Mado Healthcare - Uptown
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 4621 North Racine Avenue, Chicago, Illinois 60640
- CMS Provider Number
- 146191
- Inspections on file
- 32
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Mado Healthcare - Uptown during CMS and state inspections, most recent first.
A resident with dementia and a history of falls was forcefully and aggressively moved in his wheelchair by a housekeeper, despite the resident's attempts to resist. The incident, captured on surveillance footage, showed the staff member spinning and tilting the resident's wheelchair in a manner that disregarded the resident's nonverbal cues and right to be free from abuse.
A resident was found on the floor by a CNA, who lifted the resident without notifying the nurse or requesting assistance, contrary to facility policy. The nurse was only informed of the resident's pain after the resident was back in bed, and was not told about the fall until later. The resident was later diagnosed with a right shoulder fracture after being sent to the hospital.
A resident with a history of schizophrenia and hallucinations physically assaulted another resident by choking him during a group activity, stating he was compelled by auditory hallucinations. The incident was witnessed by a staff member who intervened, and the aggressor was later referred for psychiatric evaluation. The assaulted resident did not sustain injuries, but the event demonstrated a failure to protect a resident from physical abuse.
A resident with stage 2 and stage 3 pressure ulcers did not receive weekly wound assessments or consistent wound care as ordered by the wound NP. Nursing staff continued previous treatments instead of following updated orders, and required documentation was missing for several weeks, contrary to facility policy.
A resident with moderate cognitive impairment and a history of ambulating independently fell and sustained a hip fracture due to the facility's failure to update and follow the fall prevention care plan. The care plan, which required extensive assistance and use of a gait belt, had not been reviewed since 2022. The facility lacked a specific fall prevention policy, relying on post-fall protocols and staff training, contributing to the incident.
The facility failed to have a licensed nurse oversee its restorative nursing program, affecting 120 residents. A COTA was responsible for creating and supervising the program, contrary to CMS guidelines requiring a licensed nurse. The DON confirmed the absence of a restorative nurse and did not supervise the COTA due to unfamiliarity with restorative services.
The facility failed to maintain a homelike environment by not repairing broken window blinds in several residents' rooms, affecting their privacy and comfort. Observations showed missing slats in the blinds, with no replacements found. A CNA and the Maintenance Supervisor confirmed the issue, citing workload and staffing limitations as reasons for the delay. The DON acknowledged the impact on residents' privacy. Affected residents had various medical conditions, and some were cognitively intact while others were severely impaired.
The facility failed to follow proper protocols for oxygen therapy, affecting three residents and potentially impacting all residents on the 5th floor. Observations showed a lack of required signage for oxygen use and improper labeling and containment of oxygen tubing. An LPN was unsure about the signage requirement, and the DON confirmed that tubing should be changed daily and properly labeled for infection control.
The facility failed to ensure that controlled drugs-count records were not prematurely signed by nurses on multiple floors. An LPN admitted to signing for both incoming and outgoing shifts simultaneously due to the absence of medications. The DON confirmed that narcotic sheets should only be signed at the beginning and end of each shift, as per facility policy, even if no medications are present.
A facility failed to discard an expired medication, Breo Ellipta, intended for a resident with asthma, COPD, and congestive heart failure. The medication, labeled to be used by a past date, was found on the medication cart and documented as administered on subsequent days. An RN acknowledged missing the expired medication, and the DON confirmed that expired medications should be removed. Facility policy requires expired medications to be returned to the pharmacy and reordered as needed.
A facility failed to relocate an Enhanced Barrier Precaution (EBP) sign and PPE bin when a resident with a gastrostomy tube was temporarily moved to a different room for maintenance. The oversight resulted in a lapse in infection control measures, as the necessary precautions were not communicated to staff in the resident's new location.
The facility failed to provide functioning call devices for two residents, impacting their ability to request assistance. A CNA and the Maintenance Supervisor confirmed the call lights were not working. The DON emphasized the importance of the call device for resident safety. The affected residents required assistance with ADLs due to medical conditions, and their care plans highlighted the need for functioning call lights.
A facility failed to protect residents' funds, resulting in unauthorized transactions on two residents' bank accounts. One resident's wallet was mishandled, leading to fraudulent ATM withdrawals and online purchases. Another resident's debit card was misused by a staff member, depleting their account through unauthorized transactions. The facility's inadequate system for safeguarding funds and belongings contributed to these incidents.
The facility failed to conduct comprehensive background checks on several staff members before they began working with residents, as required by their policy. This oversight included missing checks against critical registries such as the Illinois Sex Offender and Health and Human Services Office of Inspector General registries. The HR Director admitted to not being fully trained on these checks, resulting in incomplete background screenings and potential risks to residents.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A deficiency occurred when a housekeeper forcefully and unnecessarily moved a male resident with diagnoses including COPD, dementia, major depressive disorder, and a history of falls. The resident, who is care planned as being at risk for abuse/neglect and ambulates independently by wheelchair, was observed on facility surveillance footage being spun around aggressively by the housekeeper while attempting to resist by placing his feet on the floor. The housekeeper then tilted the wheelchair back and pushed the resident away from the area in an aggressive manner, despite the resident's nonverbal cues indicating he did not want to be moved. There were no other witnesses to the incident, and the event was captured on video during a routine review by corporate staff. The resident later confirmed the incident during an interview, recalling that the housekeeper spun his wheelchair and moved him from the area after he exited the elevator, and that he tried to stop the movement by putting his feet down. The housekeeper had previously attended an inservice on abuse and neglect. The facility's abuse prevention policy states that residents must be free from all forms of abuse, including physical and mental abuse. The incident demonstrated a failure to protect the resident's right to be free from physical abuse.
Failure to Notify Nurse and Assess Resident After Fall
Penalty
Summary
A deficiency occurred when facility staff failed to follow policy regarding the immediate assessment and notification of nursing staff after a resident fall. A certified nursing assistant (CNA) found a resident sitting on the floor in their room and, without notifying the nurse or requesting assistance, independently lifted the resident from the floor and assisted them back to bed. The CNA did not inform the nurse on duty about the fall at the time it was discovered, contrary to facility policy which requires immediate nurse notification and assessment before moving a resident post-fall. The resident involved was an older adult with a history of osteoarthritis and a recent diagnosis of a nondisplaced fracture of the right shoulder. The resident was cognitively intact and ambulatory, requiring stand-by assistance for showers. On the day of the incident, the resident was found on the floor by the CNA, who then lifted the resident without a nursing assessment. The resident subsequently complained of severe right arm pain and swelling, which was only communicated to the nurse after the resident was already back in bed. The nurse was not initially informed of the fall, but only of the resident's pain, and only learned of the fall and possible injury during the assessment prompted by the resident's complaints. Documentation and interviews confirm that the CNA acknowledged not following protocol, stating that the mistake was in transferring the resident post-fall without nurse notification or assessment. The nurse's assessment revealed a swollen, painful right arm, and the resident was sent to the hospital, where a closed fracture of the right shoulder was diagnosed. The failure to immediately notify the nurse and ensure a prompt assessment after the fall constituted a breach of facility policy and resulted in a delay in appropriate medical evaluation for the resident.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with a history of schizophrenia, schizoaffective disorder, and audio hallucinations physically assaulted another resident by approaching from behind and placing his arm around the other resident's neck in a chokehold during a group activity in the dining room. The aggressor stated, through a translator, that he was compelled by auditory hallucinations, specifically that God told him to choke the other resident. The incident was witnessed by a staff member who intervened and separated the two residents. The aggressor was calm after the incident and did not display agitation. The assaulted resident, who has diagnoses including schizophrenia, chronic obstructive pulmonary disease, and hypertension, reported being surprised by the attack and did not recall any provocation or warning. He denied pain or injury following the incident, and a licensed practical nurse confirmed there were no visible signs of harm. The aggressor had a documented history of behavioral disturbances, hallucinations, and a felony history for aggravated stalking, and was known to be at risk for abuse/neglect according to his care plan. The facility's abuse policy and residents' rights documents state that all residents must be protected from abuse, neglect, and harm. Despite these policies, the incident occurred in a supervised setting with only one staff member present, who was required to physically intervene. The aggressor was subsequently referred for psychiatric evaluation due to his aggressive and psychotic behavior, but the event demonstrated a failure to protect a resident from physical abuse by another resident.
Failure to Provide Consistent Pressure Ulcer Care and Weekly Assessment
Penalty
Summary
The facility failed to assess and document pressure ulcer characteristics and measurements on a weekly basis and did not ensure that wound care orders provided by the wound nurse practitioner were followed for one resident. The resident was admitted with multiple diagnoses, including stage 2 and stage 3 pressure ulcers, and required substantial assistance with activities of daily living. Interviews with staff confirmed that wound treatments were performed by nurses on duty, but there were inconsistencies between the treatments ordered by the wound nurse practitioner and those actually administered, as documented in the treatment administration record (TAR). The wound nurse practitioner specified that Hydrofera should be used for both the sacrum and right heel wounds, but the TAR and order summary indicated that Santyl and Xeroform were still being used for these wounds during the same period. The nurse practitioner emphasized the importance of following current wound care orders to promote healing and prevent complications. Additionally, the nurse practitioner noted that wound assessments and documentation were missing for several weeks, which is necessary to monitor wound progress and determine if treatment changes are needed. The facility's own policies required weekly documentation of wound characteristics, measurements, and pain, as well as adherence to physician orders for wound care. However, the facility was unable to provide weekly wound assessment documentation for several specified dates, and the orders from the wound nurse practitioner were not consistently implemented as directed. This resulted in a failure to provide appropriate pressure ulcer care and to prevent the development or worsening of pressure ulcers for the resident involved.
Failure to Update Fall Prevention Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to follow and update the fall prevention care plan for a resident, leading to a fall incident that resulted in a right hip/pelvic fracture requiring surgery. The resident, who had been in the facility since 2020, was noted to have moderate cognitive impairment and a history of ambulating without assistance. However, the care plan indicated that the resident required extensive assistance during transfers, including the use of a gait belt and evaluation before transfers. Despite these requirements, the care plan had not been reviewed or updated since 2022, and the resident was allowed to ambulate independently without the necessary support. The incident occurred when the resident was observed limping in the hallway, and subsequent medical evaluation revealed a right hip fracture. The resident was transferred to the hospital, where surgery was performed. Interviews with facility staff revealed a lack of clarity and communication regarding the resident's need for assistance and the use of mobility aids. The Director of Nursing and MDS Coordinator acknowledged that the care plan was outdated and not reflective of the resident's current needs, which contributed to the incident. The facility lacked a specific fall prevention policy, relying instead on post-fall protocols and staff training. This deficiency in proactive fall prevention measures, combined with the failure to update the resident's care plan, directly contributed to the resident's fall and subsequent injury. The absence of a restorative nurse and the lack of regular care plan reviews further exacerbated the situation, highlighting gaps in the facility's approach to resident safety and fall prevention.
Lack of Licensed Nurse Oversight in Restorative Nursing Program
Penalty
Summary
The facility failed to have a qualified licensed nurse oversee its restorative nursing program, which potentially affects all 120 residents receiving restorative programming. The Restorative Director, identified as a Certified Occupational Therapist Assistant (COTA), was responsible for creating, evaluating, and supervising the restorative programs. This individual also assessed residents for restorative needs and developed care plans, despite not being a licensed nurse. The Director of Nursing (DON) confirmed the absence of a restorative nurse and admitted to not providing supervision to the Restorative Director due to unfamiliarity with restorative nursing services. The facility's job description for the Restorative Director outlines responsibilities that include developing, implementing, and evaluating the restorative nursing program, as well as ensuring compliance with applicable laws and standards. However, the CMS's RAI Manual specifies that a registered nurse or licensed practical nurse must supervise restorative nursing activities. Despite the Restorative Director having taken a course in restorative nursing, the facility's reliance on a COTA for supervision does not meet the regulatory requirement for licensed nurse oversight.
Deficiency in Maintaining Homelike Environment Due to Broken Window Blinds
Penalty
Summary
The facility failed to ensure a homelike environment by not maintaining window blinds in several residents' rooms, affecting their privacy and comfort. Observations revealed missing panels or slats in the window blinds of five residents' rooms, with no replacement panels found on the floor. A Certified Nursing Assistant confirmed the lack of coverage and privacy due to the missing slats. The Maintenance Supervisor acknowledged awareness of the issue for about two months but cited a heavy workload and limited staffing as reasons for not addressing the problem. The Director of Nursing also recognized that the missing panels compromised the residents' privacy and the facility's obligation to provide a homelike environment. The affected residents included those with various medical conditions such as bipolar disorder, major depressive disorder, COPD, dysphagia, gastrostomy status, Type 2 Diabetes Mellitus, essential hypertension, obsessive-compulsive disorder, and epilepsy. Cognitive assessments indicated that some residents were cognitively intact, while others had severe impairments. The facility's policy mandates maintaining a safe, clean, and homelike environment, which was not upheld in this instance. The maintenance department's policy and job description for the Maintenance Director emphasize the responsibility for repairs, which were not fulfilled in this case, leading to the deficiency.
Failure to Ensure Proper Oxygen Therapy Protocols
Penalty
Summary
The facility failed to ensure proper respiratory care for residents requiring oxygen therapy, affecting three residents and potentially impacting all residents on the 5th floor. Observations revealed that a resident was using an oxygen concentrator without any signage indicating oxygen use on the door, which is against the facility's standard practice. An LPN confirmed the absence of the sign and expressed uncertainty about the requirement for such signage, despite acknowledging the flammable nature of oxygen. The facility's policy mandates that a sign should be posted on the resident's door when oxygen is in use. Additionally, the facility did not adhere to its policy regarding the labeling and containment of oxygen tubing. Two residents were observed with undated and uncontained oxygen tubing next to their beds. The Director of Nursing stated that oxygen tubing should be changed daily, dated, and placed in a plastic bag when not in use for infection control purposes. The facility's policy specifies that tubing must be discarded and replaced every 72 hours and labeled with the date and nurse's initials. These lapses in protocol could lead to potential safety and infection control issues.
Premature Signing of Controlled Drugs-Count Records
Penalty
Summary
The facility failed to ensure that the controlled drugs-count record form was not prematurely signed by both incoming and outgoing nurses. This issue was observed on multiple floors, including the second, fourth, fifth, and sixth floors, where the controlled drugs-count sheets were signed for the outgoing nurse before the end of the shift. During an inquiry, an LPN admitted to signing for both incoming and outgoing shifts simultaneously, citing the absence of medications as the reason for this practice. This practice was confirmed by the Director of Nursing (DON), who stated that the narcotic sheet should only be signed at the beginning and end of each shift, even if no medications are present. The facility's policies, dated February 21, 2024, and January 21, 2024, clearly state that narcotic counts must be conducted every shift with both incoming and outgoing nurses signing the records. Despite these policies, the premature signing of narcotic sheets was a common practice, as evidenced by the records reviewed by the surveyor. The DON acknowledged that the nurses should not sign the sheets before the end of their shifts, emphasizing the importance of verifying the count and confirming the absence of medications if applicable.
Expired Medication Not Discarded
Penalty
Summary
The facility failed to discard an expired medication, specifically Breo Ellipta (Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath), which was labeled to be used by 11/14/24. This medication was found on the third-floor medication cart on 11/17/24, and it was intended for a resident with a diagnosis that includes asthma, COPD, and congestive heart failure. The resident's active orders required the medication to be administered once daily for antiasthma purposes. Despite the expiration date, the medication was documented as administered on 11/15/24, 11/16/24, and 11/17/24, as indicated by check marks on the Medication Administration Record (MAR). During an interview, a registered nurse (RN) acknowledged missing the expired medication while cleaning the cart. The Director of Nursing (DON) confirmed that expired medications should not be present in the medication cart and should be removed by the nurse on duty. The facility's policy on Medication Discard and Labeling mandates that expired medications be removed and returned to the pharmacy, with reordering as necessary. The job descriptions for both registered nurses and licensed practical nurses include responsibilities for ordering prescribed medications and ensuring compliance with established policies.
Failure to Relocate EBP Signage and PPE Bin During Room Change
Penalty
Summary
The facility failed to ensure that an Enhanced Barrier Precaution (EBP) sign was posted and a personal protective equipment (PPE) bin was available for a resident on EBP. This deficiency was identified during an observation on the 3rd floor, where the EBP sign and PPE bin were found outside a room that was not occupied by the resident in question. The resident, who had a gastrostomy tube, was observed in a different room without the necessary EBP sign and PPE bin. The oversight occurred because the resident had been temporarily moved to another room for maintenance work, and the EBP sign and PPE bin were not relocated with the resident. The resident involved had a medical history that included dysphagia and gastrostomy status, requiring feeding formula via a gastrostomy tube. The resident's care plan indicated an increased risk for spreading multi-drug resistant organisms (MDRO) due to the indwelling medical device. The facility's policy required EBP signage and PPE to be present to inform staff of the necessary precautions. However, due to the room change, these precautions were not adequately communicated, leading to a lapse in infection control measures.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility failed to provide functioning call devices for residents requiring assistance, affecting two residents in a sample of 57. On November 17, 2024, a Certified Nursing Assistant (CNA) identified that the call lights for two residents were not working, as the call light boxes were not lit. This observation was confirmed by the Maintenance Supervisor, who acknowledged the issue and emphasized the importance of a functioning call light system for resident safety and assistance. The Director of Nursing (DON) and the Administrator both acknowledged the deficiency, with the DON highlighting the critical nature of the call device as a lifeline for residents. The facility's policy requires immediate notification of maintenance and implementation of 30-minute rounds when the call light system is not working. The affected residents had various medical conditions, including epilepsy and movement disorders, and required assistance with activities of daily living (ADLs). Their care plans emphasized the need for functioning call lights to ensure their safety and prompt assistance.
Failure to Safeguard Residents' Funds Leads to Financial Exploitation
Penalty
Summary
The facility failed to establish a system of accounting for residents' funds and safeguarding them against theft, leading to fraudulent debit card transactions on the bank accounts of two residents. The facility did not follow its system for updating residents' belongings and failed to ensure that the shipping address for online purchases was directed to the facility. These failures resulted in an Immediate Jeopardy situation, which was identified when a family member of one of the residents reported unexplained activities on the resident's bank account. One resident, who had a history of bipolar disorder, essential hypertension, and depression, experienced unauthorized transactions on their bank account. The resident's wallet was kept in the business office manager's office without a proper log or inventory of its contents. The wallet was given to a psychiatric rehabilitation services coordinator (PRSC) when the resident needed to make withdrawals or purchases, but there was no verification of the wallet's contents upon return. Unauthorized transactions, including ATM withdrawals and online purchases, were made using the resident's debit card, with some items being shipped to a non-facility address. Another resident, diagnosed with chronic obstructive pulmonary disease and unspecified dementia, entrusted their debit card to the same PRSC, who promised to manage their finances. The resident later discovered that their account had been depleted, with unauthorized transactions made using a person-to-person mobile payment application. The resident had not consented to these transactions and was unaware of the extent of the financial abuse until it was brought to their attention. The facility's lack of a robust system for safeguarding residents' funds and belongings contributed to these incidents of financial exploitation.
Removal Plan
- Removed V5 from the facility, suspended without pay pending investigation as part of actions to mitigate risks to R1 and any other resident.
- Implemented a revised personal items log to account for resident personal items such as debit, credit, ID, and wallet.
- Revised the resident personal property policy to include language regarding investigating misappropriation of resident funds/property.
- Conducted in-services about abuse and resident belongings.
- Hired an outside team of Private Investigator to check on the situation, on anything that has to do with financial abuse.
- Revised personal property policy to require witnesses and receipts, and a detailed log of community visits including the staff members who accompanied the resident.
- Assisted residents in retrieving any loss of value owed to them once the investigation is complete.
Failure to Conduct Comprehensive Background Checks on Staff
Penalty
Summary
The facility failed to adhere to its own policy regarding conducting comprehensive background checks on employees before they begin working with residents. This deficiency was identified during interviews and record reviews, revealing that several employees, including a PRSC, CNA Supervisor, and multiple CNAs, were hired without complete background checks. The facility's policy mandates that background checks be conducted to ensure that staff are eligible to work in a nursing home and to prevent abuse. However, the Office Manager/HR Director admitted to not fully checking the backgrounds of employees against various registries, including the Illinois Sex Offender, Department of Corrections Sex Offender, and Health and Human Services Office of Inspector General registries. The personnel files of the employees in question showed that background checks were initiated, but results from critical registries were missing. For instance, the background check for one employee was initiated on a specific date, but there were no results provided for several important registries. This pattern was consistent across the files reviewed, indicating a systemic issue in the facility's hiring process. The HR Director acknowledged not being taught to check these registries, which resulted in incomplete background checks and potential risks to residents. The facility's abuse policy, dated earlier in the year, clearly outlines the requirement for screening employees before they work with residents, including conducting criminal background checks. The policy explicitly states that the facility will not hire individuals with findings of abuse, exploitation, or misappropriation of property. Despite this, the facility's failure to conduct thorough background checks as per their policy has left residents vulnerable to potential harm from staff with undisclosed backgrounds.
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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