Pavilion On Main Street, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Sandwich, Illinois.
- Location
- 515 North Main, Sandwich, Illinois 60548
- CMS Provider Number
- 145712
- Inspections on file
- 36
- Latest survey
- October 9, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Pavilion On Main Street, The during CMS and state inspections, most recent first.
A resident requiring total staff assistance for transfers and supervision with wheelchair use was transported to an outside appointment without wheelchair footrests. After being fitted with a back brace, the resident slipped out of the wheelchair while being pushed by a staff member, resulting in a fall and head injury. Staff interviews and facility policy confirmed that footrests are necessary for safe transport unless specifically refused and care planned, but no such refusal was documented.
A resident with severe cognitive impairment, reduced mobility, and fragile skin sustained a deep leg laceration requiring hospital treatment after contact with a bed rail missing its end caps. Investigation found that multiple side rails in the facility lacked protective end caps, leaving rough metal edges exposed. Staff and maintenance confirmed the equipment was not in safe working condition at the time of the incident, and the resident had a history of skin tears and required extensive assistance for transfers.
A resident with a history of chronic pain management did not receive methadone and Lyrica for several days after admission due to missing prescriptions, resulting in multiple missed doses. Staff were unable to obtain timely scripts from the hospital, and the facility's medical director eventually provided them after a delay. Upon discharge, the resident also did not receive a prescription for a diuretic, causing further missed medication doses at home.
A resident with a history of skin tears and dependence on staff for transfers sustained a large skin tear requiring 11 stitches during a transfer from wheelchair to bed. The CNA involved noticed the injury after the transfer, and the resident was sent to the ER for treatment. The resident had experienced multiple similar injuries during previous transfers and repositioning, despite care plans and facility policies outlining the need for safe handling.
Two residents with significant weight loss did not receive their prescribed therapeutic diets, including double portions and specific supplements, as ordered by the registered dietitian. Despite clear dietary recommendations and care plans, staff provided only regular portions and omitted required items such as super cereal and ice cream during observed meals.
The facility did not follow prescribed recipes or menu requirements for pureed and mechanical soft diets, resulting in residents receiving incorrect food textures and inadequate portions. Pureed foods were prepared with unmeasured ingredients and insufficient protein, and mechanical soft diets were not properly ground as required. These failures affected all residents requiring therapeutic diets.
Surveyors observed unsanitary conditions in the kitchen and food prep areas, including overflowing garbage, dirty floors and equipment, improper storage of clean utensils, and food debris throughout. Staff failed to use required beard guards and did not follow hand hygiene protocols after handling garbage. Facility cleaning schedules and hygiene policies were not followed or enforced, affecting all residents.
Surveyors observed that several residents on pureed diets were served meals that were unappetizing, unidentifiable, and unpleasant in taste and texture. One resident voiced repeated dissatisfaction, and both surveyors and the administrator confirmed the poor quality of the pureed food after sampling. The facility's dietician acknowledged that recipes should be followed, but the meals did not meet the facility's guidelines for palatability.
Two residents were found to have significant wall damage, including heavy gouging and missing paint, behind their headboards and a recliner. The Director of Maintenance confirmed no work order had been submitted for repairs, despite facility policy requiring a safe and homelike environment.
Two residents with ADL self-care deficits did not receive scheduled showers as required. One missed a shower due to staff unavailability, with inconsistent documentation and a substantiated grievance. Another was marked as having refused a shower without proper documentation or nurse verification, and later denied refusing care. Facility policy for documenting refusals and re-attempting care was not followed.
A resident with a persistent, itchy body rash was not provided a timely dermatology consult as ordered by the physician. Despite ongoing symptoms and documentation indicating the need for referral, the scheduler was unaware of the order and no appointment was made, resulting in a delay in appropriate specialist evaluation.
Two residents experienced medication administration errors when RNs failed to follow proper procedures: one did not prime an insulin pen as required, and another gave an incorrect dose of Bumex due to a misunderstanding of tablet strength. These actions resulted in a medication error rate above the acceptable threshold.
A registered nurse used a blood glucose monitoring device on two residents consecutively without cleaning it between uses, contrary to facility policy requiring disinfection after each use. The nurse reported that the device is only cleaned after each shift. Both residents had orders for blood glucose monitoring, with one also receiving insulin therapy.
The facility did not have a certified Infection Preventionist, as the acting IP, an LPN, had not completed the required training and certification, and the previous DON with the necessary credentials was no longer employed. This failure had the potential to affect all 94 residents.
The facility failed to ensure staff wore beard coverings while serving food, as observed during a survey. Residents raised concerns about this issue, and a dietary aide was seen serving meals without a beard covering. The dietary manager acknowledged the requirement for beard coverings and noted plans to order new ones.
A resident was found with medications left at her bedside, which she forgot to take, despite not having a self-administration order. An LPN and the DON confirmed that medications should not be left at the bedside and that nurses should ensure residents take their medications. The facility's policy requires a competency assessment for self-administration.
A facility failed to provide a bed hold notice to a resident's representative during a transfer due to safety concerns. The Social Service Director marked a form indicating the policy was given, but admitted it was not sent. The DON confirmed no documentation of the notice was provided, violating the facility's policy.
Failure to Provide Wheelchair Footrests During Transport Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of compression fracture, rheumatoid arthritis, spondylosis, and spinal stenosis, who required total staff assistance for transfers and supervision or touch assistance with wheelchair use, was transported to an outside medical appointment without wheelchair footrests. During the return from the appointment, the resident, who had just been fitted with a back brace and was sitting abnormally in the wheelchair, reported slipping out of the chair. The transport driver was unable to prevent the resident from falling forward out of the wheelchair, resulting in the resident hitting her head on the concrete sidewalk and sustaining a hematoma and scalp abrasion. The wheelchair used for transport did not have footrests, and the resident was unable to keep her feet elevated, which contributed to her slipping and falling from the chair. Interviews with facility staff confirmed that footrests are necessary for safe wheelchair transport unless specifically refused by the resident and care planned accordingly. The resident's care plan did not indicate any refusal or preference against footrest use. The facility's policy also required footrests to be used unless the resident self-propels. The lack of footrests during staff-assisted transport, combined with the resident's physical condition and recent back brace fitting, directly led to the fall and injury. There was no facility policy regarding footrest use at the time of the incident.
Failure to Maintain Safe Bed Rail Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to maintain a bed rail in a safe condition, resulting in a resident sustaining a significant injury. The resident, who had a complex medical history including severe cognitive impairment, reduced mobility, osteoporosis, repeated falls, and fragile skin, required substantial to maximal assistance for most activities of daily living and was dependent on staff for all transfers. During an attempt to transfer the resident from bed, a CNA noticed the resident was fearful and holding tightly to the side rail. As the transfer was being performed, the resident suddenly complained of leg pain, and a significant laceration with heavy bleeding was discovered on her right leg. The injury required hospital treatment and sutures. Investigation revealed that the side rail involved in the incident was missing its end caps, leaving rough, exposed metal edges. The CNA reported that the resident was not combative but was fearful and resistant to getting up, and that the injury occurred within minutes of starting the transfer. Maintenance staff later confirmed that multiple side rails throughout the facility were missing end caps, with a documented list showing over 20 side rails in need of repair or replacement of end caps. The maintenance director acknowledged that the end caps were installed and padding was added only after the incident occurred. Staff interviews and record reviews indicated that the resident had a history of multiple skin tears and wounds in recent months, and that the facility's policy required equipment to be monitored for good working condition and repairs as needed. The DON stated that staff are expected to report any equipment that might pose a safety issue and to remove it from service until repaired. The physician described the resident as extremely fragile, with a propensity for severe skin injuries, and expected that equipment used with such residents should be free of rough edges. The facility's investigation confirmed that the injury was caused by the exposed metal on the bed rail.
Failure to Provide Timely Medication Administration Due to Prescription Delays
Penalty
Summary
The facility failed to ensure that a resident's medications were available and administered as ordered upon admission. The resident, who had a history of chronic pain management with methadone and Lyrica, did not receive these medications for several days after admission due to the lack of a valid prescription. The resident's wife reported that he missed his medications for three days and expressed concern about potential withdrawal, particularly because he had been on methadone for 13 years. Nursing staff confirmed that the medications were not available and documented missed doses in the medication administration record (MAR). The delay in medication administration was attributed to the absence of signed prescriptions from the hospital at the time of admission. The facility's process required a signed script from a physician before the pharmacy could dispense the medications. Staff attempted to obtain the necessary prescriptions by contacting both the hospital and the facility's medical director. The hospital declined to provide the scripts, and the facility's medical director eventually signed them after being notified. During this period, the resident missed multiple doses of methadone and Lyrica, as documented in the MAR and progress notes. Additionally, upon discharge, the resident did not receive a prescription for a diuretic (Bumetanide), resulting in missed doses at home until a home health nurse intervened. The facility's medication reconciliation policy outlined steps to ensure continuity of medication administration during transitions, but these procedures were not effectively followed, leading to interruptions in the resident's prescribed medication regimen.
Failure to Prevent Skin Tears During Resident Transfers
Penalty
Summary
A resident with a history of multiple skin tears and impaired skin integrity sustained a significant injury during a transfer from wheelchair to bed. The certified nursing assistant (CNA) involved reported noticing a blood stain on the resident's sock and, upon removing it, discovered a fresh wound on the left lower leg. The wound was later assessed as a large skin tear requiring 11 stitches, and the resident was transferred to the emergency room for treatment. Interviews with staff and the resident's daughter confirmed that the injury occurred during the transfer process, with the CNA unable to specify exactly how the injury happened. The resident's medical doctor and wound care nurse both confirmed the injury was sustained during the transfer. The resident's records indicate a pattern of similar incidents, including multiple previous skin tears and bruises occurring during transfers and repositioning. The care plan documented the resident's dependence on staff for transfers due to activity intolerance and dementia, requiring a two-person assist. Despite these documented needs and a policy requiring safe transfer practices, the resident continued to experience skin injuries during care, culminating in the significant laceration that required emergency intervention.
Failure to Provide Prescribed Therapeutic Diets for Residents with Significant Weight Loss
Penalty
Summary
The facility failed to implement dietary recommendations for residents with a history of significant weight loss, resulting in two residents not receiving their prescribed therapeutic diets. Observations revealed that the dietary manager prepared insufficient quantities of pureed chicken nuggets for residents on pureed diets, providing only half the required amount. Meal tickets for both affected residents indicated the need for double portions and specific supplements, but these were not provided during multiple observed meals. One resident with diagnoses including toxic encephalopathy, dysphagia, and dementia experienced significant weight loss over several months. Despite a registered dietitian's recommendation for double portions to address ongoing weight loss, the resident consistently received only regular pureed diet portions at meals. Documentation confirmed the resident's weight had decreased by over 10% in four months, and the care plan included interventions to increase meal portions, which were not followed. Another resident with major depressive disorder, complete loss of teeth, and severe underweight status was also affected. This resident's meal ticket specified a pureed diet with double portions, two bowls of super cereal at breakfast, and ice cream at lunch and dinner. Observations showed the resident did not receive the required double portions, super cereal, or ice cream during meals. The registered dietitian confirmed that these interventions were necessary to address the resident's significant weight loss, but the dietary recommendations were not implemented as ordered.
Failure to Prepare and Serve Therapeutic Diets According to Menu and Recipe Requirements
Penalty
Summary
The facility failed to properly prepare and serve pureed and mechanical soft diets according to prescribed recipes and menu requirements for all 97 residents. Specifically, for residents requiring pureed diets, the Dietary Manager did not follow the facility's pureed chicken nugget recipe, instead using unmeasured amounts of hot water and bread crumbs rather than the specified chicken broth and thickener. The Dietary Manager also failed to provide the correct portion size, pureeing only 21 chicken nuggets for 11 residents instead of the required 55, resulting in each resident receiving less than the intended amount of protein. Additionally, no pureed bread was served, despite it being listed on the menu, due to the Dietary Manager forgetting to include it. For residents requiring mechanical soft diets, the facility did not prepare the chicken nuggets according to the mechanical soft recipe, which required the nuggets to be ground with gravy. Instead, residents on mechanical soft diets were served whole chicken nuggets, not in the required texture. The Dietician confirmed that recipes and menus were not followed, and that water and bread crumbs should not have been used unless specified in the recipe. The facility's policy states that menus are to meet nutritional needs and be prepared as planned, but these procedures were not followed, resulting in residents not receiving meals consistent with their dietary requirements.
Failure to Maintain Sanitary Food Service Practices and Proper Staff Hygiene
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen and food preparation areas, as evidenced by multiple observations during a survey. The kitchen was found with an overflowing garbage container under the handwashing sink, sticky floors, and food and liquid debris present in several areas, including the sides and front of the oven and food processor. Clean utensils such as large spoons and metal scoops were stored on a dirty drainage mat contaminated with food debris and a sticky white liquid. The Dietary Manager acknowledged the unsanitary storage of utensils and was unsure when the kitchen was last cleaned, stating it had likely not been cleaned in over a week. In the walk-in freezer and dry storage room, food items and packets were scattered on the floor among opened boxes and debris. Additionally, two dietary aides with full beards were observed working in the kitchen without facial hair coverings, contrary to facility policy. Further unsanitary conditions were noted in the first-floor kitchenette, where the coffee machine was dirty, and the sink contained a soiled spoon, wet washcloth, cup, empty pitcher, and food debris, including scrambled eggs, with flies present. The floor was sticky and littered with food debris, and the steam table had spilled food with flies crawling on it. During food preparation, the Dietary Manager handled garbage and then prepared food without washing hands. Facility policies required daily cleaning schedules and the use of hair restraints and beard guards, but these were not followed or enforced, as confirmed by staff interviews and observations.
Unappetizing and Unpalatable Pureed Meals Served to Residents
Penalty
Summary
Surveyors found that the facility failed to ensure that residents on pureed diets received appetizing and flavorful meals. One resident, who required a pureed diet, repeatedly expressed dissatisfaction with the taste and appearance of his meals, stating he could not eat most of the food provided. Observations revealed that his trays often contained unidentifiable or unappetizing items, such as pureed pancakes and eggs with an unpleasant taste and consistency. Surveyors and the facility administrator sampled the pureed eggs and found them to be milky white, with a thin pudding-like consistency and an unpleasant, watery, powdery taste. Pureed chicken nuggets and carrots were also sampled and found to be very thick, sticking to the roof of the mouth, and unpalatable. The facility's dietician acknowledged that kitchen staff should be following recipes, but the meals served did not meet the guidelines for palatability and appetizing presentation. The deficiency affected at least four residents on pureed diets, including those with cognitive impairments who could not be interviewed. The facility's own guidelines require food to be prepared and served in a manner that is both safe and appetizing, but observations and interviews confirmed that this standard was not met for residents receiving pureed meals.
Failure to Maintain Homelike Environment Due to Wall Damage
Penalty
Summary
The facility failed to provide a homelike environment for two residents, as evidenced by heavy gouging and missing paint on the walls behind both residents' headboards and behind one resident's recliner. The damaged areas measured approximately 2-3 feet by 2-3 feet. During an interview, the Director of Maintenance confirmed that there was no work order submitted for the room and stated that resident rooms should not have wall damage or holes. Facility policy requires that residents be provided with a safe, clean, comfortable, and homelike environment.
Failure to Provide Scheduled Bathing and Proper Documentation for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled bathing assistance for two residents who required staff support for activities of daily living (ADLs). One resident, with a documented self-care deficit and a care plan indicating the need for staff assistance with bathing, was scheduled to receive showers twice weekly. However, records showed a significant gap between showers, and documentation was inconsistent between the shower sheets and the electronic medical record. The resident reported missing a scheduled shower due to staff being unavailable, and a grievance filed by the resident's son was substantiated, confirming the missed care. Another resident, also with an ADL self-care deficit and scheduled for twice-weekly showers, was documented as having refused a shower on a scheduled day. However, the documentation lacked a reason for the refusal, the name of the staff member who recorded it, and a nurse's signature, as required by facility policy. The resident later denied refusing the shower, stating he was waiting for it. Staff interviews confirmed that refusals should be documented with a nurse's involvement and that re-attempts should be made, but these steps were not followed.
Failure to Follow Physician's Orders for Dermatology Consult
Penalty
Summary
The facility failed to follow physician's orders for a dermatology consult for a resident with a persistent body rash that had been ongoing since July 2025. The resident was observed with a red, scabby rash covering his arms, abdomen, and inner thighs, and reported ongoing itching and discomfort. Despite being treated with Permethrin Cream for suspected scabies in July, the rash persisted. Progress notes from early August indicated a referral to dermatology was needed and that the resident's power of attorney agreed with this plan. However, the facility scheduler was unaware of the need for the appointment and had not scheduled it, resulting in a significant delay in obtaining the dermatology consult as ordered by the physician.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 6.67%, which exceeds the acceptable threshold of 5%. In one instance, a registered nurse (RN) administered Insulin Degludec to a resident without priming the needle as required by the manufacturer's guidelines. The nurse incorrectly believed that priming was only necessary for the first dose from the pen, despite instructions specifying that the pen should be primed before each injection to ensure proper dosing. In another case, a different RN administered only one tablet of Bumex (bumetanide) to a resident instead of the prescribed two tablets. The nurse misinterpreted the dosage, believing the tablets were 2 mg each when they were actually 1 mg, as indicated on the medication administration record and the medication card. This resulted in the resident receiving less medication than ordered by the physician. Both incidents demonstrate a failure to follow physician orders and established medication administration policies.
Failure to Clean Glucose Monitoring Device Between Resident Uses
Penalty
Summary
The facility failed to ensure proper cleaning of the blood glucose monitoring machine after each resident use, as observed during a survey. On the morning of 8/26/2025, a registered nurse used the glucose monitoring device to check the blood sugar of one resident and, without cleaning the machine, proceeded to use it on a second resident. The nurse then placed the uncleaned device back into the medication cart. When questioned, the nurse stated that the machine is cleaned after each shift with disinfectant wipes, rather than after each resident use. Both residents involved had physician orders for blood glucose monitoring, with one also receiving insulin aspart per sliding scale. The facility's policy requires cleaning and disinfecting of blood glucose meters between patient uses to prevent transmission of pathogens.
Lack of Certified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified Infection Preventionist (IP) who had successfully completed the required infection preventionist training and certification. The acting IP, an LPN, had been serving in this role for over a year but had not passed the test portion of the infection preventionist course and therefore had not received certification. The previous DON, who held the necessary IP certification, was no longer employed at the facility. The facility administrator confirmed that there was currently no certified IP on staff, despite the facility's job description requiring such certification for the position. This deficiency had the potential to affect all 94 residents in the facility, as noted in the facility data sheet.
Failure to Ensure Beard Coverings During Meal Service
Penalty
Summary
The facility failed to ensure that staff wore beard coverings while serving food, as observed during a survey. During a resident council meeting, residents expressed concerns about staff not wearing beard coverings when serving meals. This issue was observed firsthand when a dietary aide with a beard was seen serving food without a beard covering during meal service on both the first and second floors. Despite being reminded by another staff member to wear a face mask, the dietary aide initially did not comply. The dietary manager acknowledged that staff with beards should wear at least a face mask to cover their facial hair when serving or plating food. The manager also noted that some staff members were dissatisfied with the current beard coverings provided by the facility and mentioned plans to order new ones. The facility's policy on hair restraints, revised in 2017, requires food and nutrition employees to wear hair restraints and beard guards, which was not adhered to in this instance.
Failure to Monitor Medication Administration
Penalty
Summary
The facility failed to monitor a resident during medication administration, which was observed during a survey. A resident was found with medications left in a pill cup on her bedside table, which she had forgotten to take. The resident confirmed that the medications were left by a nurse about an hour prior, despite not having a self-administration order for medications. A Licensed Practical Nurse (LPN) stated that the resident did not have a self-administration order and that medications should not be left at the bedside. The Director of Nursing (DON) also confirmed that medications should not be left at the bedside and that nurses should ensure residents take their medications. The facility's policy requires that residents may only self-administer medications if they have been deemed competent to do so by the Attending Physician and the Interdisciplinary Care Planning Team.
Failure to Provide Bed Hold Notice During Resident Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to a resident's representative at the time of transfer, which is a violation of resident rights. The incident involved a resident who was transferred out of the facility due to safety concerns. The Notice of Involuntary Transfer or Discharge form, dated 5/21/24, indicated that a copy of the facility's bed hold policy was given to the resident or their responsible party. However, the Social Service Director admitted that she did not actually send a copy of the bed hold policy at that time, despite marking the form to indicate that it had been provided. The Director of Nurses confirmed that there was no documentation of a bed hold notice being sent with the resident at the time of transfer. The facility's policy requires that information concerning the bed-hold policy be provided upon admission and when a resident is transferred for hospitalization or therapeutic leave.
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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