Michaelsen Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Batavia, Illinois.
- Location
- 831 North Batavia Avenue, Batavia, Illinois 60510
- CMS Provider Number
- 145409
- Inspections on file
- 20
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Michaelsen Health Center during CMS and state inspections, most recent first.
A deficiency occurred when the facility failed to follow its own policies for contact isolation and Enhanced Barrier Precautions (EBP). A resident with a history of C. diff, ongoing loose stools, and Vancomycin therapy was not placed on contact precautions, had no isolation or EBP signage or PPE outside the room, and staff entered without PPE. The ID NP was not notified of the change in the resident’s bowel pattern despite facility policy requiring contact precautions for symptomatic C. diff. In addition, multiple residents on the facility’s EBP list for wounds, indwelling urinary catheters, central lines, PEG tubes, and IV access had EBP signage and PPE bins placed inside their rooms instead of outside, and none had EBP orders on their POS. Staff interviews showed inconsistent understanding of EBP implementation, while the IP acknowledged that the facility did not obtain EBP orders and was not following its written EBP policy requiring signage and PPE outside resident rooms.
A resident received continuous topical triamcinolone and miconazole for groin fungal dermatitis over many months without stop dates, despite the skin condition being intermittent and having resolved about a month before surveyors’ observation. MAR review showed the steroid was given twice daily for five months and the antifungal daily for nine months. An LPN reported continuing to apply both medications even when the skin was clear, and the Infection Preventionist confirmed the orders were written as continuous rather than PRN. The Infectious Disease NP noted that long-term triamcinolone use can cause adverse effects and that both medications are typically temporary treatments, while facility policy requires contacting the prescriber when a medication may be inappropriate or excessive, which did not occur.
A resident with multiple comorbidities experienced a fall and reported hip pain, but staff failed to perform a thorough post-fall assessment or timely pain evaluation. The resident's pain worsened over several hours without adequate intervention or prompt transfer for imaging, resulting in a delayed diagnosis of a hip fracture that required surgical repair.
A resident with multiple complex medical conditions experienced a fall resulting in injury, but the facility failed to notify the resident's emergency contact and POA as required. Nursing staff documented the incident and notified the physician, but did not inform the family until the resident's spouse arrived the next day. The resident's pain worsened, leading to hospital transfer and surgical repair of a hip fracture. The administrator and DON confirmed the lack of timely family notification.
A resident with significant mobility limitations and poor bone quality, who required two-person assistance for incontinence care, was rolled and changed by a single CNA. During the process, the resident slid off the bed and sustained bilateral femur fractures, as confirmed by clinical and hospital records. Staff interviews verified that two-person assistance was required but not provided at the time of the incident.
The facility failed to provide necessary ADL assistance and personal hygiene care for residents. A resident was left with her meal out of reach, resulting in her expressing hunger and not eating, despite needing extensive assistance due to severe cognitive impairment. Additionally, two residents were observed with long, unkempt nails, indicating a lack of personal hygiene care, despite their care plans requiring staff assistance.
The facility failed to securely store medications for four residents. Medications were found in residents' rooms without proper orders or secure storage, including eye drops, pain creams, and a pill organizer with unknown pills. The Director of Nursing was unaware of some medications being unsecured, contrary to facility policy.
The facility failed to ensure proper infection control practices, including hand hygiene between resident feedings, handling of soiled linen, and educating visitors on PPE use for a resident under isolation. CNAs were observed not following hand hygiene protocols, and soiled linen was improperly managed. Visitors were not informed about PPE requirements, despite the facility's policy to educate them.
A resident missed significant medications for four days due to the facility's failure to transcribe physician orders upon admission. The resident, with multiple cardiac conditions, did not receive Eliquis and Atorvastatin as prescribed. The error was discovered when the family requested a medication review, revealing missed doses. The oversight was attributed to the nursing staff's failure to review entered orders.
A CNA was observed standing over three residents with severely impaired cognition while feeding them, contrary to the facility's policy requiring staff to sit next to residents during meals to ensure dignity. The DON confirmed that staff should be seated to promote a dignified dining experience.
A resident with multiple medical conditions was found with a mattress that did not fit the bed frame, exposing eight inches of metal and creating a potential hazard. Despite being reported by a CNA and acknowledged by a nurse, the issue remained unaddressed for several days. The Facilities Management Director confirmed the frame required a bariatric mattress, but a regular-sized one was in use. The DON stated it was everyone's responsibility to ensure proper equipment, and a work order should have been sent.
The facility failed to address monthly pharmacy recommendations for two residents, as the DON did not provide the necessary pharmacy regimen reviews and physician responses. The DON admitted to being behind in submitting these reviews to the physician, which is part of the facility's policy to ensure medication efficacy and safety. Documentation for the residents was unavailable, indicating a lapse in the medication review process.
A facility failed to check a resident's blood glucose level before a meal, leading to a potentially inaccurate reading and insulin administration. The resident had multiple diagnoses, including type 2 diabetes and chronic kidney failure. The DON confirmed the correct procedure was not followed and that no policy was in place.
A resident with multiple diagnoses, including pneumonia, received one dose of IV Ampicillin instead of the ordered IV Zosyn due to a delay in medication delivery from the pharmacy. The nurse administered the incorrect antibiotic from the facility's convenience box, and the physician was informed. The facility's medication administration policy was not followed.
Failure to Follow Contact Isolation and Enhanced Barrier Precaution Policies
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control policies for contact isolation and Enhanced Barrier Precautions (EBP). One resident with a known history of Clostridium difficile (C. diff) infection was not placed on contact precautions despite having loose bowel movements and receiving Vancomycin for a gastrointestinal issue. On multiple observations, there was no EBP or contact isolation signage on or outside this resident’s room, and no PPE bin was present outside the room. A registered nurse was observed in the room without PPE and stated the resident was not on isolation, even though the resident’s medication administration record showed ongoing Vancomycin therapy and the physician order sheet documented Firvanq for a history of C. diff. The Assistant DON/Infection Preventionist later stated that contact isolation orders for this resident had been discontinued when loose bowel movements had stopped, but that the resident began having loose bowel movements again on subsequent days. The Infection Preventionist acknowledged that the infectious disease nurse practitioner (ID NP) should have been notified when the loose bowel movements resumed so that contact isolation could be reinstated. The ID NP confirmed the resident’s history of C. diff and current Vancomycin treatment and stated he had not been informed of the recent loose bowel movements. He stated that the resident should have been placed back on contact isolation when the loose bowel movements began, consistent with the facility’s Clostridium Difficile Policy, which requires residents with diarrhea associated with C. difficile to be placed on contact precautions. The deficiency also includes the facility’s failure to implement its own EBP policy for multiple residents identified on the facility’s EBP list. For 16 residents on EBP for conditions such as wounds, indwelling urinary catheters, central lines, PEG tubes, and IV access, surveyors observed that EBP signage and PPE bins were placed inside the residents’ rooms rather than on the door or wall outside the room, contrary to facility policy and CDC guidance. Additionally, none of these residents had physician orders for EBP documented on their physician order sheets, despite being listed by the facility as on EBP. Staff interviews revealed inconsistent understanding of where EBP signage and PPE bins should be located, with some nurses stating they should be at the door and others explaining they were placed inside the room so staff could distinguish EBP from contact precautions. The Infection Preventionist confirmed that the facility did not obtain orders for EBP and that signage and PPE bins were intentionally placed inside rooms, even though the written EBP policy required signs and PPE to be posted and available outside resident rooms.
Unnecessary Prolonged Use of Topical Steroid and Antifungal Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s medication regimen was free from unnecessary drugs. Review of the physician order sheet showed continuous orders for triamcinolone acetonide 0.1% ointment twice daily for fungal dermatitis starting 9/17/25 with no stop date, and miconazole nitrate 2% cream daily for groin fungus starting 5/27/25 with no stop date. Medication administration records from May 2025 through February 2026 showed both topical medications were administered as ordered for extended periods, with triamcinolone given twice daily for five consecutive months and miconazole given daily for nine consecutive months. During interviews and observations, an LPN reported that the resident’s groin redness was intermittent and related to hygiene, and that he continued to apply both ointments daily even when the skin appeared clear. On observation, the resident’s bilateral groin was clear with no redness, and the resident stated the redness had resolved about a month earlier while staff continued applying both medications. The Infection Preventionist RN confirmed the orders were written as continuous rather than as needed despite the intermittent nature of the condition. The Infectious Disease NP stated that triamcinolone has potential side effects when used long term and that both triamcinolone and miconazole are usually temporary treatments, indicating triamcinolone should be discontinued and miconazole used only as needed. The facility’s own medication administration policy requires staff to contact a prescriber if a medication is believed to be inappropriate, excessive, or associated with potential adverse consequences, which was not done in this case.
Failure to Provide Timely and Comprehensive Post-Fall Assessment and Pain Management
Penalty
Summary
A resident with a complex medical history, including cancer, heart disease, chronic kidney disease, neurocognitive disorder, and a history of falls, experienced a fall in the facility. The resident reported pain in the left hip and was found sitting on the floor by staff. Nursing documentation indicated that the resident rated the pain as moderate initially, but there was no evidence of a comprehensive post-fall assessment, such as evaluation for range of motion, limb alignment, or a detailed pain assessment. The nurse on duty confirmed that she did not assess for musculoskeletal injury or conduct a complete pain assessment following the incident. Over the next several hours, the resident's pain escalated to severe and was unrelieved by Tylenol. Despite the resident's increasing pain and the absence of timely x-ray imaging, the transfer to the hospital was delayed for approximately five hours. The attending physician stated that she had ordered a hospital transfer based on facility policy for residents on anticoagulants after an unwitnessed fall, but was not aware the resident remained in the facility overnight. The resident was eventually transferred to the hospital, where an acute left hip fracture was diagnosed and surgically repaired.
Failure to Notify Emergency Contact After Resident Fall
Penalty
Summary
The facility failed to notify a resident's emergency contact and legal representative following a significant fall incident. The resident, who had a complex medical history including B cell lymphoma, lung cancer, intracerebral hemorrhage, atrial fibrillation, and other serious conditions, experienced a fall in his room, resulting in head, upper body, and left hip trauma with moderate pain. Nursing documentation confirmed that the physician was notified, but there was no documentation that the resident's emergency contacts were informed of the incident. The incident report also validated that no family notification was made regarding the fall. Subsequent nursing notes indicated that the resident's pain worsened, and the resident was eventually sent to the hospital, where an acute left hip fracture was diagnosed and surgically repaired. Interviews with nursing staff and the resident's spouse and daughter confirmed that neither the emergency contact nor the POA were notified of the fall or the change in the resident's condition until the spouse arrived at the facility the following day. The facility's administrator and DON acknowledged that the family was not notified of the incident, which was contrary to the facility's policy on resident rights.
Resident Fall and Fractures Due to Inadequate Assistance During Incontinence Care
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of osteitis deformans and poor bone quality, who was bedbound and required substantial/maximal assistance for mobility and incontinence care, was not provided adequate supervision and assistance during incontinence care. The resident's care plan and MDS indicated the need for two staff members to assist with rolling and hygiene activities. However, on the day of the incident, a single CNA attempted to change and roll the resident alone. During this process, the resident's legs, described as heavy and difficult to manage, slid off the bed due to the slippery air mattress and lack of control, resulting in the resident falling to the floor. Multiple staff interviews confirmed that the resident required two-person assistance for such care, and the CNA involved acknowledged she was alone at the time. The fall led to the resident sustaining bilateral femur fractures, as confirmed by clinical notes, hospital records, and an orthopedic surgeon. The incident was directly linked to the failure to follow the required two-person assist protocol for a resident with significant mobility limitations and high risk for injury.
Failure to Provide Adequate ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for residents requiring staff support. One resident, identified as R52, was observed in bed with her lunch placed out of reach, resulting in her meal remaining untouched despite expressing hunger. Her care plan indicated a need for extensive assistance with eating due to severe cognitive impairment and risk of weight loss. The Director of Nursing (DON) acknowledged that R52's care needs had changed to hospice, necessitating staff attempts to feed her and provide adequate time for eating. Additionally, the facility did not provide necessary personal hygiene care for several residents. R11 was observed with long, jagged fingernails and reported not receiving nail care for weeks, despite his care plan indicating a need for supervision in personal hygiene. R46 had long toenails and could not recall his last toenail care, although his care plan required moderate assistance with personal hygiene. R60 also had long, jagged fingernails and expressed a desire for staff assistance with nail care. The DON confirmed that staff should provide nail care as needed for infection control, dignity, and safety.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were safely and securely stored for four residents. For one resident, medications including eye drops, pain-relieving cream, and gas relief tablets were found on end tables in her room without a physician's order for them to be unlocked and at the bedside. The resident's sister confirmed she brought these medications from home. Another resident had a pill organizer with unknown pills, which she believed the nurses were administering, but the assigned nurse stated she did not use medications from the organizer. The Director of Nursing was unaware of the pill organizer's presence. A third resident had a glycerin laxative suppository and cortisone cream on her end table, which were brought from home, but there were physician orders for these medications. The facility's policy requires home medications to be collected and locked until a physician's order is obtained. Lastly, a fourth resident had two bottles of lubricant eye drops in his room, which were not ordered in his electronic health record. The Director of Nursing acknowledged that these should not have been in the resident's room unsecured.
Infection Control Deficiencies in Hand Hygiene, Linen Handling, and Visitor Education
Penalty
Summary
The facility failed to ensure proper hand hygiene and handling of soiled linen, as well as educating visitors on isolation practices, leading to multiple deficiencies in infection control. During a dining observation, a CNA was seen feeding multiple residents without cleaning her hands between assisting each resident, contrary to the facility's hand hygiene policy. Another CNA provided incontinence care without changing gloves or performing hand hygiene after moving from a contaminated area to a clean area. Additionally, soiled linen was improperly handled by being carried against a CNA's clothing and left on the floor, violating the facility's policy on handling soiled laundry. Furthermore, the facility did not adequately educate visitors on the use of PPE for a resident under isolation precautions for rhinovirus. Despite the presence of a registered nurse, visitors were observed not wearing PPE while in close proximity to the resident, and they reported not being informed about the requirement. The facility's policy mandates that visitors be educated on PPE use and that any refusal be documented, which was not adhered to in this instance.
Failure to Transcribe Medication Orders Leads to Missed Doses
Penalty
Summary
The facility failed to transcribe physician medication orders upon admission, resulting in a resident missing significant medications for four days. The resident, who was admitted with conditions including atrial fibrillation, hypertensive heart diseases with heart failure, and other cardiac issues, did not receive her prescribed Eliquis and Atorvastatin. The omission occurred because the registered nurse, who was busy with nighttime medication administration, delegated the task of entering the medication orders to the unit manager. Both nurses failed to review the entered orders, leading to the oversight. The resident's family member discovered the error when they requested a review of the medication list, revealing that the resident had missed eight doses of Eliquis and three doses of Atorvastatin. The Director of Nursing confirmed that the oversight was due to the nursing staff's failure to transcribe the prescribed orders. The resident's physician acknowledged the oversight, noting that it could have led to severe consequences, although fortunately, no adverse events occurred.
Failure to Provide Dignified Meal Assistance
Penalty
Summary
The facility failed to provide care with dignity to three residents during a dining observation. A CNA was observed standing over residents while feeding them, which is contrary to the facility's policy that requires staff to sit next to residents during meals to promote a dignified and home-like environment. This practice was observed with three residents, all of whom have severely impaired cognition and require partial to moderate assistance with eating. The facility's policies on Assistance with Meals and Dignity emphasize the importance of providing meal assistance in a manner that meets individual needs and promotes dignity. The CNA's actions of standing over the residents while feeding them did not align with these policies, as confirmed by the Director of Nursing, who stated that staff should be seated while assisting residents with meals. The residents involved in this deficiency were identified as having severely impaired cognition, highlighting the need for careful and respectful assistance during meals.
Improper Mattress Fit on Bed Frame
Penalty
Summary
The facility failed to ensure a resident's mattress fit the bed frame, creating a potential hazard for injury. This deficiency was observed in a resident with multiple medical conditions, including streptococcal sepsis, urinary tract infection, atrial fibrillation, pulmonary embolism, heart failure, spinal stenosis, and a history of transient ischemic attack and cerebral infarction. The resident's care plan identified them as at risk for falls due to impaired mobility, balance, and cognitive impairment. During observations, it was noted that approximately eight inches of the metal bed frame was exposed on the right side of the bed, indicating that the mattress was too small for the frame. Despite the issue being reported by a CNA to a nurse, and the nurse acknowledging the problem and intending to notify maintenance, the exposed bed frame remained unaddressed for several days. The Facilities Management Director and Associate Director confirmed that the frame was designed for a bariatric mattress, but a regular-sized mattress was in use. The Director of Nursing stated that it was everyone's responsibility to ensure the resident had the appropriate equipment, and a work order should have been sent. The facility's policies on hazardous areas and bed safety emphasize the importance of identifying and addressing equipment-related hazards to ensure resident safety.
Failure to Address Monthly Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that monthly pharmacy recommendations were addressed for two residents, R21 and R51, as part of a sample of 23 residents reviewed for medication review. On December 19, 2024, the surveyor requested the Director of Nursing (DON), identified as V2, to provide all pharmacy monthly medication reviews and physician responses to pharmacy recommendations for these residents from March 2024 to the current date. V2 admitted that he did not have any monthly pharmacy regimen reviews to provide and acknowledged that it was his responsibility to submit the pharmacy reviews to the physician for review. However, he had fallen behind in this process. The facility's policy, dated April 2018, outlines that the consultant pharmacist should use monthly and interim drug regimen reviews to identify potentially problematic medications. The policy requires the physician to adjust medications based on their efficacy, indications, and the presence of clinically significant risks, providing a rationale when necessary. Despite this policy, V2 stated that the process involved the pharmacy emailing him the recommendations, which he was supposed to place in a binder for the physician to sign off on. The physician would then leave the addressed recommendations in the binder for V2 to follow up on. However, documentation for R21 and R51 was not available, indicating a lapse in the established procedure for medication review and follow-up.
Failure to Monitor Blood Glucose Levels Before Meals
Penalty
Summary
The facility failed to obtain a resident's blood glucose level for sliding scale insulin administration prior to the resident eating a meal. This deficiency was observed in a resident who was admitted with diagnoses including sepsis due to MRSA, paroxysmal atrial fibrillation, type 2 diabetes mellitus without complication, non-pressure chronic ulcer on the right foot, and chronic kidney failure. The Physician Order Sheet indicated that blood sugar should be monitored, and insulin aspart administered per sliding scale at 8 AM and 5 PM. On the morning of the incident, the RN checked the resident's blood glucose level after the resident had already finished breakfast, resulting in a reading of 222 and the subsequent administration of 2 units of insulin aspart. The Director of Nursing confirmed that blood glucose levels should be checked prior to eating to avoid false high readings and acknowledged that the facility lacked a policy regarding this procedure.
Failure to Administer IV Antibiotics According to Physician Orders
Penalty
Summary
The facility failed to administer intravenous (IV) antibiotics according to physician orders for one resident. The resident, who had diagnoses including hypertensive heart disease, rhabdomyolysis, acute kidney failure, and pneumonia, was admitted to the facility and had an order for IV Zosyn every 8 hours for 17 days starting on 3/14/24. However, on 3/15/24, the resident received one dose of IV Ampicillin instead of Zosyn because the ordered medication had not arrived from the pharmacy. The nurse administered the incorrect antibiotic from the facility's convenience box, and the physician was informed of the incident. The facility's policy on administering medications, which requires verifying the right medication, dosage, time, and method, was not followed in this instance. The Director of Nursing (DON) confirmed that the resident was sent to the hospital on 3/1/24 due to symptoms including not eating, being only alert and oriented to self, and being sweaty and clammy. The resident was diagnosed with pneumonia and returned to the facility on 3/14/24 with the IV Zosyn order. The Registered Nurse (RN) who administered the incorrect antibiotic acknowledged the error, and the Medical Director confirmed that the resident received one dose of Ampicillin instead of Zosyn before the correct medication was resumed. The facility's failure to follow the physician's orders and its own medication administration policy led to this deficiency.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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