disorder. The resident had been receiving buspirone 10 mg three times daily since late February 2025, and a consultation report dated January 9, 2025, recommended a gradual dose reduction to 10 mg twice daily. However, this recommendation was not addressed by the physician. The Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator were identified as responsible for ensuring gradual dose reductions, but both acknowledged that the reduction had not been addressed or followed up on. Additionally, the facility failed to ensure that an as-needed (PRN) anti-anxiety medication for another resident had a stop date. The resident had a physician's order for hydroxyzine tablets to be given every six hours as needed for anxiety, but the order lacked a stop date. The DON confirmed that PRN psychotropic medications should have a stop date of 14 days, which was not implemented in this case. A pharmacy recommendation review also noted the need to discontinue the PRN hydroxyzine dose, citing CMS requirements for a 14-day limit on PRN orders for non-antipsychotic psychotropic drugs.
Significant Medication Error Due to Missed Doses of Apixaban
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of apixaban. The resident, who was admitted with multiple diagnoses including acute embolism and thrombosis, was prescribed apixaban to be taken twice daily. However, upon admission, the resident missed five doses of this critical medication. The omission occurred because the previous facility sent an empty medication card, and the necessary medication was not available at the new facility. The issue was compounded by a delay in processing the resident's insurance information, which was only faxed to the pharmacy two days after the resident's admission. The resident's medication orders were entered into the system on the evening of the admission, but the absence of the medication was not realized until two days later. This series of inactions and oversights led to the resident receiving their first dose of apixaban three days after admission, contrary to the facility's policy to prevent significant medication errors.
Inaccurate RN Staffing Data Reporting
Penalty
Summary
The facility failed to ensure RN staffing data was accurately entered in the Payroll-Based Journal (PBJ) system, affecting all 42 residents. The Administrator (V1) indicated uncertainty about the reporting issue, suggesting it might be due to the corporate office pulling punch codes from the time clock, which outside agency staff do not use, or how the time clock codes the nurses. The person responsible for reporting the PBJ data (V17) only works weekends and did not respond to an email inquiry. The PBJ Staffing Data Report for October 1-December 31, 2023, showed no RN hours and failed to have licensed nursing coverage 24 hours a day, despite the nursing schedule indicating otherwise, demonstrating inaccurate reporting.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered in accordance with manufacturer's directions, failed to monitor residents during medication administration, and failed to provide ordered medications. For Resident 21, the facility did not provide the prescribed Icosapent Ethyl medication for high triglycerides since March 2024 due to an insurance denial. The Director of Nursing (DON) confirmed that the physician was notified of the denial, but there was no documented notification in the resident's progress notes. Additionally, during a medication administration observation, the LPN did not provide the Icosapent Ethyl medication as it was not available, and the resident had not received it for several months. The facility also failed to monitor Resident 21 during medication administration. The LPN dispensed all morning medications into a plastic cup, and the resident inadvertently threw away a small peach-colored pill, which was later identified as hydrochlorothiazide for high blood pressure. The LPN did not notice the resident had failed to take the medication. Furthermore, the LPN did not instruct Resident 21 to rinse and spit after using a combination inhaler for COPD, which is necessary to prevent fungal infections in the mouth. For Resident 26, the LPN did not follow the manufacturer's instructions for administering Lispro Insulin using an insulin pen. The LPN failed to wipe the tip of the pen with an alcohol wipe and did not prime the pen before injection, which could result in an incorrect dose of insulin. The DON confirmed that the LPN should have followed the manufacturer's instructions to ensure the resident received the correct dose and to prevent infection.
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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