Loft Rehab & Nursing Of Canton
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, Illinois.
- Location
- 2081 North Main Street, Canton, Illinois 61520
- CMS Provider Number
- 145600
- Inspections on file
- 31
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Loft Rehab & Nursing Of Canton during CMS and state inspections, most recent first.
A resident with multiple comorbidities and mild cognitive impairment developed a full-thickness burn on the left lateral knee after a CNA repeatedly applied homemade hot packs for knee pain. The CNA prepared the hot packs using hot water from a coffee maker on washcloths, sealed in a plastic biohazard bag and wrapped in pillowcases, then placed them directly on the resident’s skin, without a physician’s order and outside CNA scope. Nursing staff initially documented the area as a blister/burn and the wound physician later identified it as a thermal burn related to heat use, while the ADON first assumed it was due to edema. The administrator and wound physician confirmed that homemade hot packs should never be used, that heat applications require a physician’s order and must be applied only by licensed staff or therapy, and the facility could not provide a policy on heat application.
A resident did not receive care and treatment in accordance with physician orders and their own preferences and goals, resulting in a failure to deliver individualized care as required.
A resident with multiple chronic conditions had a blood thinner discontinued, but neither the resident nor their Power of Attorney was notified of this significant medication change. Interviews and record review confirmed that required notifications were not made or documented, despite facility policy mandating such communication.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident was not provided with hospice services, nor was assistance given to transfer the resident to a facility that could arrange for hospice care, resulting in a deficiency related to the provision of end-of-life services.
The facility failed to implement effective infection control measures after a CNA tested positive for COVID-19 and two residents exhibited symptoms. Despite the facility's policy, symptomatic residents were not tested or placed in transmission-based precautions, potentially exposing all 67 residents to the virus.
A resident with hemiplegia and hemiparesis fell and dislocated their shoulder during a sit-to-stand mechanical lift transfer due to a CNA transferring them alone, contrary to the facility's policy requiring two staff members. The resident, unable to maintain grip, fell and sustained a severe injury, highlighting a breach in the facility's transfer protocol.
The facility failed to provide physician-ordered wound care for three residents, as documented in their Treatment Administration Records. The records showed missed treatments, including cleansing, dressing applications, and topical creams. Interviews with staff confirmed the treatments were not completed as per orders, with the Wound Nurse and Director of Nursing acknowledging the lapses.
The facility failed to maintain sanitary conditions in food preparation by not ensuring proper use of PPE. Maintenance men were observed in the kitchen without hair or beard restraints, and a cook had exposed hair while preparing lunch trays. The Dietary Manager confirmed the need for proper hair coverage according to facility policy.
A facility was cited for deficiencies in infection control and medication administration. Staff failed to use PPE and perform hand hygiene properly during wound care for a resident with multiple medical conditions. Additionally, the DON improperly handled medications after they were contaminated, acknowledging the error. These practices potentially affected several residents.
A resident admitted for therapy after a Cerebral Vascular Accident was transferred to an emergency room without a completed transfer document. The resident, who was on anticoagulant medication, exhibited behaviors and requested to leave the facility. The transfer forms lacked essential information such as the reason for transfer, primary care clinician details, and risk alerts. The DON and Administrator acknowledged the incomplete documentation.
A resident admitted for hospice care and documented as totally dependent for bathing and grooming was found with unkempt facial hair and long fingernails, despite requesting assistance. The facility's policy requires personal hygiene services for residents unable to perform activities of daily living, but there was no documentation of refusal, indicating a failure in care provision.
A resident with Type 2 Diabetes Mellitus did not receive proper blood glucose monitoring and insulin administration upon returning to the facility post-hospitalization. The resident's glucose levels were not checked for three days, leading to elevated levels and symptoms like lethargy and diaphoresis. Insulin was administered after a delayed check, and a nurse confirmed the lapse in monitoring and order acquisition.
A facility failed to provide proper catheter care for a resident with an indwelling catheter, leading to a deficiency. Despite the resident's spouse expressing concerns about a potential UTI, a urinalysis was not obtained, and catheter care was delayed for four days after the resident's return from hospitalization. The resident was treated for a UTI and pneumonia during their hospital stay.
The facility failed to identify and document specific triggers for re-traumatization in the care plans of two residents with PTSD. One resident's care plan lacked identified triggers despite a history of child sexual abuse, while another resident's PTSD diagnosis was overlooked entirely. The Social Services/Care Plan Coordinator acknowledged these oversights.
The facility failed to identify appropriate indications for antipsychotic medications for three residents, leading to unnecessary medication use. One resident was given Olanzapine without a psychiatric diagnosis or behaviors justifying its use. Another resident's Quetiapine dosage was increased at the family's request despite no bipolar disorder diagnosis, and the behaviors observed did not meet antipsychotic criteria. The third resident was prescribed Quetiapine for behaviors related to vascular dementia, but the care plan lacked target behaviors, and staff noted the behaviors were due to pain and communication issues.
Burn Injury from Unauthorized Homemade Hot Pack Applied by CNA
Penalty
Summary
The deficiency involves the facility’s failure to prevent a burn injury caused by an unsafe, homemade hot pack applied to a resident’s left outer knee. The resident had multiple medical conditions, including COPD, mild protein-calorie malnutrition, type 2 diabetes mellitus, hereditary and idiopathic neuropathy, and later multiple rib fractures and acute respiratory failure, and had mild cognitive impairment with a BIMS score of 11/15. Following a fall, the resident reported bilateral knee discomfort and pain in the left knee. On the day after the fall, nursing documentation noted a new water blister on the resident’s left outer knee, and the wound was entered on the facility’s wound log as a blister/burn measuring 3.5 cm by 3 cm. The wound physician later documented a full-thickness burn wound of the left lateral knee, with duration greater than seven days, and noted that the resident had been using a heating pad for knee pain and suffered a thermal burn. Interviews and record review showed that the resident later reported the burn was caused by a hot pack placed on the outer knee that felt like it was burning, but the resident thought it was helping the pain. The administrator confirmed that homemade hot packs should never be used, that CNAs are not allowed to apply any type of heat application, and that heat packs require a physician’s order and must be applied by licensed nursing staff or therapy. The wound physician stated he was not aware the burn was caused by a homemade hot pack applied by staff and affirmed that only specific, safe products with a physician’s order should be used, and only by licensed nursing staff. The ADON initially assumed the blister was due to edema and treated it as a fluid-filled blister without any report of hot pack use, and only later learned from the resident that a CNA had applied a hot pack. The CNA admitted making and applying homemade hot packs at the resident’s request by using hot water from a coffee maker on washcloths, placing them in a plastic biohazard bag, wrapping them in pillowcases, and placing them directly on the resident’s skin, and stated she was unaware CNAs were not allowed to apply hot packs. The facility was unable to provide any policy or procedure addressing resident heat application, and the CNA job description only generally required reporting complaints and using only equipment for which the CNA had been trained.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. The report indicates that care was not delivered in alignment with the established plan, which may include disregarding specific medical orders or not considering the resident's expressed wishes and objectives for their care. This lapse resulted in the resident not receiving the individualized care that was ordered and preferred, as required by regulatory standards.
Failure to Notify Resident Representative of Medication Discontinuation
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the medication regimen for one of three residents reviewed. Specifically, a resident with diagnoses including Chronic Obstructive Pulmonary Disease, Alzheimer's Disease, and Chronic Atrial Fibrillation had their Xarelto (a blood thinner) discontinued, but there was no documentation that either the resident or the resident's Power of Attorney was informed of this change. The facility's policy requires prompt notification of the resident and their representative when there is a change in treatment, such as discontinuation of medication. Interviews and record reviews confirmed that neither the resident's Power of Attorney nor the resident's spouse, who was actively involved in care, were notified of the discontinuation. The administrator acknowledged entering the verbal order to discontinue the medication but did not notify the resident or their representative, believing hospice should have handled the notification. The hospice nurse practitioner and the spouse also confirmed they were not aware of the medication change, and the clinical record lacked evidence of required notifications.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Arrange Hospice Services
Penalty
Summary
The facility failed to arrange for the provision of hospice services for a resident or assist the resident in transferring to a facility that would provide such services. This deficiency indicates that the necessary steps were not taken to ensure the resident received appropriate hospice care as required.
Failure to Implement COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to implement effective Infection Prevention and Control (IPC) practices after a staff member tested positive for COVID-19 and residents exhibited symptoms of the virus. The facility's policy mandates that appropriate interventions be implemented to prevent the spread of COVID-19 and to respond promptly to any suspected or confirmed infections. However, the facility did not adhere to these guidelines, as evidenced by the lack of testing and transmission-based precautions for residents who showed symptoms of COVID-19. A Certified Nursing Assistant (CNA) worked a full shift while experiencing symptoms such as a sore throat and runny nose, later testing positive for COVID-19. Despite this, the facility did not test any residents who had been in contact with the CNA, nor did they implement transmission-based precautions for symptomatic residents. This oversight was acknowledged by the Director of Nursing, who admitted that residents were not tested or isolated as per the facility's policy. Two residents, one with chronic atrial fibrillation, chronic obstructive pulmonary disease, and hypertension, and another with type II diabetes mellitus, chronic obstructive pulmonary disease, and hypertension, exhibited symptoms consistent with COVID-19. Despite their symptoms, neither resident was tested for COVID-19, nor were they placed in transmission-based precautions. This failure to follow established protocols potentially exposed all 67 residents in the facility to the virus.
Failure to Use Two Staff Members for Mechanical Lift Transfer
Penalty
Summary
The facility failed to adhere to its Safe Resident Handling/Transfers policy, which mandates the use of two staff members during mechanical lift transfers. This deficiency was observed when a Certified Nursing Assistant (CNA) attempted to transfer a resident using a sit-to-stand mechanical lift without the assistance of a second staff member. The resident, who has a history of hemiplegia and hemiparesis following a cerebral infarction, was unable to maintain grip on the lift's hand grips, resulting in a fall and a severely painful dislocated left shoulder. The resident's medical records indicate a dependency on assistance for transfers due to limited physical mobility and cognitive intactness. During the incident, the CNA was the sole staff member present, contrary to the facility's policy requiring two staff members for such transfers. The resident reported severe pain and was unable to move the left arm, necessitating emergency room treatment for a shoulder dislocation. Interviews with facility staff confirmed the breach of protocol, attributing the CNA's actions to it being their last day of employment.
Failure to Provide Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide physician-ordered treatments for three residents reviewed for wound care. The facility's Wound Treatment Management Policy mandates evidence-based treatments in accordance with physician orders, but the Treatment Administration Records for the residents did not document the completion of these orders. For Resident 1, several wound care treatments, including cleansing and dressing applications, were not documented as completed on multiple dates. Similarly, Resident 2's records showed missed applications of topical creams and medicated pads, while Resident 3's records indicated missed applications of barrier cream and external cream for stasis dermatitis. Interviews with facility staff, including the Wound Nurse, Wound Doctor, and Director of Nursing, confirmed that the treatments were not completed as per the physician's orders. The Wound Nurse stated that if there were no signatures or initials on the Treatment Administration Record, the treatment was not done. The Wound Doctor emphasized that the Nursing Department should follow physician orders for skin treatments. The Director of Nursing acknowledged that treatments were missed and not documented, and the Administrator confirmed that nurses should follow physician orders and document the completion of treatments.
Improper Use of PPE in Food Preparation
Penalty
Summary
The facility failed to ensure food was prepared under sanitary conditions by not properly using Personal Protective Equipment (PPE) to prevent hair from contacting food. The facility's policy, dated 11/10/21, requires food and nutrition services employees to wear hair restraints and beard guards at all times in the kitchen. On 8/21/24, two maintenance men were observed working on an ice machine in the kitchen without hair or beard restraints. Additionally, a cook was seen with multiple pieces of hair exposed from under the hair restraint while preparing lunch trays. The Dietary Manager acknowledged that the maintenance men should have donned hair restraints and beard guards before entering the kitchen, and the cook should have ensured all hair was covered by the hair restraint.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility was found deficient in its infection prevention and control practices. Specifically, the staff failed to appropriately use Personal Protective Equipment (PPE), disinfect patient-use items, and perform hand hygiene according to policy. This was observed in the care of a resident with sacral and ankle wounds, a gastrostomy tube, an indwelling urinary catheter, and a history of urinary tract infections. During wound care, a registered nurse and a certified nurse aide did not don gowns as required by the Enhanced Barrier Precautions policy. The nurse also failed to perform hand hygiene after removing soiled gloves and before handling a tube of ointment, which was then placed back into the ointment box without disinfection. Additionally, the facility failed to administer medications in a manner that prevents contamination. The Director of Nursing was observed preparing medications and accidentally knocking them over onto the medication cart. Instead of discarding the contaminated medications, the director used a gloved hand to scoop them back into the medicine cup and administered them to a resident. This practice was acknowledged by the director as inappropriate, as the medication cart surface is not considered clean, and the medications should have been discarded. This incident had the potential to affect multiple residents residing on the same hall.
Incomplete Transfer Documentation for Resident
Penalty
Summary
The facility failed to provide a completed transfer document for a resident who was reviewed for discharge. The resident, who had been admitted for therapy following a Cerebral Vascular Accident, was receiving skilled therapy and an anticoagulant medication. On the day of the incident, the resident exhibited behaviors such as refusing to complete therapy sessions, sliding out of his wheelchair, and requesting personal phone numbers from staff. After reporting numbness, the resident was sent to a local emergency room for evaluation. However, the transfer form accompanying the resident was incomplete, missing critical information such as the reason for transfer, primary care clinician details, risk alerts, immunizations, and behavioral issues. The Director of Nursing and the Administrator acknowledged the deficiencies in the transfer documentation. The Director of Nursing was unaware of why the forms were incomplete, as she was not the one who filled them out. The Administrator confirmed that the forms should have been fully completed and noted that the resident's behaviors and anticoagulant use should have been documented. The lack of complete documentation was evident in both the SNF/NF to Hospital Transfer Form and the eInteract Transfer Form, as well as the Acute Care Transfer Document Checklist, which indicated that none of the recommended documents accompanied the resident to the emergency room.
Failure to Provide Personal Grooming for Dependent Resident
Penalty
Summary
The facility failed to provide necessary personal care for a resident, identified as R20, who was unable to perform activities of daily living independently. R20 was admitted for hospice care due to adult failure to thrive and muscle wasting, and was documented as totally dependent for bathing and grooming. Despite this, R20 was observed with a full beard stubble, a long mustache covering his lips, and long fingernails, indicating a lack of personal grooming. R20 expressed dissatisfaction, stating that he had requested staff to shave him and cut his nails, but these requests were not fulfilled. R20's family member also noted the need for grooming and mentioned attempts to bring clippers to address the issue themselves. The facility's policy mandates that residents unable to perform activities of daily living should receive necessary services to maintain personal hygiene. However, there was no documentation of R20 refusing personal grooming, and the administrator confirmed that it was expected for residents to receive grooming during showers. Despite R20 receiving a shower, there was no evidence of personal grooming being completed, highlighting a deficiency in the facility's care provision.
Failure in Diabetic Monitoring and Care
Penalty
Summary
The facility failed to complete diabetic monitoring and care for a resident with Type 2 Diabetes Mellitus who was insulin-dependent. The resident was admitted with standing orders for blood glucose monitoring before meals and at bedtime, and a sliding scale for insulin administration. However, upon returning to the facility post-hospitalization, the resident's blood glucose levels were not monitored according to these orders. The first blood glucose check was conducted on the day of admission, but the next check was not performed until three days later. During this period, the resident exhibited symptoms such as yelling, lethargy, and diaphoresis, which prompted a blood glucose check revealing a level of 471. Insulin was administered according to the sliding scale, and the physician was notified of the elevated levels. Subsequent checks showed persistently high glucose levels, necessitating further insulin administration. It was confirmed by a registered nurse that the resident's blood glucose levels were not monitored per standing orders, nor were insulin orders obtained upon the resident's return to the facility until three days later.
Failure to Ensure Proper Catheter Care and Timely Response to UTI Symptoms
Penalty
Summary
The facility failed to ensure proper catheter care for a resident with an indwelling catheter, leading to a deficiency in care. The resident's care plan required monitoring for signs and symptoms of a urinary tract infection (UTI), but there was a lack of documentation that a urinalysis was obtained despite concerns raised by the resident's spouse. The resident was eventually sent to the hospital for evaluation and was treated for a UTI and pneumonia, with a urine culture showing the presence of Pseudomonas Aeruginosa, Enterococcal Faecalis, and Coag-negative Staphylococcus. Upon the resident's return to the facility, there was a delay in conducting catheter care as per the physician's order, which was not initiated until four days after the resident's return. A registered nurse acknowledged the resident's spouse's concerns about a potential kidney infection and attempted to facilitate a clean catch urine specimen, but the sample was never obtained. The nurse noted that physician orders were not addressed promptly, likely due to the weekend, contributing to the deficiency in care.
Failure to Identify Trauma Triggers in Care Plans
Penalty
Summary
The facility failed to identify specific triggers of re-traumatization for two residents with a history of PTSD, as required by their trauma-informed care policy. One resident, who had a documented history of child sexual abuse, had care plan interventions that suggested speaking to Social Services or Nursing if experiencing triggers, but the care plan did not identify specific triggers for potential re-traumatization. This oversight was acknowledged by the Social Services/Care Plan Coordinator, who stated that triggers should have been identified and documented. Another resident with a history of sexual abuse was noted to have no symptoms or triggers per the resident's assessment. However, the resident's care plan did not include any mention of PTSD or trauma-informed care, including triggers or interventions. The Social Services/Care Plan Coordinator admitted that the diagnosis of PTSD was overlooked in the care plan. These deficiencies highlight a failure to adhere to the facility's policy on trauma-informed care, which mandates the identification and documentation of triggers to prevent re-traumatization.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to identify appropriate indications for the use of antipsychotic medications for three residents, leading to unnecessary medication administration. For the first resident, identified as R28, the facility administered Olanzapine despite the absence of any documented psychiatric diagnosis or behaviors warranting such medication. Observations and staff interviews confirmed that R28 had not exhibited any behaviors since admission that would justify the use of antipsychotic medication. The resident's care plan and psychiatric evaluations did not support the need for Olanzapine, and the resident was noted to be drowsy, raising concerns about the medication's appropriateness. The second resident, R32, was prescribed Quetiapine for an unspecified mood disorder, with the dosage increased at the family's request despite the absence of a bipolar disorder diagnosis. The resident's care plan indicated mood disorder and depression, but the behaviors observed, such as occasional verbal aggression and resistance to care, did not meet the criteria for antipsychotic use. The facility's social services and nursing staff acknowledged that the behaviors did not justify the medication, and there was a discrepancy in the documented diagnosis on the psychotropic consent forms. For the third resident, R39, Quetiapine was prescribed for verbal aggression and crying related to vascular dementia with agitation. However, the care plan did not address the use of antipsychotic medication or identify target behaviors. Observations during the survey showed no inappropriate behaviors, and staff indicated that the resident's behaviors were often due to pain and communication difficulties. The Assistant Director of Nursing acknowledged a disconnect between nursing and care planning, and the current diagnosis was deemed inappropriate for the medication's use.
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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