Manor Court Of Carbondale
Inspection history, citations, penalties and survey trends for this long-term care facility in Carbondale, Illinois.
- Location
- 2940 W Westridge Place, Carbondale, Illinois 62901
- CMS Provider Number
- 146171
- Inspections on file
- 34
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Manor Court Of Carbondale during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia, prior traumatic subdural hemorrhage, cognitive communication deficit, vascular dementia, major depressive disorder, anxiety, and a documented history of trauma was sharing a room with another cognitively impaired resident. During an argument in their room about a boyfriend, the roommate grabbed the resident’s hand and bit it, causing an immediately visible, crescent-shaped bruise and blood blister on the palmar surface of the hand that resembled a human bite, with lipstick noted around the area. A bystander resident alerted CNAs by yelling that someone was fighting, and staff arrived to find the residents already separated, with the injured resident holding her hand and stating she had been bitten. The facility’s abuse policy stated that abuse is prohibited and that special attention would be given to identifying behaviors that increase the risk of abusing others or being a victim of abuse, yet the resident was not protected from this episode of physical abuse.
The facility failed to follow physician orders and implement ordered pressure-injury prevention and treatment measures for three residents at risk for, or with, pressure ulcers. One resident with diabetes, incontinence, and limited mobility developed three stage II ulcers on the buttocks and intergluteal cleft while reporting that staff did not routinely reposition him in bed or chair; surveyors observed no off-loading boots in use, no heel skin prep applied, and buttock wounds that were not listed on the wound log. A second resident with documented boggy heels and orders for bilateral off-loading boots and heel skin prep was repeatedly seen in bed and in a wheelchair without boots, with very red, boggy heels, and reported that staff did not offer or apply the boots, which were found unused in the closet. A third resident with an unstageable left heel ulcer and orders for an off-loading boot and specific wound care was observed multiple times without the boot, including while the wrapped heel rested on a metal wheelchair foot pedal; this resident stated staff did not put a boot on, and a wound clinic NP confirmed the boot was never in place during clinic visits despite ongoing orders.
A resident with intact cognition but significant mobility limitations, including dependence on staff for transfers and substantial assistance for bed mobility, routinely sat in a wheelchair at the back of the room where the call light could not reach. Staff, including CNAs and the DON, acknowledged that the resident regularly positioned herself by the window and that the call light cord did not extend to that area. The resident reported difficulty propelling forward due to slick shoes and stated she sometimes tried to reach the call light, called her daughter, or went to the doorway to yell for help. The resident’s daughter confirmed these difficulties and frequent calls for assistance, while the care plan required the resident to call for help before transfers and to be oriented to the call light system, resulting in a failure to reasonably accommodate the resident’s need for accessible call light use.
A resident with multiple chronic conditions, intact cognition, and dependence on staff for toileting and transfers received peri and incontinence care during which a CNA repeatedly discarded soiled wipes, a saturated brief, and a urine-soaked pad onto the floor, causing urine to splash, and then carried the soiled pad against his uniform. The CNA left and re-entered the room multiple times wearing the same contaminated gloves, used those gloves to open doors and access the clean linen cart, and changed gloves without performing hand hygiene between glove changes. Another CNA and the DON acknowledged that these practices did not follow facility policy for standard precautions, which requires proper hand hygiene, PPE use, linen handling, and waste disposal.
A resident suffered a nondisplaced spiral fracture of the right tibia when their foot got caught in the rubber strips of a shower chair. The incident occurred during a transfer to the shower room, and the facility's investigation found that the rubber strips were loose and stretched out. The resident, who had impairments in both upper and lower extremities, was dependent on staff for transfers. The maintenance director admitted that bathroom equipment was only checked on an as-needed basis, contributing to the oversight.
The facility failed to provide adequate staffing, resulting in delayed care for residents. Multiple residents reported long wait times for assistance with toileting and incontinence care, leading to discomfort and potential health risks. Staff acknowledged the shortages, particularly on weekends, and the facility could not provide consistent documentation to verify adequate staffing levels.
The facility failed to respond to call lights promptly, affecting four residents' dignity and care. Residents reported long wait times, particularly in the evenings and weekends, leading to inadequate incontinence care and self-transfers. The DON acknowledged the issue, stating call lights should be answered within 15 minutes, but this expectation is not consistently met.
The facility failed to provide adequate ADL assistance and timely incontinence care for four residents, leading to deficiencies in care. One resident received only one shower during a five-day stay, while another reported inconsistent call light responses and delayed toileting assistance. A third resident had previously filed a grievance about delayed care, noting staffing shortages, particularly on weekends. A fourth resident reported delays in incontinence care, resulting in skin issues, with a CNA confirming inadequate night shift care and staffing shortages.
A resident with severe cognitive impairment and behavioral issues was involuntarily discharged from a facility without adequate physician documentation or a clear plan to manage their needs. The facility failed to document the resident's specific needs, attempts to meet those needs, or services available at the receiving facility. Staff interviews revealed a lack of detailed notes on the resident's behaviors and interventions, and the resident was not allowed to return during the appeal process.
A resident, who required substantial assistance for bathing, did not receive scheduled showers as per their care plan. Despite being cognitively intact and needing showers on specific days, the resident reported receiving mostly bed baths, with documentation showing extended periods without a shower. The facility's policy required at least one complete bath weekly, but records indicated non-compliance, leading to inadequate personal hygiene care.
A facility failed to reassess and implement individualized interventions for a resident with dementia, leading to increased combative behaviors. The resident, with severe cognitive impairment, exhibited physical aggression during personal care. Despite having a care plan, it lacked specific strategies for managing the resident's aggressive behaviors. Staff reported multiple incidents of aggression and expressed concerns about the lack of guidance. The facility's policy on proactive interventions was not effectively applied, and documentation was insufficient to update the care plan.
A resident with Multiple Sclerosis and other conditions experienced a significant delay in receiving assistance after activating the call light, leading to her being left soaked in urine for hours. The delay was attributed to severe staffing shortages, particularly on weekends, which had been a persistent issue at the facility. Staff members, including CNAs and LPNs, confirmed the inadequate care provided due to insufficient staffing, and the facility's administrator acknowledged the grievances received regarding the incident.
A resident with a history of chronic pain and other medical conditions experienced increased pain due to the facility's failure to administer pain medication as ordered. The resident's care plan lacked pain management interventions, and the prescribed Hydrocodone-acetaminophen was unavailable on several occasions. Despite adjustments to medication orders, the facility did not effectively utilize the emergency medication kit, resulting in unmanaged pain and discomfort.
The facility experienced significant staffing shortages, particularly on weekends, leading to inadequate care for residents. On a specific weekend, only 5 CNAs were available instead of the usual 8-10, resulting in prolonged wait times for assistance and unmet care needs. Residents and staff reported delays in care, with some residents left in soiled conditions and call lights going unanswered for extended periods.
Three residents experienced significant delays in receiving toileting assistance due to inadequate staffing, particularly on weekends. One resident, with multiple health issues, was left in a state of incontinence for hours, while another resident, who requires moderate assistance, chose not to use the call light due to known delays. A third resident, with severe cognitive impairment, was found by a family member lying in urine, prompting a grievance. Staff confirmed the staffing shortages and the resulting care delays.
A facility failed to timely acquire medication refills, resulting in missed doses for three residents. One resident did not receive their anxiety medication due to a clerical error with a DEA number. Another resident experienced significant pain due to unavailable pain medication, and a third resident missed a crucial diabetic injection. The facility's medication refill procedures were not followed, leading to these deficiencies.
A resident experienced a significant weight loss of 16.8% over six months due to the facility's failure to follow therapeutic dietary recommendations. The resident, with multiple diagnoses including dementia and dysphagia, did not consistently receive prescribed supplements, and the dietary system had communication issues preventing proper preparation of these supplements. The resident's weight dropped from 125.8 pounds to 96 pounds, and the comprehensive care plan lacked a focus on nutrition or weight loss.
The facility failed to properly label and store foods, affecting all 100 residents. Observations included gnats around ripe bananas, an improperly stored scoop in the powdered milk bin, and opened, unsealed, and undated cookies, bread, and hamburgers. The facility's Food Storage and Labeling procedure was not followed.
The facility failed to provide high calorie high protein supplements as ordered for four residents. Observations and staff interviews confirmed that the residents did not receive the required dietary supplements due to labeling errors in the dietary system.
A resident with multiple diagnoses reported $100 missing, but the facility failed to report the allegation to the state agency within 24 hours. The Director of Nursing confirmed no investigation was completed, and the Administrator admitted to not reporting the incident after local law enforcement could not substantiate the claim.
The facility failed to investigate a resident's allegation of missing money. Despite the resident being cognitively intact and reporting $100 missing, the facility did not conduct a thorough investigation or report the incident to the Illinois Department of Public Health. The Director of Nursing and the Administrator did not follow the facility's policy for handling such allegations.
The facility failed to provide written notification of the reason for transfer or discharge to two cognitively impaired residents, their representatives, and the Long Term Care Ombudsman. Despite verbal notifications and standard procedures, no written documentation was available for these transfers.
The facility failed to provide written notification of the bed hold policy to the representatives of two cognitively impaired residents upon their transfer to a hospital. Despite documentation indicating the policy was sent with the residents, the representatives did not receive any written notifications. The Director of Nursing confirmed that the policy is only provided to the resident, regardless of their cognitive status, and not sent to the family.
A facility failed to coordinate a PASRR Level II Screening for a resident with major depressive disorder, despite the resident being prescribed Aripiprazole. The Admission Coordinator was unaware of the requirement, and the facility lacked a specific PASRR policy, leading to the oversight.
The facility failed to refer a PASRR Level II Screening for a resident diagnosed with bipolar disorder. The Admission Coordinator was unaware of the requirement, and the facility lacks a specific PASRR policy. The Director of Nursing confirmed the absence of a PASRR screening policy, leading to the identified deficiency.
A resident at high risk for falls experienced a fall while attempting to use the restroom without assistance. Despite the care plan requiring visual cues to remind the resident to use the call light, these cues were not present in the resident's room or bathroom. Staff confirmed the absence of visual cues and were unaware of the requirement, indicating a failure to follow the care plan and implement necessary safety interventions.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by Roommate
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and protection from physical abuse for one resident with severe cognitive impairment and a history of trauma, including sexual and other forms of abuse. The resident had diagnoses of dementia, traumatic subdural hemorrhage, cognitive communication deficit, and vascular dementia, and a care plan problem category of mood state documenting major depressive disorder and anxiety. The resident’s Minimum Data Set showed a BIMS score of 4, indicating severe cognitive impairment. Despite this vulnerability and documented history of trauma, the resident remained in a shared room with another cognitively impaired resident who later became physically aggressive. On the date of the incident, the cognitively impaired roommate approached the resident while she was going through her closet and accused her of taking her boyfriend. A verbal argument ensued, during which the resident yelled that she did not want the boyfriend. The roommate then grabbed the resident’s hand and bit it, causing an immediately visible bruise. A bystander resident yelled that someone was fighting, prompting CNAs to run to the room. When staff arrived, the residents were already separated, with the injured resident holding her hand and stating that the roommate had bitten her. Staff observed a crescent-shaped, dark purple to almost black bruise on the palmar surface of the resident’s right hand below the fifth finger, resembling a human bite mark, with a blood blister and lipstick noted around the area; the skin was closed and not broken. Interviews and documentation showed that the incident was characterized as a resident-to-resident altercation and physical assault, with both residents marked as interviewable but unable to make informed decisions. The injured resident repeatedly reported that her right hand was hurting, and staff confirmed the presence of a bruise in the shape of a human bite or crescent moon. The facility’s abuse policy stated that the facility actively prohibits resident abuse and that special attention will be given to identifying behavior that increases a resident’s potential for abusing others or being a victim of abuse. Despite this policy and the resident’s known history of trauma and severe cognitive impairment, the facility failed to prevent the physical abuse that occurred when the roommate bit the resident’s hand, resulting in a bruise.
Failure to Follow Pressure Ulcer Orders and Implement Off-Loading Interventions
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and implement ordered pressure-injury prevention and treatment interventions for multiple residents at risk for, or with, pressure ulcers. One resident with intact cognition, decreased mobility, diabetes, incontinence, and a documented risk for pressure sores had care plan interventions for pressure reduction devices, turning and repositioning assistance, incontinence care after each episode, and ordered treatments including skin prep to bilateral heels, Triad cream and dressings to shearing on the buttocks and coccyx, antifungal powder to moisture-associated skin damage of the genital area, and off-loading boots. Despite these orders, the resident reported that staff did not reposition him in the recliner and only sometimes repositioned him in bed, especially at night only when he asked. Surveyors observed that off-loading boots were not in place on multiple occasions, and no skin prep was applied to the heels during a treatment observation. The resident was found with three open, bleeding areas on the buttocks and intergluteal cleft, consistent with stage II pressure ulcers, and with extensive redness and flaky skin over the buttocks. During observed peri care and wound treatment for this resident, CNAs and nursing staff did not have dressings in place on the buttock wounds prior to care, and the wounds were not listed on the facility’s Wound Summary Report. The DON stated that she believed these areas were “shears” and therefore not measured or included on the wound log, and that such areas were monitored only through weekly skin notes. Weekly skin assessments documented ongoing bilateral shearing to the buttocks with bleeding at times and boggy heels with treatment applied, but the wounds were not formally entered into the wound management system until after surveyor identification. The DON also acknowledged there was no facility policy for turning and repositioning and that staff did not document turning and repositioning, instead stating they “just follow the standard” of every two hours. The resident reported not receiving showers due to the sores on his buttocks and stated he could not reposition himself in bed or chair, and that staff did not routinely reposition him in the recliner. A second resident, cognitively intact and dependent or requiring substantial assistance for transfers and bed mobility, had documented risk for pressure ulcers, boggy heels, and physician orders and care plan interventions for skin prep to bilateral heels twice daily and off-loading boots to both lower extremities twice daily. The Wound Summary did not list this resident’s boggy heels, although progress notes documented bilateral boggy heels on several dates with sure-prep applied and no open areas. Surveyors repeatedly observed the resident without off-loading boots while in a wheelchair and in bed, with very red heels and one heel described by an RN as very soft, boggy, and non-blanchable. The resident stated that staff did not offer or attempt to apply the boots, that she could not put them on herself, and that she had only ever seen one boot, which was found in her closet; staff and the resident’s daughter reported not seeing boots in use. A third resident with dementia, diabetes, decreased mobility, and documented unstageable pressure injuries to the left heel and buttocks had care plan and physician orders for off-loading boots twice daily, pressure-reducing devices in bed and wheelchair, and specific wound treatments to the left heel and buttocks. The facility’s Wound Summary showed an unstageable pressure ulcer to the left heel that was not present on admission and was improving in size. However, surveyors observed this resident multiple times in bed and in a wheelchair without an off-loading boot on the affected foot; at one point, the wrapped left heel was resting directly on the metal wheelchair foot pedal. The resident reported that she sat in the wheelchair all day on some days, was not repositioned in the wheelchair, and that staff did not apply a large boot to her foot. The wound clinic NP later stated that the resident had never had the off-loading boot on during clinic visits and that the resident reported staff told her she did not need it anymore, despite the NP’s belief that the boot was needed to aid healing and prevention. Across these residents, the facility did not consistently implement or document ordered off-loading boots, heel protection, and turning/repositioning for residents at risk for or with existing pressure injuries. The DON confirmed that staff were expected to apply off-loading boots and follow physician orders but acknowledged that some residents refused and that nurses had “a lot to learn.” The physician and NP both stated they expected staff to follow orders and that off-loading boots help prevent and heal heel wounds. The facility’s Pressure Injury/Pressure Ulcer Prevention and Treatment Protocol required assessment of high- and moderate-risk residents for heel protectors and bridging of heels, yet residents with boggy heels and pressure injuries were observed without ordered off-loading devices in place, and some wounds were not entered into the wound summary for ongoing monitoring.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s need for access to a call light. The resident had chronic atrial fibrillation, osteoarthritis, anemia, essential hypertension, a history of TIA, and sleep apnea, and was assessed with a BIMS score of 15 indicating intact cognition. The MDS documented that the resident was dependent on staff for sit-to-stand, chair/bed-chair transfers, and toilet transfers, and required substantial/maximal assistance for bed mobility. The care plan identified the resident as at risk for falls and included interventions to instruct the resident to call for assistance before getting out of bed or transferring, and to orient the resident to the room and use of the call light system. On multiple observations, the resident was seen sitting in a wheelchair at the back of the room, several feet away from the call light, which was tied to the left bed rail and could not reach the resident’s preferred seating location. CNAs confirmed that the resident routinely sat in that spot, that the call light did not reach there, and that the resident pushed herself backward in the wheelchair but had difficulty moving forward. The DON acknowledged the resident sat in that location and was unsure if the call light would reach. The resident reported that she could push herself back but had trouble moving forward due to slick shoes, and that when she needed help she would try to get to the call light, call her daughter, or go to the doorway and yell for staff. The resident’s daughter confirmed the resident frequently sat by the window, struggled to propel herself forward, and often called her when she could not reach the call light, and stated she was concerned that the call light did not reach where the resident sat.
Failure to Follow Standard Precautions During Peri and Incontinence Care
Penalty
Summary
The deficiency involves failure to implement standard precautions during incontinence and peri care for one resident. The resident had intact cognition, multiple chronic conditions including chronic atrial fibrillation, osteoarthritis, anemia, essential hypertension, history of TIA, and sleep apnea, and was dependent on staff for transfers and toileting, with occasional bladder and bowel incontinence and a history of UTIs. During early morning care, a CNA provided peri care while the resident was side-lying, removed a urine-soaked brief and pad with strong urine odor, and began cleaning the buttocks with disposable wipes. After each use, the CNA threw the soiled wipes onto the floor. The CNA left the room to obtain a clean pad without removing gloves or performing hand hygiene, used the same contaminated gloves to open the door and access the clean linen cart, then returned and changed gloves without hand hygiene between glove changes. The CNA again left the room wearing gloves to obtain assistance, returned with another CNA, and continued care. Soiled wipes, the saturated brief, and the soiled bed pad were repeatedly thrown onto the floor, causing urine to splash onto the floor when the brief landed. After completing peri care and repositioning the resident, the CNA gathered the soiled items from the floor, bundled the used wipes and brief together, folded the soiled bed pad, and carried it under his arm with the contaminated surface touching his uniform. He then left the room still wearing the same gloves, disposed of the trash and linen, and handled the lids of the trash and soiled linen containers before finally removing his gloves and washing his hands at the end of the hall. Another CNA and the DON both confirmed that placing soiled items on the floor and wearing the same gloves from resident care into the hall and to the clean linen cart were not consistent with facility policy, which requires standard precautions including hand hygiene, proper PPE use, environmental care, linen handling, and waste disposal.
Shower Chair Deficiency Leads to Resident Injury
Penalty
Summary
The facility failed to maintain a shower chair in a safe condition, resulting in a resident's foot getting caught in the rubber strips of the chair, causing a nondisplaced spiral fracture of the right tibia. The resident, who was unable to complete a mental status interview and had impairments in both upper and lower extremities, was dependent on staff for showering and transfers. During a transfer to the shower room, the resident's foot slipped through the slats of the footrest, and a CNA heard a pop in the resident's ankle, leading to the injury. The incident occurred when two CNAs were pushing the resident in a shower chair to the shower room. The resident screamed in pain, and upon inspection, it was found that the foot had slipped through the rubber strips of the chair. Despite attempts to free the foot, a pop was heard, indicating a fracture. The resident was subsequently sent to the emergency room for evaluation and treatment of the fracture and a skin tear on the shin. The facility's investigation revealed that the rubber strips on the shower chair were stretched out and loose, which contributed to the incident. The maintenance director confirmed that the rubber strips were loose and stretched out, and the chair was taken out of use until it could be repaired. The facility's policy required regular equipment checks, but the maintenance director admitted that bathroom equipment was only checked on an as-needed basis, which may have contributed to the oversight.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, affecting all 111 residents. Multiple residents reported delays in receiving assistance with toileting and incontinence care, which are critical for their health and well-being. For instance, one resident, R3, who is cognitively intact and requires assistance due to cerebral infarction and hemiplegia, reported frequent incontinence and delays in receiving care, leading to discomfort and potential health risks. Another resident, R8, also cognitively intact, experienced similar issues, noting that timely incontinence care was not provided, contributing to ongoing skin issues. The report highlights several instances where residents had to wait extended periods for assistance, as evidenced by call light response times. R10, who is moderately cognitively impaired and requires assistance for various activities, reported waiting over an hour for help, resulting in a sore bottom due to delayed incontinence care. Similarly, R6 and R12 expressed frustration with the call light system, indicating that they often had to wait too long for assistance, sometimes resorting to self-care, which could lead to falls or other injuries. Staff interviews corroborated the residents' complaints, with CNAs and the Director of Nursing acknowledging staffing shortages, particularly on weekends. The facility was unable to provide consistent documentation to verify adequate staffing levels during the reported period. This lack of sufficient staffing and the inability to provide timely care and assistance to residents constitute a significant deficiency in the facility's operations.
Delayed Call Light Response Affects Resident Care
Penalty
Summary
The facility failed to respond to call lights in a timely manner, affecting the dignity and care of four residents. Resident R10, who is moderately cognitively impaired and requires assistance for various activities, reported long wait times for call light responses, particularly in the evenings. Documentation showed multiple instances where R10's call light was not answered for extended periods, including one instance where the response time was over an hour. R10 expressed that the delay in response led to inadequate incontinence care, resulting in a sore bottom. Resident R6, who is cognitively intact but requires assistance with daily activities, also reported difficulties in getting timely help. R6 mentioned being left in the bathroom for extended periods and experiencing inconsistent response times to call lights. The incident list confirmed delays in response times, with one instance lasting over thirty minutes. R6's care plan emphasizes the need for assistance to prevent falls, yet the delays in response compromise this intervention. Resident R3, who is cognitively intact and has a history of cerebrovascular accident, reported that there are times when no CNA is assigned to their hallway, especially on weekends. R3 stated that call light response times are inconsistent, and sometimes staff turn off the call light without returning. R12, who is also cognitively intact and recently admitted, echoed similar concerns, stating that call lights are often not answered promptly, leading her to take herself to the bathroom. The Director of Nursing acknowledged the issue, stating that call lights should be answered within 15 minutes, but this expectation is not consistently met.
Deficiencies in ADL Assistance and Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for four residents, leading to deficiencies in care. Resident 1, who was admitted for a short stay, was noted to have received only one shower during her five-day stay, despite her care plan indicating she should have showers on specific days. Concerns were raised by her power of attorney about her appearance, but staff assured that her needs were being met. However, there was a discrepancy in staff accounts regarding the provision of showers. Resident 3, who is cognitively intact and requires assistance due to hemiplegia and other mobility issues, reported not receiving timely assistance for toileting and incontinence care. She expressed frustration with inconsistent call light response times, which sometimes resulted in her being left incontinent for extended periods. Her care plan indicated she should be checked every two hours, but this was not consistently happening. Resident 8, who is also cognitively intact, had previously filed a grievance about delayed incontinence care and personal hygiene assistance. He noted that while care had improved slightly, staffing shortages, particularly on weekends, continued to impact the timeliness of care. Resident 10, with moderate cognitive impairment, also reported delays in receiving incontinence care, leading to skin issues. A CNA confirmed that night shift care was lacking, and staffing shortages were a recurring issue, especially on weekends and Fridays.
Inadequate Documentation and Involuntary Discharge of Resident
Penalty
Summary
The facility failed to provide adequate documentation by a physician regarding the involuntary transfer or discharge of a resident, identified as R8, who had severe cognitive impairment and a history of behavioral issues. The report highlights that the facility did not document the specific needs of R8 that could not be met, the attempts made by the facility to meet those needs, or the services available at the receiving facility to address R8's needs. Additionally, the facility did not allow R8 to return during the appeal process of the involuntary discharge. R8 had a history of Alzheimer's disease, cognitive communication deficit, and other mental health issues, which contributed to physical and verbal behavioral symptoms. The care plan for R8 included strategies to manage these behaviors, such as encouraging walks and providing emotional support. However, the care plan lacked specific goals or approaches related to R8's Alzheimer's or dementia diagnosis. Staff interviews revealed that there was no clear plan for managing R8's agitation, and the facility's electronic medical records did not contain detailed notes on R8's behaviors or the effectiveness of interventions. The facility's actions led to R8 being discharged to a hospital's acute psychiatric unit without proper documentation or a physician's order for discharge. The facility's Director of Nursing and other staff members acknowledged the lack of detailed documentation and the decision not to allow R8 to return during the appeal process. The facility's policies on memory care and resident transfer were not adequately followed, contributing to the deficiency identified in the report.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate bathing care for a resident, identified as R2, who was dependent on staff for assistance with activities of daily living. R2, who was cognitively intact with a BIMS score of 15, required substantial assistance for bathing as documented in the Minimum Data Set. The care plan specified that R2 should receive showers or whirlpool baths on Mondays, Wednesdays, and Fridays. However, observations and interviews revealed that R2 had not received a shower in over a week, with her hair appearing greasy and unwashed. R2 reported receiving mostly bed baths with moistened wipes instead of the scheduled showers. The facility's policy required at least one complete bath and hair wash weekly, with additional baths as necessary for personal hygiene. Despite this, documentation showed that R2 went 14 days without a shower or bath at one point, and another period of 9 days without a shower or bath. The Director of Nurses stated that the facility's policy was for residents to receive one shower or bath a week, with attempts to reschedule if a resident refused. However, the records indicated a failure to adhere to the care plan and facility policy, resulting in inadequate personal hygiene care for R2.
Failure to Implement Individualized Dementia Care Interventions
Penalty
Summary
The facility failed to reassess and implement individualized interventions for a resident diagnosed with dementia, leading to increased occurrences of combative behaviors. The resident, identified as R8, had a history of Alzheimer's disease, cognitive communication deficit, and other mood disorders. Despite having a care plan in place, the plan did not address R8's diagnosis of Alzheimer's disease or dementia, nor did it provide specific strategies for managing R8's aggressive behaviors. The care plan included general approaches such as encouraging walks and stopping tasks when the resident became agitated, but these were not tailored to R8's specific needs or effective in preventing aggressive incidents. R8 exhibited severe cognitive impairment with a BIMS score of 6 and displayed physical and verbal behaviors towards others, particularly during personal care activities. Staff members reported multiple incidents where R8 became physically aggressive, such as grabbing and punching a CNA during incontinence care. These behaviors were documented in the resident's records, but the interventions attempted, such as redirection and one-on-one attention, were not effective. The facility's documentation lacked detailed notes on the effectiveness of these interventions, making it difficult to update the care plan appropriately. Interviews with staff revealed that there was no clear plan for managing R8's agitation, and staff expressed concerns about the lack of guidance and the need for medication adjustments. The facility's policy emphasized proactive interventions and recognizing stress signs in residents, but these were not effectively implemented for R8. The Director of Nursing acknowledged the absence of detailed behavior notes, which hindered the ability to update the care plan and address R8's needs adequately.
Resident's Dignity Compromised Due to Delayed Call Light Response
Penalty
Summary
The facility failed to respond to call lights in a timely manner, compromising the dignity and care of a resident, R1, who was part of a sample of seven residents reviewed for dignity. R1, who was admitted with multiple diagnoses including Multiple Sclerosis and anxiety disorder, required substantial assistance with daily activities such as toileting and transfers. On the morning of August 11, 2024, R1 activated the call light for assistance to use the bathroom but was left waiting for hours, resulting in her being soaked in urine and experiencing feelings of desertion, fear, frustration, and embarrassment. Interviews with staff and review of call light logs confirmed that R1's call light was activated for over an hour before assistance was provided. The Occupational Therapist Assistant, who eventually helped R1, reported that the resident was found crying and soaked through her clothes and bedding. The facility's call light log corroborated the delay, showing a duration of over an hour for R1's call light on the day in question. Staff members, including CNAs and LPNs, acknowledged the severe staffing shortages on that day, which contributed to the delayed response to call lights and inadequate care. The facility's administrator and other staff members admitted awareness of the staffing issues, particularly on weekends, which had been ongoing for several months. Despite receiving grievances about the care provided on August 11, 2024, the facility struggled to maintain adequate staffing levels, resulting in compromised care for residents like R1. The administrator confirmed that the staffing on that day was not preferred and acknowledged the grievances received regarding the care issues.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as ordered and develop interventions to manage pain for a resident, resulting in increased pain due to missing four doses of ordered pain medication. The resident, who was cognitively intact, had a history of encephalopathy, end-stage renal disease, low back pain, and other conditions. Despite being on a scheduled pain medication regimen, the resident experienced significant pain, particularly after a fall, and reported that the pain medication was not administered timely, causing prolonged periods of severe pain. The resident's care plan did not address pain management, and the facility's Medication Administration Record indicated that the prescribed Hydrocodone-acetaminophen was unavailable on several occasions. The resident's pain was documented as severe, with scores ranging from 6 to 9 on a 10-point scale, and the resident expressed that the pain was not adequately controlled with the available medications. The facility's Director of Nursing acknowledged that the resident ran out of pain medications and was only given Tylenol, which was insufficient for managing the resident's chronic back pain. The Nurse Practitioner involved was aware of the resident's increased pain and had adjusted the medication orders accordingly. However, there were instances when the facility ran out of the prescribed medication, and the emergency medication kit was not utilized effectively to provide alternative pain relief. The facility's policy on pain management emphasized the importance of individualized care plans, which was not implemented in this case, leading to the resident's unmanaged pain and discomfort.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of its residents, particularly on the weekend of 8/11/2024. Multiple residents reported inadequate care due to staffing shortages, with some residents experiencing prolonged wait times for assistance. For instance, one resident was left in a soiled state for an extended period, and another resident's call light went unanswered for over an hour. These incidents were corroborated by family members and staff, who noted that the facility was significantly understaffed, especially on weekends. Staff interviews revealed that the facility typically operates with 8-10 CNAs on weekends, but on 8/11/2024, only 5 CNAs were present. This shortage was exacerbated by call-ins and no-shows, leaving some halls with only one CNA to care for numerous residents. The Director of Nursing acknowledged the staffing issues and the resulting delays in care, admitting that the situation was not acceptable and that residents were not adequately tended to. The facility's call light log confirmed extended wait times, with one resident's call light remaining active for over an hour. Staff members, including CNAs and LPNs, reported struggling to provide timely care due to the insufficient number of staff. The facility's administrator and other management personnel were aware of the staffing issues but were unable to rectify the situation promptly, leading to substandard care for the residents on that day.
Inadequate Staffing Leads to Delayed Care and Resident Distress
Penalty
Summary
The facility failed to provide timely toileting assistance to three residents, leading to significant distress and discomfort. Resident 1, who has multiple diagnoses including Multiple Sclerosis and requires substantial assistance with toileting, reported being left in a state of incontinence for several hours due to unresponsive call lights. The resident expressed distress over the situation, noting that the staffing was particularly low on weekends, which contributed to the delay in receiving care. An Occupational Therapist Assistant confirmed the prolonged wait time and the resident's condition upon finally receiving assistance. Resident 3, who is cognitively intact but requires moderate assistance for toileting, also experienced delays in care. The resident reported that the care is generally adequate but noted that the past weekend was particularly challenging due to staffing shortages. The resident chose not to use the call light, aware of the existing delays, and instead waited for the staff to assist him as part of the routine morning care. This indicates a systemic issue with staffing levels, particularly on weekends, affecting the timeliness of care. Resident 5, who has severe cognitive impairment and is dependent on staff for toileting, was found by a family member to be lying in urine, prompting a grievance. The family member expressed frustration over the persistent staffing issues and had to hire a private sitter to ensure adequate care. The CNA Supervisor and other staff members corroborated the reports of inadequate staffing, particularly on the day in question, which led to delayed care and unmet needs for the residents. The facility administrator acknowledged the staffing issues and the grievances received regarding the care provided.
Medication Refill Delays Lead to Missed Doses for Residents
Penalty
Summary
The facility failed to acquire medication refills in a timely manner, resulting in missed doses for three residents. Resident 1, who has multiple diagnoses including generalized anxiety disorder, did not receive their prescribed Dextroamphetamine-amphetamine (Adderall) on two occasions due to the medication being unavailable. The Director of Nursing acknowledged the issue, citing a clerical error with the Nurse Practitioner's DEA number as a contributing factor. The resident expressed distress over not receiving their anxiety medication and other necessary prescriptions. Resident 2, who suffers from chronic back pain among other conditions, experienced delays in receiving their prescribed Hydrocodone-acetaminophen. The resident reported significant pain due to the unavailability of the medication, which was documented as being out of stock on several occasions. The Director of Nursing confirmed that the resident had to be given Tylenol instead, as the facility ran out of the prescribed pain medication. Resident 3, diagnosed with type 2 diabetes mellitus, did not receive their scheduled Trulicity injection due to the medication being unavailable. The resident expressed concern over missing their diabetic medication, which is crucial for their condition. The pharmacist confirmed that the refill request was received late, and the medication was not available at the time it was due. The facility's policy and procedural manual outlines the process for medication refills, which was not adhered to, leading to these deficiencies.
Failure to Follow Dietary Recommendations Leads to Significant Weight Loss
Penalty
Summary
The facility failed to follow therapeutic dietary recommendations for a resident at risk for weight loss, resulting in a significant weight loss of 16.8% over six months. The resident, who has diagnoses including unspecified dementia, dysphagia, anxiety disorder, and cognitive communication deficit, was on a mechanical soft, high calorie/high protein (HCHP) diet. Despite this, the resident reported not consistently receiving the prescribed fortified milk, egg/tuna salad, or hard-boiled eggs. Observations confirmed that the resident's meal did not include fortified milk, and the resident's comprehensive care plan lacked a focus area for nutrition or weight loss. The facility's dietary system had issues with communication between two computer programs, leading to the failure of generating labels for dietary staff to prepare the necessary supplements. The Registered Dietitian (RD) noted significant weight loss and recommended additional supplements, but these were not consistently provided. The dietary supervisor acknowledged the system issue, and the RD confirmed that residents with HCHP supplements should receive them at all meals. The physician also expected that supplements would be provided to prevent weight loss. The resident's weight records showed a decline from 125.8 pounds to 96 pounds over the specified period, and the resident had a history of poor meal intake and pressure ulcers.
Improper Food Labeling and Storage
Penalty
Summary
The facility failed to properly label and store foods, which has the potential to affect all 100 residents residing in the facility. During an initial tour of the kitchen, multiple deficiencies were observed: a case of bananas in the dry storeroom had multiple gnats swarming around the ripe fruit; the bulk powdered milk bin had a scoop with the handle touching the food source; a bag of cookies and a loaf of bread were found opened, unsealed, and not dated in the dry storeroom; and hamburgers were found opened, unsealed, and not dated in the freezer. The facility's Food Storage and Labeling procedure, revised in 9/22, requires all food to be covered in a resealable bag or container, or the original container if applicable, and labeled with the product name, date, and discard date.
Failure to Provide Prescribed Dietary Supplements
Penalty
Summary
The facility failed to provide high calorie high protein supplements as ordered for four residents (R14, R23, R26, and R246) reviewed for therapeutic diets. For R246, who has a diagnosis of End Stage Renal Disease and is cognitively intact, the facility did not provide the prescribed high calorie supplement and high protein snack. Despite the dietary card indicating specific dietary restrictions and supplements, R246 was served regular meals without the required supplements. Interviews with dietary staff and CNAs confirmed that R246 did not receive the high calorie supplement or high protein snack due to a labeling error in the dietary system. R26, who has severe cognitive impairment and a diagnosis of unspecified protein-calorie malnutrition, was also not provided with the prescribed high calorie high protein supplement and extra gravy. Observations during meal times showed that R26 was served regular mechanical soft diets without the extra gravy or supplements. Family members and CNAs confirmed that R26 did not receive the required dietary supplements, and the dietary supervisor acknowledged a labeling error that prevented the supplements from being provided. R14, who is cognitively intact and has diagnoses including chronic kidney disease, did not receive the prescribed high calorie high protein supplement and extra protein at meals. Despite the meal ticket indicating the need for extra protein, R14 was served regular meals without the additional protein. Similarly, R23, who has moderate cognitive impairment and diagnoses including Alzheimer's Disease and chronic kidney disease, did not receive the fortified whole milk and fortified pudding as prescribed. Observations and staff interviews confirmed that R23 was not provided with the required supplements due to a failure in the dietary labeling system.
Failure to Report Allegation of Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the state agency within 24 hours. A resident with diagnoses including dementia, insomnia, bipolar disorder, anxiety disorder, depression, and hypothyroidism reported $100 missing from her belongings. The resident's Minimum Data Set (MDS) indicated she was cognitively intact, but her care plan noted she often misinterprets staff's intentions and has delusional episodes. The incident was documented in a Loss Control/Damage Report, but the money was never found, and no formal investigation was completed by the facility. Interviews revealed that the resident had informed the Activities Director about her missing money, but the Director was unaware of the allegation. The Director of Nursing confirmed that no investigation was completed and that the Administrator was responsible for reporting such incidents to the Illinois Department of Public Health (IDPH). The Administrator admitted to being aware of the allegation but did not report it to IDPH after local law enforcement could not substantiate the claim. This failure to report was acknowledged as a lapse in protocol by the Administrator.
Failure to Investigate Allegation of Misappropriation of Resident Property
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of misappropriation of resident property for one resident. The resident, who was cognitively intact with a BIMS score of 15, reported $100 missing from her belongings. The facility's documentation indicated that the money was last observed on 5/19/24 and discovered missing on 5/21/24. Despite the resident's report, the facility did not conduct a comprehensive investigation as required by their Abuse Prohibition and Reporting policy. The Director of Nursing confirmed that no investigation was completed, and the Administrator admitted that the allegation was reported to local law enforcement but not to the Illinois Department of Public Health (IDPH) due to insufficient evidence. Additionally, the Social Services Director noted that staff had not seen the resident with money, and the Activities Director was unaware of the missing money allegation. The facility's policy mandates interviews with all involved parties, obtaining signed statements, and maintaining documentation of the investigation. However, these steps were not followed. The Director of Nursing and the Administrator failed to produce any investigation documentation, and the Administrator did not supervise the investigation or report the results to IDPH. The lack of a thorough investigation and proper reporting constitutes a deficiency in the facility's handling of the resident's allegation of missing money.
Failure to Provide Written Notification for Transfers
Penalty
Summary
The facility failed to provide written notification of the reason for transfer or discharge to residents, their representatives, and the Long Term Care Ombudsman office for two cognitively impaired residents. Resident 39, who had severe cognitive impairment and multiple medical conditions, was transferred to the hospital on two occasions without written notification being provided to the resident or their Power of Attorney (POA). Despite requests for documentation, the Director of Nursing (DON) was unable to present any written notifications for these transfers, and the POA confirmed that no written notifications were received. Similarly, Resident 93, who was alert only to person and had a family member as their responsible party, was transferred to the hospital for shortness of breath. Although the family member was notified via phone, there was no documentation to show that written notification was provided. The DON and Medical Records staff confirmed that while the bed hold policy is typically sent with the resident's paperwork to the hospital, there were no records available to show that written notifications were sent to the family or the Ombudsman for this hospitalization.
Failure to Provide Written Notification of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to the resident representatives for two cognitively impaired residents, R39 and R93, upon their transfer to a hospital. R39, who has severe cognitive impairment and multiple diagnoses including heart failure and dementia, was transferred to the hospital on two occasions. Despite the facility's documentation that the bed hold policy was sent with the resident, R39's POA stated she did not receive any written notifications regarding the bed hold policy. The Director of Nursing confirmed that the facility only provides the bed hold policy to the resident upon transfer, regardless of their cognitive status, and does not send written documentation to the family. Additionally, the facility was unable to present evidence of the requested documents for R39's transfers when asked by the surveyor. This indicates a failure to comply with the requirement to notify the resident's representative in writing about the bed hold policy during transfers to the hospital. R93, who is alert only to person, was transferred to the hospital for shortness of breath, and the responsible party was notified via phone. However, the Director of Nursing again confirmed that the bed hold policy is only provided to the resident upon transfer and not sent to the family. The Medical Records staff stated that the form is filled out and mailed to the family, but no records were available to show that this occurred for R93's hospitalization. This further demonstrates the facility's failure to provide the required written notification of the bed hold policy to the resident's representative.
Failure to Coordinate PASRR Level II Screening
Penalty
Summary
The facility failed to coordinate a PASRR Level II Screening for a resident (R53) who was admitted on 7/31/2023 with a diagnosis of major depressive disorder. Despite the resident being prescribed Aripiprazole for major depressive disorder starting on 9/01/2023, the facility did not complete the necessary PASRR Level II Screening. The resident's PASRR Level I Screen Outcome dated 4/12/2019 indicated no suspicion of developmental disability or mental illness, and the Minimum Data Set (MDS) admission assessment did not consider the resident to have serious mental illness or intellectual disability. However, the resident's condition and medication indicated otherwise, necessitating a Level II Screening which was not performed. The Admission Coordinator (V4) admitted to not being aware that the resident required a PASRR Level II Screening and stated that the electronic PASRR system did not notify her of this requirement. The resident's stay, initially intended for respite care, extended beyond a few days, but the necessary screening was not initiated. Both the Admission Coordinator and the Director of Nursing (V2) confirmed that the facility lacked a specific PASRR policy. The facility's existing policy on Pre-Admission, Admission, and Orientation of Residents, revised on 6/1/2022, mandates pre-screening by the Department of Aging or other State Agency, but this was not adhered to in this case.
Failure to Refer PASRR Level II Screening for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to refer a PASRR Level II Screening for a resident diagnosed with bipolar disorder, current episode hypomanic. The resident's initial admission to the facility was documented on 4/16/24, and the PASRR Level I Screen Outcome dated 3/22/2023 indicated that no Level II was required. However, the Minimum Data Set (MDS) Admission assessment documented the resident's active diagnosis of bipolar disorder, which should have triggered a Level II PASRR screening. The Admission Coordinator was unaware that the resident needed a PASRR Level II and stated that the electronic PASRR system did not notify her of this requirement. Additionally, the facility does not have a specific PASRR policy in place. The Director of Nursing confirmed that the facility lacks a specific PASRR screening policy. The facility's Pre-Admission, Admission, and Orientation of Residents policy, revised on 6/1/2022, states that all residents should be pre-screened by the Department of Aging or other State Agency, and the Admissions Director should ensure that the screening form is placed in the electronic medical record. Despite this policy, the facility failed to complete the necessary PASRR Level II screening for the resident with a serious mental illness diagnosis, leading to the identified deficiency.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement new interventions to prevent falls for a resident identified as high risk for falls. The resident, who is cognitively intact and requires partial assistance for toilet transfer, experienced a fall while attempting to use the restroom without assistance. Despite the care plan including visual cues to remind the resident to use the call light, these cues were not present in the resident's room or bathroom. Staff members, including CNAs and an LPN, confirmed the absence of visual cues and were unaware that such interventions were required for the resident. The resident's care plan documented the need for visual cues after a fall incident, but these were not implemented. The resident confirmed the absence of reminders to use the call light, and staff verified that visual cue cards, which should say 'Stop. Press Call Button' in red letters, were not placed as required. This oversight indicates a failure to follow the care plan and implement necessary safety interventions for a high-risk resident, leading to a deficiency in accident prevention and supervision.
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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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