Pearl Of Hillside,the
Inspection history, citations, penalties and survey trends for this long-term care facility in Hillside, Illinois.
- Location
- 4600 North Frontage Road, Hillside, Illinois 60162
- CMS Provider Number
- 145946
- Inspections on file
- 41
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Pearl Of Hillside,the during CMS and state inspections, most recent first.
Two residents did not receive catheter care according to standard practice and MD orders. A resident with severe cognitive impairment and a urinary catheter had stool on the catheter, and a CNA was observed wiping the catheter toward the urethra instead of from the insertion site outward; the spouse reported repeated infections and hospitalizations for UTI and sepsis. Another resident with a suprapubic catheter had a dirty insertion site with dry blood extending several inches around it, despite MD orders to cleanse the site daily and PRN with soap and water.
A resident with mild cognitive impairment and malignant neoplasm of the mouth missed multiple outside oncology and infusion appointments because staff did not arrange transportation in accordance with the facility’s appointments and transportation policy. Records showed that the resident was transported only to a cardiology visit while scheduled oncology and infusion appointments on the same day, as well as a separate oncology appointment, were not attended. An oncology clinic NP reported that the resident missed several appointments with various providers and that the resident attributed these missed visits to lack of transportation, poor communication, and failure to document appointments for staff follow-up, while the DON acknowledged that staff are responsible for setting up such appointments.
A cognitively intact, Spanish-speaking resident with a history of spinal fracture, hepatic encephalopathy, and prior falls, who was non-ambulatory and required substantial/maximal assistance and a transfer device with two staff for transfers, was assessed as low fall risk and later developed severe left-sided pain and immobility. Staff reported the resident complained of left arm and leg pain after lying on his left side, EMS documented pain beginning the prior night with denial of falls, and the resident was sent to the ER to rule out stroke, where imaging revealed multiple acute and chronic fractures, intracranial and intra-abdominal hemorrhages, and bruising estimated to be several days old. Hospital documentation noted the resident at one point accepted that someone hurt him but was reluctant to provide details, while a facility liaison later recorded the resident’s account that he attempted to get out of bed, fell toward the window, and was helped back to bed by staff; in a later interview with an interpreter, the resident said he did not remember falling. Numerous CNAs, LPNs, and RNs denied witnessing a fall or knowing what happened, no fall incident report was available, and staff consistently described the resident as unable to get out of bed or walk independently, while the physician stated the injuries were consistent with a fall and that the resident should never have been rated low fall risk.
A resident with Mild Alzheimer's and on Eliquis sustained a depressed orbital floor fracture and orbital globe rupture after an incident involving a CNA and a broken necklace. The first clinician on the scene documented the resident’s immediate allegation that the CNA hit him, observed the CNA’s agitation and anger, and reported these findings, including that a staff member had called 911 to report an assault. The facility’s investigation omitted these critical observations from the report to law enforcement, concluded the injury was accidental and self-inflicted, did not clinically evaluate whether the necklace or a self-blow could cause such trauma, and did not consider the resident’s cognitive impairment or have a neutral advocate present when the resident allegedly recanted. As a result, an incomplete and medically implausible account of the incident was provided to law enforcement.
Two residents experienced issues with gnats in their rooms, including gnats around full trash cans and food items, while gnats and a mosquito were also observed in the kitchen dishwashing area. The maintenance director linked the pest issue to unemptied trash, and a pest control inspection confirmed fruit flies in the kitchen, with recommendations for floor maintenance.
A resident with hemiplegia and moderate cognitive impairment, who was dependent on staff for toileting and always incontinent, was not provided incontinence care for over four hours. The resident was found with a saturated brief, wet bed pad, and dried urine stain on the sheet, despite staff and care plan requirements for care every two hours.
A resident with a history of falls, cognitive deficits, and unsteady gait did not have a specific fall care plan or adequate supervision upon admission. The resident, who had limited English proficiency, was found urinating on the floor and subsequently slipped in the urine, resulting in a head injury and hospitalization for intracranial bleeding. Staff interviews revealed that the resident's needs for supervision and toileting assistance were not adequately addressed, and the assigned CNA was attending to another resident at the time.
A resident with significant medical needs reported a leaking bathroom sink that had gone unrepaired for two weeks, with staff placing a bucket under the sink to collect water. Despite the facility's work order system, the maintenance issue was not reported or addressed until the survey, resulting in an unsanitary and non-functional environment for the resident.
The facility failed to provide annual dental exams and routine monitoring for dental care needs for several residents, as required under the State health plan. Five residents did not have documented dental visits or evidence of declining services, despite being covered by Medicaid or a combination of Medicare and Medicaid. Staff provided inconsistent information about dental visit frequency and insurance impact, and there was no documentation to support claims of service provision.
A resident with severe cognitive impairment and neuromuscular dysfunction of the bladder developed a catheter-associated UTI due to inadequate care at the facility. The resident's urinary catheter was found with maggots, indicating poor hygiene. Staff reported challenges in cleaning the catheter and a lack of documentation on catheter care and output. The resident was hospitalized with proteus bacteremia and a complicated UTI.
A resident with severe cognitive impairment and high fall risk fell during a smoke break due to inadequate supervision. The nurse monitoring the resident stood over seven feet away, and when the resident dropped a cigarette, he attempted to pick it up and fell from his wheelchair, sustaining a nasal fracture and laceration. The resident had been given a reacher for safety but forgot to use it.
Failure to Follow Standard and Ordered Catheter Care for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow standard practice and physician orders for urinary catheter care for two residents. One resident with severe cognitive impairment had a urinary catheter with stool present on it. A CNA was observed providing catheter care by wiping the catheter toward the urethra and then away from it, rather than from the insertion site outward as described by the DON as standard practice. The resident’s spouse reported that the resident had been sent to the hospital for a severe infection and alleged that staff were not changing gloves between care, which was causing infection. Health status notes documented multiple hospital admissions for this resident for UTI and sepsis on several prior dates. Another resident with intact cognition and a suprapubic catheter was observed in bed with the suprapubic catheter insertion site dirty and surrounded by dry blood extending almost four inches around the site. The physician’s orders for this resident directed staff to cleanse the suprapubic catheter insertion site daily and as needed with soap and water unless otherwise ordered. At the time of observation, the suprapubic catheter site was not clean as ordered, and the DON stated that the suprapubic catheter should have been kept clean to prevent potential infection.
Failure to Arrange Transportation for Oncology and Infusion Appointments
Penalty
Summary
The deficiency involves the facility’s failure to follow its appointments and transportation policy by not arranging transportation for a resident’s outside oncology and infusion appointments. The resident is an adult male with mild cognitive impairment and an admitting diagnosis that includes malignant neoplasm of the mouth, as documented on the MDS. On one observation, he was noted in bed with swollen lips and was unable to communicate effectively. The facility’s policy, reviewed on 4/16/2025, states that when a resident has an appointment outside the facility, staff will make transportation arrangements unless the responsible party chooses to make them. The DON acknowledged not remembering why the resident missed appointments and stated that the resident has the right to go for an appointment and that staff are supposed to set it up. Record review showed that the resident had multiple scheduled outside appointments, including cardiology, oncology, and infusion visits. Physician orders documented that on 2/4/26 he was scheduled for a cardiology appointment at 9:05 AM, an oncology appointment at 12:00 PM, and an infusion appointment at 2:00 PM. The transportation schedule and nursing progress notes from 2/1/26 through 2/6/26 showed that he was sent only to the cardiology appointment and not to the oncology or infusion appointments. A review of the January transportation schedule and nursing progress notes from 1/25/26 through 1/30/26 further documented that he was not sent to an oncology appointment scheduled for 1/27/26 at 11:40 AM. The oncology clinic nurse practitioner reported that the resident missed around five appointments with various care providers, and that the resident stated he missed appointments due to lack of transportation, communication, and not writing the appointments in the records for staff to follow up after setting transportation. The nurse practitioner stated the resident is at high risk for relapse if he misses his oncology appointments.
Failure to Prevent and Adequately Account for Resident’s Multiple Traumatic Injuries of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to protect and prevent a cognitively intact resident from sustaining injuries of unknown origin, including multiple fractures and intracranial and intra-abdominal hemorrhages. The resident was admitted with significant medical history including an unstable burst fracture of T11–T12, hepatic encephalopathy, cirrhosis, pancytopenia, and a history of falls and alcohol dependence. The resident’s primary language was Spanish, and the most recent MDS documented a BIMS score of 15, indicating intact cognition, with use of a wheelchair for ambulation and a need for supervision or touching assistance for transfers. Therapy records and staff interviews consistently indicated that the resident could not walk independently, could not transfer independently, and required substantial/maximal assistance and a transfer device with two staff for transfers. Despite this, the resident’s fall risk assessments categorized him as low risk for falls, and the physician later stated that the resident should never have been rated low risk and that he was high risk for falls. On the day of the incident, the resident complained of left shoulder and left leg pain with limited mobility and inability to move the affected extremities. A CNA who spoke Spanish reported that the resident stated he had slept on his left side for a long time and requested help to turn; she assisted by pulling the incontinent pad to reposition him and notified the RN. Another CNA assigned to the resident that morning observed him in pain, with a swollen left arm, and heard him indicate pain in the left arm, again with the explanation that he had been lying on his left side. The RN assessed the resident, noted extreme pain and numbness in the left upper extremity and limited mobility in the left arm and leg, and obtained orders from the NP to send the resident to the ER to rule out stroke. The EMS run sheet documented that the resident complained of left shoulder and hip pain that began the previous night and denied any falls or trauma. The facility’s initial incident report recorded that the resident denied anyone hurting him and stated he felt safe at the facility. At the hospital, diagnostic imaging revealed multiple acute and chronic fractures, including an acute comminuted and displaced left humeral head fracture, bilateral subcapital femoral neck fractures, sacral fractures, a right L4 transverse process fracture, a small left subdural hematoma, a right parietal subarachnoid hemorrhage, intra-abdominal hemorrhage, and bruising to the anterior chest wall and left shoulder estimated to be 3–4 days old. The ER RN, who spoke Spanish, reported that the resident initially said he did not remember what happened, and hospital documentation noted that at one point he accepted that somebody hurt him but was reluctant to provide details due to fear of police involvement or other social reasons. A facility liaison later interviewed the resident in the hospital; the resident stated he had been doing exercises in bed, felt stronger than normal, attempted to get out of bed, fell toward the window side, and was assisted back to bed by staff, but he reported no pain at that time and said he did not want anyone to get in trouble. During a subsequent in-facility interview with an interpreter, the resident stated he did not know what happened, did not remember falling, and only recalled waking up in pain and being sent to the hospital. Throughout the facility’s internal investigation, multiple CNAs, LPNs, and RNs who worked with or around the time of the incident denied witnessing any fall or knowing what happened to the resident, and no fall incident report could be produced. Staff interviews consistently described the resident as unable to get out of bed, unable to sit on the edge of the bed or scoot, and requiring two-person assistance with a transfer device for any out-of-bed activity. The physician and NP both stated that the resident had not been able to walk since admission and could not independently get up from bed or dangle his feet to exercise. The physician opined that the resident’s injuries were consistent with a fall and that he was a high fall risk. The administrator and DON maintained that the resident did not fall based on staff interviews, and one CNA who worked the night before the resident’s complaints denied picking the resident up from the floor. However, when shown pictures of night CNAs, the resident identified that CNA as the person who picked him up from the floor. The facility’s abuse prevention policy defined injury of unknown source as an injury not observed and not explainable by the resident, with suspicious extent or location, and the facility concluded that none of the staff knew what happened or the cause of the resident’s injuries.
Failure to Conduct Thorough and Credible Abuse Investigation After Severe Eye Injury
Penalty
Summary
The facility failed to conduct a thorough and credible abuse investigation for one resident who sustained a depressed orbital floor fracture and left orbital globe rupture requiring emergent surgical intervention. The resident, who had Mild Alzheimer's and was taking Eliquis (Apixaban), initially alleged that a CNA hit him, an allegation documented by the first clinician on the scene, an agency RN. This RN also observed the CNA in an agitated and angry state over a broken necklace and reported these observations, including the resident’s statement that the CNA hit him and that a staff member had reported the incident as an assault via a 911 call, to the Administrator and management. However, these critical observations and the documented allegation of assault were omitted from the facility’s formal report to law enforcement. The facility concluded that the injury was accidental, suggesting the resident struck his own eye, and did not consider or document the possibility that the necklace chain or pendant could have been the blunt object causing the injury. There was no evidence that the facility consulted a medical professional to assess whether a swinging pendant or a self-inflicted blow by an elderly resident with Mild Alzheimer's could generate sufficient force to cause the documented orbital fracture and globe rupture, or to reconcile how a minor accident could result in severe hemorrhaging requiring emergent surgery in a resident on Eliquis. Additionally, the Administrator reported to police that the resident recanted the allegation, but facility records did not show that the resident’s cognitive impairment or potential suggestibility after traumatic injury were considered, nor that a neutral advocate or social worker was present during the recantation. These omissions and failures in the investigative process resulted in an incomplete and medically implausible narrative being provided to law enforcement and demonstrated that the facility lacked a thorough implementation of an abuse investigation system required by Federal regulations.
Failure to Implement Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest management program, resulting in the presence of gnats in resident rooms and the kitchen area. In one resident's room, multiple gnats were observed flying around two trash cans near the entryway, with more than ten gnats crawling on the outside of a white trash can. The trash can was noted to be full, and the maintenance director attributed the presence of gnats to the trash not being emptied by CNAs. The same resident was also observed with gnats on his bed sheet and around a partially open bag of restaurant food on his bedside table, with several gnats crawling on and inside the food bag and on the wall nearby. Another resident reported having a problem with gnats, and three gnats were observed flying around her bed and bedside table. During a tour of the kitchen, three to four gnats and a large mosquito were observed flying near the handwashing sink in the dishwashing area. The dietary manager confirmed the presence of gnats and a mosquito in this area. A pest control service inspection report documented the presence of fruit flies in the main kitchen area and noted that the kitchen floor needed to be regrouped to prevent fruit flies from breeding. The facility's pest control policy emphasized the importance of maintaining a healthy environment and specifically mentioned the need to keep trash cans lined and emptied regularly.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A resident with hemiplegia and hemiparesis, who was documented as always incontinent and dependent on staff for toileting, was not provided incontinence care at least every two hours as required by their care plan. On observation, the resident was found with a saturated adult brief, a wet bed pad, and a dried urine stain on the fitted sheet, indicating that incontinence care had not been provided for over four hours. The resident reported last being changed in the early morning, and the assigned CNA confirmed the last care was provided at 9:00am, despite facility policy and staff statements that care should be provided every two hours and as needed. Documentation and staff interviews confirmed the resident's need for frequent incontinence care due to heavy urinary incontinence.
Failure to Implement Adequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to develop and implement an adequate care plan with increased monitoring and supervision for a resident who was identified as having poor safety awareness, a history of falls, unsteady gait, and cognitive deficits. Despite being newly admitted with diagnoses including abnormal gait, lack of coordination, hypotension, and aphasia, the resident did not have a fall care plan in place upon admission. Staff relied on a general fall focus system rather than a resident-specific plan, and the resident's needs for supervision and toileting assistance were not sufficiently anticipated or addressed. As a result, the resident was found urinating on the floor and subsequently slipped in his own urine, leading to a fall that caused a bump to the head and a change in consciousness. The resident, who only spoke Mandarin and had limited ability to communicate, was found lethargic and drowsy after the incident and was later diagnosed with intracranial bleeding and admitted to the hospital. Staff interviews confirmed that the resident was unsupervised at the time of the incident, and that the CNA assigned to the unit was attending to another resident. The lack of a tailored fall prevention plan and insufficient supervision directly contributed to the accident.
Failure to Maintain Functional and Sanitary Resident Environment Due to Unaddressed Sink Leak
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including diabetes, congestive heart failure, atrial fibrillation, hypertension, acute kidney disease, osteomyelitis, and bilateral leg amputations, reported that their bathroom sink had been leaking for two weeks. The resident, who was cognitively intact and required partial/moderate assistance for mobility, stated that staff had placed a gray bucket under the sink to catch the leaking water but had not arranged for repairs despite being notified. Upon observation, the surveyor found the bucket half full of dirty water and witnessed water dripping into it when the faucet was used. Interviews with facility staff revealed that the Maintenance Director was only made aware of the issue on the day of the survey and began repairs immediately. The Administrator and Director of Nursing both stated they were not previously informed of the leak, despite the facility having a policy and system in place for submitting maintenance work orders, including QR codes for easy reporting. The failure to report and address the leaking sink resulted in the resident's environment not being maintained in a functional and sanitary condition.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure that residents received annual dental exams and routine monitoring for dental care needs, as required under the State health plan. This deficiency was identified for five out of seven residents reviewed for dental services. Specifically, one resident had not received a dental visit within the past year, and there was no documentation indicating that the resident declined services. Four other residents had no documented dental visits or evidence of declining services since their admission to the facility. All these residents were covered by Medicaid or a combination of Medicare and Medicaid. During the survey, facility staff provided inconsistent information regarding the frequency of dental visits and the impact of insurance on service provision. The Assistant Director of Nursing was unsure about the frequency of dental visits, while the Social Worker mentioned that an in-house dentist visits twice a month and that transportation is arranged for residents using outside dentists. However, there was no documentation to support these claims for the residents in question. The facility's policy states that it will provide routine and emergency dental services and assist residents with appointments and transportation, but the lack of documentation and follow-through indicates a failure to adhere to this policy.
Inadequate Catheter Care Leads to Resident Hospitalization
Penalty
Summary
The facility failed to prevent a resident from developing a catheter-associated urinary tract infection (UTI), which necessitated hospitalization. The resident, a male with severe cognitive impairment and neuromuscular dysfunction of the bladder, was dependent on staff for toileting and hygiene. Observations and interviews revealed that the resident's urinary catheter care was inadequate, with reports of dark, cloudy urine and a lack of proper documentation of catheter care and output. The resident was found to be lethargic and unresponsive, leading to his transfer to the hospital. Upon examination at the hospital, the resident was diagnosed with proteus bacteremia and a complicated UTI, with maggots found in the urinary catheter. This indicated poor hygiene and improper catheter care at the facility. The facility's staff, including a CNA and an LPN, reported challenges in cleaning the catheter due to the resident's contracted lower extremities and noted a lack of urine output documentation. The facility's policy required daily catheter care, but there was no documentation of such care being performed. The facility's failure to document and perform adequate catheter care led to the resident's severe infection and subsequent hospitalization. The lack of documentation and communication among staff members contributed to the oversight in the resident's care. The facility's policy on indwelling catheter care was not adhered to, resulting in the resident's deteriorating condition and the presence of maggots in the catheter, which is a sign of neglect and poor hygiene practices.
Inadequate Supervision During Smoke Break Leads to Resident Fall
Penalty
Summary
The facility failed to adequately supervise and monitor a resident during a smoke break, resulting in an accident. The resident, who has schizophrenia, dementia with behavioral disturbances, and severe cognitive impairment, was identified as high risk for falls. During a smoke break, the resident dropped a cigarette and attempted to pick it up, leading to a face-forward fall from his wheelchair. The fall resulted in an open fracture of the nasal bone and a nasal laceration requiring sutures. The incident occurred when a nurse, who was not a smoker, took the resident to the smoking area. The nurse stood inside the entrance/exit smoking patio door, monitoring the resident from a distance of seven feet and seven inches. When the resident bent down to pick up the cigarette, the nurse attempted to intervene but was unable to prevent the fall. The resident's jacket slipped off as the nurse tried to grab it, and the resident fell onto the concrete patio. The resident had previously been given a reacher to assist with picking up items from the floor due to poor safety awareness and impulsiveness. Despite this, the resident forgot to use the reacher during the incident. The facility's fall prevention and management policy emphasizes the need for individualized interventions for high-risk residents, but the supervision provided during the smoke break was insufficient to prevent the fall.
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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