Pearl Of Rolling Meadows,the
Inspection history, citations, penalties and survey trends for this long-term care facility in Rolling Meadows, Illinois.
- Location
- 4225 Kirchoff Road, Rolling Meadows, Illinois 60008
- CMS Provider Number
- 145350
- Inspections on file
- 34
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Pearl Of Rolling Meadows,the during CMS and state inspections, most recent first.
The facility did not enforce its smoking policy, allowing residents to smoke near the main entry door and failing to provide metal containers with self-closing covers in designated smoking areas. Staff were aware that residents were not consistently using the designated area, and cigarette butts were observed in multiple locations without the required safety equipment.
A resident with delirium and cognitive impairment was transferred to the emergency room after an unwitnessed fall, but staff failed to notify the receiving hospital as required by facility policy. Nurses on duty did not communicate the transfer, believing it was the ambulance driver's responsibility, despite the resident's inability to advocate for themselves.
Three residents with dementia and high fall risk experienced multiple unwitnessed falls, including incidents in the dining room and hallways, due to inadequate supervision and insufficient implementation of care plan interventions. One resident sustained a hip fracture and head injury, while another fell after dozing off in a wheelchair, and a third had repeated falls related to impulsive behaviors and lack of monitoring. Staff interviews confirmed that supervision was not consistently maintained, especially during busy periods such as mealtimes.
Several dependent residents did not receive scheduled showers or adequate grooming, with documentation and observation confirming infrequent bathing and poor hygiene. Residents reported missed showers and primarily received bed baths, despite care plans and facility policy requiring regular showers and hygiene support. No documentation of shower refusals was provided, indicating a failure to ensure necessary ADL care.
Multiple residents reported that food was consistently cold, bland, or unappetizing, with some relying on outside food or groceries instead of facility meals. Grievances and council meeting minutes documented ongoing dissatisfaction with meal quality, temperature, and variety. The Dietary Director was not always present at council meetings and relied on staff to communicate resident concerns, indicating a breakdown in addressing food-related issues.
A resident dependent on staff for ADLs was not provided timely incontinence care, resulting in prolonged exposure to urine, skin redness, and excoriation. The resident was found with two soaked adult briefs and wet bedding, and staff confirmed the lack of care since the previous night. Facility leadership acknowledged this was unacceptable and not in accordance with the care plan or facility policy.
Staff did not consistently document the administration of narcotic medications on required count sheets or ensure that actual medication amounts matched records. During medication cart reviews, discrepancies were found between documented and actual quantities of morphine sulfate and lorazepam for three residents with complex medical histories. Nursing staff were unable to explain the differences, and required protocols for documentation and reconciliation of controlled substances were not followed.
A resident's UTI was not managed properly due to a delay in administering the prescribed antibiotic Bactrim and a failure to document its administration. Additionally, a urinalysis was not conducted as ordered, only a urine culture was performed. These actions contributed to a deficiency in the resident's care.
A resident with severe cognitive impairment and a history of aggression was involved in an altercation with another resident, resulting in physical contact classified as abuse. Despite the known aggressive behaviors, the resident was not monitored closely, leading to the incident. The facility's policy on abuse was not upheld, as the residents' right to be free from abuse was compromised.
A facility failed to return a resident's belongings after discharge, leading to a deficiency in misappropriation of property. The resident was discharged after calling 911 and being admitted to another facility. Despite multiple calls from the resident, the facility did not return his items, including books and clothing, which were discarded after 30 days. The facility lacked an inventory list for the resident's belongings, contributing to the deficiency.
A resident with multiple health issues, including a surgical wound, did not receive prescribed wound care, and necessary medical documentation was not sent to a follow-up appointment. The surgeon reported the absence of paperwork and unchanged wound dressing, contrary to facility claims. Staff interviews revealed discrepancies in handling the resident's care and documentation, violating facility policies.
Two residents reported a lack of bath towels, impacting their ability to maintain personal hygiene. Staff interviews and observations revealed systemic issues in linen management, including insufficient towel supply and limited laundry room hours. The facility lacks a dedicated laundry supervisor, contributing to the problem.
A high fall risk resident with dementia and repeated falls history rolled out of bed during incontinence care, resulting in a head laceration requiring sutures. The CNA providing care momentarily turned away, and bed bolsters were not confirmed to be in place, leading to inadequate supervision and safety measures.
The facility failed to ensure call light cords were within reach for four residents capable of using them. Observations revealed that the cords were either misplaced, tangled, or wrapped around objects, making them inaccessible. Staff acknowledged the requirement for cords to be within easy reach, but this was not adhered to, resulting in a deficiency.
Failure to Enforce Smoking Policy and Provide Required Safety Equipment
Penalty
Summary
The facility failed to implement its smoking policy by allowing residents to smoke near the main entry door and by not providing metal containers with self-closing cover devices in designated smoking areas. Observations revealed that cigarette butts were found on the ground near benches close to the main entry door, as well as in the designated smoking areas on both the left and right sides of the building. The facility's policy specifies that smoking is only permitted in designated outdoor areas and that metal containers with self-closing covers must be available in these areas. Interviews with staff confirmed that residents were not consistently using the designated smoking area and that staff were aware of the issue but had not ensured compliance. Four residents who smoke were identified, and at least one resident admitted to sometimes smoking in non-designated areas. Staff acknowledged that residents were being told to use the designated area, but enforcement was lacking, and the required safety equipment was not present in the smoking areas.
Failure to Notify Receiving Hospital of Resident Transfer
Penalty
Summary
A deficiency occurred when staff failed to notify the local emergency room hospital of a resident's transfer following an unwitnessed fall. The resident, who was found on the bedroom floor with a pillow under his head, was alert but only oriented to one sphere and unable to explain what happened. The nurse on duty prepared documents and gave a report to the oncoming nurse but did not notify the receiving hospital, citing uncertainty about the ambulance's arrival time. The oncoming nurse also did not notify the emergency room, stating that it was the ambulance driver's responsibility. Both the Director of Nursing and the Administrator stated that it is expected for nurses to notify the receiving facility of any transfer, especially for residents unable to advocate for themselves. The resident involved had a diagnosis of delirium due to a known physiological condition, cognitive function impairment, and abnormalities in gait and mobility, as documented in the admission record and care plan. Facility policy requires that the receiving facility be notified during emergency transfers or discharges. Despite this policy, the required notification was not made, resulting in a failure to communicate essential information about the resident's condition and transfer to the emergency room.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions for residents at high risk for falls, particularly those with wandering behaviors. Three residents with significant cognitive impairments and histories of falls experienced multiple unwitnessed falls, some resulting in serious injuries. One resident with dementia and behavioral disturbances sustained a right hip fracture and a head laceration requiring medical treatment after repeated falls, some of which occurred in the dining room and were unwitnessed due to insufficient staff presence. Staff interviews confirmed that at times, only one nurse was present in the dining room while other staff were occupied with tasks such as passing trays or assisting other residents, leaving high-risk residents without adequate supervision. Another resident with Alzheimer's and agitation experienced an unwitnessed fall in the dining room after apparently falling asleep in her wheelchair while waiting for dinner. Staff acknowledged that the fall was unwitnessed because they were engaged in other duties, such as passing trays, and were unable to intervene in time. The care plan for this resident identified her as high risk for falls, but the interventions in place were not sufficient to prevent the incident. A third resident with dementia and behavioral disturbance had multiple unwitnessed falls both in his room and in the hallway, often related to attempts to self-transfer or move without assistance. Despite being identified as high risk for falls and requiring frequent supervision, the resident was able to move about unsupervised, leading to repeated incidents. Staff interviews indicated that interventions such as keeping the resident close to staff for monitoring were not consistently implemented, contributing to the occurrence of unwitnessed falls.
Failure to Provide Scheduled Showers and Grooming for Dependent Residents
Penalty
Summary
The facility failed to provide adequate shower and grooming care for residents who are dependent on staff for activities of daily living (ADL). Multiple residents reported not receiving scheduled showers, with documentation and observation confirming that showers were missed or infrequent, and bed baths were often substituted. For example, one resident, with a history of hemiplegia and chronic illnesses, stated she did not receive her scheduled showers twice a week and could not recall her last shower, reporting that her skin felt raw. Shower records showed she received only about four showers over a three-month period, despite being totally dependent on staff for bathing. Another resident, with spinal stenosis and lymphedema, reported receiving only three showers since admission and was primarily given bed baths, despite being scheduled for showers twice weekly and requiring substantial assistance. A third resident, with bilateral leg amputations and end-stage renal disease, also reported not getting out of bed or receiving showers, with records indicating only one shower in three months. This resident expressed willingness to receive showers, suggesting lack of refusal. A fourth resident, with severe obesity and neurocognitive disorder, was observed with poor hygiene, dirty fingernails, and overgrown hair, and had only about four showers documented over three months, despite care plans specifying regular hygiene and grooming. Interviews with the administrator revealed that staff are expected to document refusals and offer alternative care, but no documentation of refusals was provided for these residents. Facility policy requires showers to be offered and encouraged twice a week, with refusals and alternative care to be documented and communicated as needed. The lack of documentation and observed poor hygiene indicate that the facility did not ensure dependent residents received necessary ADL care as required.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide palatable, attractive, and appropriately tempered food and drink to all 13 residents reviewed for dining. Multiple residents reported dissatisfaction with the quality, temperature, and variety of food, with several stating that meals were consistently cold, bland, or unappetizing. Some residents indicated they avoided facility meals altogether, relying on outside food or groceries stored in their rooms. Specific complaints included hard waffles, insufficient frosting on cake, lack of sauce or spices, and poor quality of food items. Seven grievances were filed over a nearly three-month period, all related to food concerns such as cold meals and general dislike of the food served. Resident Council Meeting minutes corroborated these issues, noting complaints about cold food and inadequate meal preparation. The Dietary Director acknowledged not always attending resident council meetings and stated that staff were expected to communicate resident concerns to her for follow-up, suggesting a breakdown in communication regarding food-related grievances. The consistent and widespread nature of the complaints, as well as documentation in both grievances and council minutes, demonstrate a pattern of failure to meet residents' expectations for meal quality and palatability.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis, chronic obstructive pulmonary disease, and chronic kidney disease, who is dependent on staff for activities of daily living, was not provided timely incontinence care. The resident reported not being changed since the previous night and stated she was very wet, with her last incontinence care occurring before bedtime the previous day. Upon observation, the resident was found with two soaked adult briefs, a wet bed pad and sheet with brownish stains, and redness and excoriation on her bottom. Staff confirmed the resident's condition and stated that barrier cream is applied after each change, but could not explain why two briefs were used, except that the resident often gets wet and prefers two briefs. The care plan indicated the need for assistance with toileting and incontinence care as needed, but these interventions were not followed as required. Facility leadership, including the DON, CNO, and Administrator, acknowledged that it is not acceptable for a resident to wait an entire day for incontinence care or to be left soaking wet, regardless of the use of two briefs. The facility's urinary incontinence care policy requires incontinence care to be provided every shift based on resident needs, and staff are expected to ensure that incontinence needs are met. The failure to provide timely incontinence care resulted in the resident experiencing prolonged exposure to urine, skin redness, and excoriation.
Failure to Accurately Document and Reconcile Controlled Substances
Penalty
Summary
Facility staff failed to follow established medication administration policies regarding the documentation and reconciliation of controlled substances for multiple residents. Specifically, staff did not consistently document the administration of narcotic medications on the narcotic count sheets, nor did they ensure that the actual amounts of medication on hand matched the amounts recorded. For one resident with a history of malignant neoplasm, chronic pancreatitis, dementia, and diabetes, the narcotic administration sheet indicated 5ml of morphine sulfate remaining, while only 3.5ml was present in the medication bottle. Another resident with a history of restlessness, anxiety, and cancer had a discrepancy between the narcotic count sheet, which showed 17.5ml of lorazepam remaining, and the actual bottle, which contained more than 30ml. A third resident with osteoarthritis, diabetes, and legal blindness had 25mg of morphine sulfate on hand, while the count sheet documented 28.5mg remaining. These discrepancies were observed during medication cart reviews with nursing staff, who were unable to account for the differences between documented and actual medication quantities. The facility's protocol requires complete documentation in the narcotic book prior to administration, verification of counts with each administration, and shift-to-shift reconciliation by both outgoing and incoming nurses. However, staff failed to consistently follow these procedures, resulting in inaccurate narcotic counts and incomplete documentation for controlled substances.
Failure in UTI Management and Medication Administration
Penalty
Summary
The facility failed to provide appropriate clinical management for a urinary tract infection (UTI) for one resident. On January 13, 2025, an order was received to start the resident on the antibiotic Bactrim, to be administered twice daily for three days. However, the first dose was not given as scheduled at 1800 hours on January 13, 2025, due to the nurse on duty not administering it. The following morning, another nurse administered the antibiotic at 0900 hours but failed to document the administration in the electronic medication administration record (EMAR). This lack of documentation and delay in medication administration contributed to the deficiency. Additionally, there was a failure to conduct a urinalysis (UA) as ordered on January 11, 2025. The order was mistakenly entered only for a urine culture, and the nurse practitioner was not informed that the UA was not performed. This oversight in following the correct order process further highlights the deficiency in the resident's care. Despite these issues, the facility's policies and procedures, including those related to fall prevention and medication administration, were reviewed and found to have no concerns.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse, as evidenced by an incident involving two residents. Resident R4, a 79-year-old with severe cognitive impairment and a history of physical aggression, was involved in an altercation with Resident R3, a 90-year-old with Alzheimer's and dementia. On the day of the incident, R4 attempted to maneuver R3's wheelchair, leading to an accidental contact with R3's face. This incident was witnessed by a CNA, who reported that R4's hand made contact with R3's face during the altercation. The LPN on duty heard the commotion and found R3 with a reddened face, indicating physical contact. R4 was known for aggressive behaviors and should have been monitored closely to prevent such incidents. The facility's failure to monitor R4 adequately allowed the resident to engage in an altercation with R3, resulting in physical contact that was classified as abuse. Despite R4's known history of aggression and the need for close monitoring, the staff did not prevent the interaction between the two residents. The incident was reported to the state agency, and both residents' families and physicians were notified. R4 was subsequently sent to the hospital for evaluation, and R3 underwent a facial X-ray, which showed no fractures. The facility's policy on abuse emphasizes the residents' right to be free from abuse, yet this incident highlights a lapse in ensuring that right for R3.
Failure to Return Resident's Belongings After Discharge
Penalty
Summary
The facility failed to return a resident's personal belongings after discharge, resulting in a deficiency related to the misappropriation of property. The resident, identified as R1, was discharged from the facility after calling 911 and being admitted to another facility. Despite several phone calls from R1 regarding his belongings, the facility did not return his items, which included books and clothing. The Social Service Director, V5, acknowledged that R1 had called multiple times about his belongings, but only his mail was available for pickup. The Housekeeping Supervisor, V6, stated that R1's belongings, including three boxes of books, were discarded after 30 days. The facility's Administrator, V1, later found two boxes of R1's belongings, which included crayons and papers, but there was no inventory list for R1's belongings. The Facility Concern Form indicated that R1 was informed about the need to pick up his belongings due to storage limitations, but there was no follow-through. The facility's policy on abuse and misappropriation of property defines such actions as the wrongful use of a resident's belongings without consent. The lack of an inventory list and the discarding of R1's belongings without proper communication or consent led to the deficiency.
Failure to Provide Prescribed Wound Care and Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident's prescribed treatment was performed for a surgical wound and did not send necessary medical information with the resident to a surgical follow-up appointment. The resident, a male with multiple diagnoses including orthopedic aftercare following surgical amputation and type 2 diabetes with foot ulcer, was readmitted to the facility and had a follow-up appointment with his surgeon. However, the resident arrived at the appointment without any paperwork, which was a significant issue as reported by the surgeon. The surgeon also noted that the resident's wound dressing appeared unchanged since discharge, contrary to the facility's claim that the dressing had been changed. The Treatment Administration Record for the resident showed no documentation of the prescribed treatment being performed on a specific date, and the facility's policies required that necessary paperwork be sent with residents to appointments. Interviews with facility staff revealed discrepancies in the handling of the resident's paperwork and wound care, with the LPN claiming to have sent the paperwork with the driver, but the surgeon reporting its absence. The facility's Wound Prevention and Healing Policy and Appointments and Transportation Policy were not adhered to, leading to the deficiency.
Inadequate Supply of Bath Towels for Residents
Penalty
Summary
The facility failed to provide an adequate supply of bath towels to meet the needs and preferences of its residents, affecting at least two residents. One resident, a female with chronic obstructive pulmonary disease and other medical conditions, reported that since her admission, she has frequently experienced a lack of shower supplies, including towels. She expressed dissatisfaction with having to wait for towels and the impact it had on her ability to maintain personal hygiene. Another resident, also with chronic obstructive pulmonary disease and additional health issues, independently takes showers but consistently finds towels unavailable, especially after the laundry room closes at 5:30 pm. Observations and interviews with staff revealed systemic issues in the facility's linen management. The laundry aide confirmed that no linen was washed on a particular day because a staff member was reassigned to other duties, leaving the linen rooms without towels. The laundry room operates only until 5:30 pm, and there is no staff available to manage linen needs after this time. The Director of Nursing acknowledged the shortage of towels and bed linen, noting that the current supply is insufficient for the facility's census of 127 residents. Further investigation showed that the facility lacks a dedicated laundry/housekeeping supervisor, with a housekeeping aide acting in this role without the authority to order supplies. The acting supervisor relies on another staff member to list needed supplies, which are then ordered by the Administrator. The facility's policy mandates a safe and comfortable environment with adequate linen supplies, but the current practices fall short of these requirements, leading to resident dissatisfaction and unmet hygiene needs.
Failure to Supervise High Fall Risk Resident During Care
Penalty
Summary
The facility failed to properly monitor and supervise a high fall risk resident, identified as R2, during incontinence care, resulting in a significant accident. R2, a resident with a history of repeated falls, dementia, and other medical conditions, rolled out of bed and suffered a head laceration requiring six sutures. The incident occurred when a CNA, V10, was providing incontinence care and momentarily turned away to grab a new brief, during which time R2 rolled out of bed. Interviews with staff, including a nurse (V6), a restorative nurse (V7), and the Director of Nursing (V8), revealed that R2 was a high fall risk due to poor safety awareness, confusion, and limited mobility. It was noted that bed bolsters, which were part of R2's care plan to prevent falls, were not confirmed to be in place at the time of the incident. The CNA reportedly did not maintain adequate supervision, allowing R2 to roll from the right side to the back and then off the bed, despite being a maximum assist resident. The facility's fall prevention policy emphasizes the importance of maintaining a safe environment and implementing universal fall precautions. However, the incident report and staff interviews suggest that these protocols were not adequately followed, as R2 was not properly monitored or positioned during care. The lack of immediate intervention and the absence of necessary safety measures contributed to the resident's fall and subsequent injury.
Inaccessible Call Light Cords for Residents
Penalty
Summary
The facility failed to ensure that call light cords were within reach for four residents who were reviewed for call light accessibility. Resident 7 was observed lying in bed without a call light cord nearby, and the RN was unable to locate it until it was found under the blanket of the roommate's bed. Resident 8's call light cord was found between the mattress and bed frame, making it inaccessible. Resident 9's call light cord was tangled in the bed frame, also rendering it unreachable. Resident 6's call light cord was wrapped around a lamp on the nightstand and dangling behind it, making it inaccessible. The facility's policy requires that call light cords be accessible to residents who are capable of using them. The staff, including a nurse and the administrator, acknowledged that call light cords should be within easy reach of residents at all times. However, during the observations, the cords were not positioned as required, leading to the deficiency in accommodating the needs and preferences of the residents.
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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