Smith Crossing
Inspection history, citations, penalties and survey trends for this long-term care facility in Orland Park, Illinois.
- Location
- 10501 Emilie Lane, Orland Park, Illinois 60467
- CMS Provider Number
- 146110
- Inspections on file
- 22
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Smith Crossing during CMS and state inspections, most recent first.
An LPN without required IV certification administered ordered IV Vancomycin to a resident with multiple complex conditions, including UTI, sepsis, CHF, kidney failure, vascular dementia, and type 2 DM with circulatory complications. The resident’s EMR and MAR showed IV Vancomycin doses given, and the MAR contained the LPN’s initials for one of the administrations. The LPN acknowledged not being certified to give IV antibiotics but confirmed having administered them, and the ADON verified that IV certification is required for LPNs to infuse IV antibiotics and that this LPN was not on the facility’s list of IV-certified LPNs.
The facility did not follow its policy for documenting complete pressure ulcer assessments for three residents with pressure injuries. For each, required admission and weekly wound assessments—including measurements and detailed descriptions—were missing from the EMR, as confirmed by the wound care nurse and DON. The facility's policy specified comprehensive documentation, but this was not consistently performed.
A cognitively impaired resident with a contracted, non-weight bearing arm suffered a comminuted and impacted humeral fracture after agency aides pulled on her arm while turning her in bed, contrary to her care plan. The resident expressed pain during and after the incident, and the injury was later confirmed by diagnostic imaging. Staff interviews revealed inadequate communication and improper handling techniques, leading to the injury.
Three high-risk residents experienced repeated falls, including incidents resulting in serious injuries such as a cervical neck fracture and head laceration, due to the facility's failure to consistently implement and monitor individualized fall prevention interventions. Staff did not always follow care plans, failed to ensure required equipment like floor mats and VST monitors were in place, and did not provide adequate supervision, leading to preventable accidents.
A resident with dementia and a history of left arm fracture was found with a new arm injury after two agency aides were observed handling her roughly during care, resulting in pain and a fracture. Despite a family member reporting the incident and showing video evidence to nursing leadership, the event was not recognized or reported as suspected abuse according to facility policy, and the administrator was not promptly informed.
The facility failed to ensure proper hand hygiene and hair restraint practices in the kitchen, affecting 74 residents. A dishwasher handled clean dishes without washing hands after loading dirty items, and several kitchen staff did not restrain their hair properly. The facility lacked beard covers, violating its dress code policy.
The facility failed to maintain privacy during personal care for several residents. Instances included a CNA and nurse leaving a resident exposed with open blinds and door, a nurse discussing a resident's health loudly in a public area, and another nurse administering care with open blinds and door. These actions violated the facility's policies on resident privacy and dignity.
A survey found that a LTC facility failed to store medications safely, with a nurse's cart containing an improperly handled controlled drug and a medication room refrigerator lacking temperature monitoring. The facility's policies on medication storage were not followed, leading to potential contamination and compromised drug integrity.
A long-term care facility failed to follow proper infection control protocols, including neglecting hand hygiene and PPE use during resident care. Staff did not adhere to isolation precautions for residents with infections like C. Diff. and ESBL, and soiled linen was improperly handled, increasing the risk of cross-contamination.
A facility failed to assess a resident's ability to self-administer medications. A Ventolin inhaler was found on the resident's bedside table, but there was no order for self-administration or assessment confirming the resident's ability to do so safely. Interviews revealed that the facility's policy requires an assessment and doctor's approval for self-administration, which was not followed in this case.
A facility failed to provide a written bed hold policy to a resident and their representative before a hospital transfer. The resident, with multiple medical conditions, was transferred due to a medical emergency. Despite the facility's policy to remind residents of the bed hold policy, there was no documentation that this was done. Staff interviews confirmed the policy was not followed, as no evidence was found that the policy was provided or discussed during the transfer.
A resident with chronic venous hypertension and ulcers did not receive wound dressing changes as per physician's orders, leading to soaked and soiled dressings. The wound nurse and DON acknowledged the failure to adhere to the dressing change schedule and inadequate documentation of the wound's condition.
The facility failed to properly store oxygen cylinders, creating a potential explosion hazard, and did not use a gait belt during a resident transfer, increasing fall risk. Observations showed unsecured oxygen cylinders and improper transfer techniques, contrary to facility policies.
A resident with chronic respiratory conditions did not receive oxygen therapy as prescribed due to improper nasal cannula positioning and staff inaction. The CNA did not understand the device's warning message, and the RN failed to check oxygen saturation or correct the cannula position, leading to an elevated respiratory rate.
Uncertified LPN Administered IV Antibiotic
Penalty
Summary
The facility failed to ensure that an LPN who administered an IV antibiotic to a resident had the required IV training/certification. The resident had multiple diagnoses, including urinary tract infection, sepsis, difficulty walking, unspecified skin changes, chronic congestive heart failure, kidney failure, unspecified organism, vascular dementia, and type 2 diabetes mellitus with circulatory complications, and had a physician’s order for Vancomycin 750 mg IV every 18 hours over several days in February 2026. The resident’s EMR and MAR showed that the ordered Vancomycin IV piggyback was administered, and the MAR for one of those days contained the initials of an LPN who later stated she was not certified to give IV antibiotics, although she acknowledged she had administered some to this resident about a month prior and planned to obtain training in the future. The Assistant Director of Nursing confirmed that LPNs at the facility are required to have specific certification to infuse IV antibiotics, verified that the initials on the MAR identify the person who administered the medication, and stated that this LPN’s name did not appear on the facility’s list of LPNs certified to administer IV medications. Thus, the IV Vancomycin was infused by an LPN who lacked the required IV certification, contrary to facility expectations and practice as described by nursing leadership.
Failure to Document Complete Pressure Ulcer Assessments
Penalty
Summary
The facility failed to follow its own policy regarding the documentation of complete pressure ulcer assessments for three residents with pressure ulcers. For one resident admitted with multiple diagnoses including orthostatic hypotension, muscle wasting, pulmonary embolism, dementia, and a stage 3 sacral pressure ulcer, the care plan required weekly wound assessments with measurements and descriptions. However, there was no documentation of a complete admission wound assessment or weekly assessments after a certain date, as confirmed by both the wound care nurse and the DON. Another resident, admitted with a fractured leg, muscle wasting, heart failure, and dementia, had a care plan addressing a deep tissue injury (DTI) to the left heel. The wound care nurse stated that she did not document wound assessments in the EMR, and the DON confirmed that neither an admission nor weekly wound assessments were completed or documented for this resident's DTI. A third resident, with diagnoses including urinary tract infection, muscle wasting, and dementia, developed a stage 4 sacral pressure injury. The care plan required monitoring and documentation of the wound's location, size, and treatment. However, there was no documentation of a weekly wound assessment, including measurements and description, for a specific week when the resident was not seen by the wound doctor. The facility's policy required complete wound assessments on admission and weekly, including specific wound characteristics, but these were not consistently documented for the affected residents.
Failure to Provide Proper Care Results in Arm Fracture for Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with a history of left humerus fracture, dementia, and severe functional limitations was dependent on staff for all activities of daily living, including dressing, bathing, and transfers. The resident's care plan specified that her left upper extremity was non-weight bearing due to a previous humerus fracture, and that a sling should be worn at all times. The resident also had a contracture in her left arm, which was to be handled with care during all care activities. On the morning in question, two agency aides assisted the resident with showering and dressing. According to interviews and a review of video footage by a family member, the aides were observed pulling on the resident's contracted left arm and thigh to turn her in bed, despite her care plan indicating that her arm should not be used for such maneuvers. The resident was heard yelling out in pain during this process and continued to complain of arm pain after being dressed and transferred to her chair. Staff and family members noted that the resident's arm appeared more limp than usual, and a bruise was observed. The incident was not immediately reported to management, and the aides involved were not fully aware of the resident's specific limitations. Subsequent assessment and diagnostic imaging revealed that the resident had sustained a comminuted and impacted fracture of the left humeral head. The injury was discovered after the resident continued to express pain and was sent to the hospital for evaluation. Interviews with staff indicated a lack of communication regarding the resident's care needs and improper handling techniques, which directly contributed to the injury. The facility's investigation confirmed that staff failed to provide care in accordance with professional standards and the resident's care plan.
Failure to Implement and Maintain Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and maintain effective fall prevention interventions for multiple residents identified as high risk for falls. For one resident with a history of falls, head injury, dementia, and significant physical limitations, the care plan included interventions such as floor mats, bed/chair alarms, and keeping personal items within reach. Despite these interventions, the resident experienced multiple falls, including incidents where she was found on the floor after attempting to access the phone or bathroom without assistance. After one such fall, the resident sustained a cervical neck fracture and facial abrasions, requiring emergency hospital transfer. Interviews with staff revealed that after repeated falls, no new interventions were added to the care plan, and only minor adjustments were made to existing interventions. Another resident with severe cognitive impairment, a history of falls, and physical limitations also experienced repeated falls, including one resulting in a head laceration that required staples. The care plan for this resident included frequent monitoring, use of floor mats, and virtual sense technology (VST) for alerting staff to movement. However, during one incident, the assigned CNA did not have the required alert tablet with her, leaving the resident unsupervised and resulting in a fall with significant injury. Staff interviews confirmed that the expected supervision and monitoring protocols were not consistently followed, and the resident was able to move unsupervised from a common area to her room, where the fall occurred. A third resident, also at high risk for falls due to dementia, weakness, and a history of fractures, was observed without all required fall prevention interventions in place. The resident was found sleeping in a bed that was not in the lowest position, with only one floor mat in place instead of the required mats on both sides. Additionally, the VST monitor intended to alert staff to movement was not present in the room, and the assigned CNA was unaware of its location. Staff interviews indicated that frequent checks were not documented, and the required interventions were not consistently implemented or monitored. These failures resulted in repeated falls and inadequate supervision for residents at high risk.
Failure to Recognize and Report Suspected Abuse Following Resident Injury
Penalty
Summary
The facility failed to recognize and report an injury of unknown origin as a suspected allegation of abuse for a resident with a complex medical history, including dementia, a prior left humerus fracture, and other chronic conditions. On the morning in question, a certified nursing assistant observed the resident guarding her left arm and expressing pain when touched, with a noticeable green bruise and abnormal arm movement. There was no prior report of a fall, and the incident was not communicated during shift change. Pain medication was administered, and an x-ray was ordered, but the resident was ultimately sent to the emergency room, where a comminuted and impacted fracture of the left humeral head was diagnosed. Interviews revealed that a family member had observed two agency aides handling the resident roughly during morning care via a room camera, specifically pulling on the resident's contracted left arm and thigh to turn her, which caused the resident to cry out in pain. The family member reported this observation to an LPN, who did not escalate the concern to management, believing the action was not malicious. The family member also showed video evidence of the incident to the DON, ADON, and other staff, who acknowledged that the aides' handling was inappropriate and contrary to proper transfer techniques for the resident's condition. Despite these observations and reports, the incident was not initially treated as a suspected abuse case or reported to the administrator as required by facility policy. The administrator was not informed until after the fact, and the incident was not viewed as abuse by some members of the leadership team. Facility policies require that injuries of unknown origin and allegations of abuse be reported and investigated according to established procedures, but these protocols were not followed in this case.
Deficiencies in Hand Hygiene and Hair Restraint in Kitchen
Penalty
Summary
The facility failed to ensure proper hand hygiene and hair restraint practices in the kitchen, affecting 74 of 75 residents who consume food prepared there. During an observation, a dishwasher staff member handled clean dishes and utensils without washing hands or changing gloves after loading dirty items into the dishwasher. This staff member also used a cloth towel to dry gloved hands after cleaning a transport cart, which is against the facility's hand hygiene policy. The policy mandates that all staff perform proper hand hygiene to prevent infection spread. Additionally, several kitchen staff members did not properly restrain their hair while preparing food. A sous chef and a cook were observed with unrestrained hair, and two staff members had large, uncovered beards. The facility's uniform dress code policy requires all food service associates to wear approved hair restraints and beard nets. However, the facility did not have beard covers available at the time of the survey, as confirmed by the Food Service Director.
Privacy Breaches During Resident Care
Penalty
Summary
The facility failed to ensure privacy during personal care for several residents, as observed by surveyors. In one instance, a CNA and a nurse provided wound and incontinence care to a resident with the blinds open, exposing the resident to view from the patio area. The nurse left the room with the door open, leaving the resident exposed to anyone passing by in the hallway. Another incident involved a nurse loudly discussing a resident's frequent urinary tract infections in a public dining area, compromising the resident's privacy. Additionally, a nurse administered medication and G-tube feeding to a resident with the door, privacy curtains, and window blinds open, while the resident was partially exposed. Further observations revealed that a CNA provided incontinence care to a resident with the window blinds open, exposing the resident to view from outside. The facility's policies on perineal care and promoting resident dignity emphasize the importance of maintaining privacy by closing doors and blinds during personal care. However, these policies were not adhered to, resulting in multiple instances where residents' privacy and dignity were compromised.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to appropriately store medications and biologicals safely for several residents, as observed during a survey. A nurse's medication cart was found with a controlled drug, alprazolam 0.5mg, that was opened and retaped, which should have been discarded due to potential contamination. The nurse was unaware of when the medication was last administered, and there was no physician's order for the 0.5mg dosage, indicating a discrepancy in medication management for the resident with an anxiety disorder. Additionally, the facility's medication room refrigerator lacked a thermometer and a temperature log, which are essential for ensuring medications are stored at the correct temperature. The refrigerator contained various medications, including vaccines and emergency kits, as well as medications for multiple residents. The absence of temperature monitoring raises concerns about the integrity of these medications, as they may have been exposed to improper temperature conditions. The Director of Nursing acknowledged the issues, stating that medications should be discarded if there is any chance of contamination or if the temperature control is compromised. The facility's policies require medications to be stored under proper temperature controls and in locked compartments to prevent contamination, diversion, or accidental exposure. However, these policies were not adhered to, leading to the deficiencies observed during the survey.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, as evidenced by multiple instances of staff not following isolation precautions and neglecting hand hygiene. For instance, a CNA entered a resident's room under Enhanced Barrier Precautions (EBP) without wearing a gown and handled the resident's urinary catheter bag improperly. The CNA also failed to perform hand hygiene after removing gloves, which is critical in preventing cross-contamination. Additionally, the resident was later confirmed to have Clostridium Difficile (C. Diff.), necessitating contact isolation, yet staff continued to enter the room without appropriate personal protective equipment (PPE). Another deficiency was observed with a resident on contact precautions for ESBL (Extended Spectrum Beta-Lactamases) in the urine. Despite the contact precautions, the resident was allowed to eat in the dining room with other residents, and staff interacted with the resident without wearing the required PPE. Housekeeping staff also failed to sanitize equipment after cleaning the resident's room, potentially spreading contaminants throughout the facility. The Infection Preventionist incorrectly believed that the infection was contained, allowing the resident to leave their room, which contradicted the facility's policy. Further deficiencies were noted in the handling of soiled linen and during incontinence and wound care. Staff were observed not changing gloves or performing hand hygiene when transitioning from dirty to clean tasks, such as after providing peri care or wound care. This lack of adherence to infection control protocols was consistent across multiple staff members and residents, indicating a systemic issue within the facility's infection control practices. Additionally, soiled linen was improperly placed on the floor, further contributing to the risk of infection spread.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess whether a resident was able to self-administer medications independently. During an initial tour, a Ventolin inhaler was found on the bedside table of a resident, who stated she took two puffs a day. The resident's Physician Order Sheet indicated an order for Ventolin to be administered every six hours, but there was no order for self-administration. Additionally, the facility could not provide a self-administration assessment or progress notes confirming the resident's ability to self-administer medications safely. Interviews with the RN and the Director of Nursing revealed that residents are allowed to self-administer medications if approved by a doctor and after an assessment is conducted. However, the RN was unaware of any residents approved for self-administration, and the Director of Nursing confirmed that an order and assessment should be documented in the Electronic Medical Record. The facility's policy states that residents have the right to self-administer medications if deemed clinically appropriate by the interdisciplinary team, but this process was not followed for the resident in question.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide a written copy of its bed hold and bed payment policy to a resident and their representative before transferring the resident to a hospital. This deficiency was identified during a review of a case involving a male resident who was transferred to a local community hospital due to a medical emergency. The resident, who had multiple diagnoses including urinary tract infection, metabolic encephalopathy, congestive heart failure, hypothyroidism, and hypertension, was transferred after being found only briefly arousable. Despite the presence of the resident's wife at the bedside, there was no documentation indicating that the bed hold policy was provided to either the resident or his representative at the time of transfer. Interviews with facility staff, including the Director of Nursing and the Social Service Director, revealed that while it is the facility's policy to remind residents of the bed hold policy during transfers, there was no evidence that this was done in this case. The facility's policy requires providing notice of transfer and the bed hold policy, but it does not specify that a hard copy must be given. The staff acknowledged that the policy was not followed, as there was no documentation to confirm that the resident or his representative received the bed hold policy or were reminded of it during the transfer process.
Failure to Adhere to Wound Dressing Change Orders
Penalty
Summary
The facility failed to provide wound dressing changes as per the physician's order for a resident with multiple diagnoses, including cerebral infarction, cellulitis, and chronic venous hypertension with ulcers on the lower extremities. The resident's care plan required dressing changes every other day and as needed, with specific instructions for cleansing and dressing application. However, during an observation, it was noted that the resident's dressings were not changed according to the schedule, resulting in soaked and soiled dressings with significant drainage. The wound nurse admitted that the dressing change should have been done earlier due to the amount of drainage, and there was a lack of proper documentation regarding the wound's condition. The Director of Nursing (DON) and the wound nurse acknowledged that the dressing changes were not performed as required, and the wound nurse failed to document the wound's status and drainage adequately. The facility's policy stated that dressing changes should be done according to the physician's orders and could be adjusted if the dressing was soiled or wet. However, the lack of adherence to these protocols and insufficient documentation contributed to the deficiency in care for the resident's wound management.
Improper Oxygen Storage and Transfer Procedures
Penalty
Summary
The facility failed to store oxygen cylinders properly, creating a potential explosion hazard. Observations revealed that a portable oxygen cylinder in a resident's room was not secured in a stand or tethered, posing a risk to nearby residents if it were to tip over. Staff interviews indicated a lack of awareness and adherence to the facility's policy on oxygen storage, which mandates that cylinders be secured to prevent accidents. Despite the policy, the oxygen cylinder remained unsecured, and staff members acknowledged the potential danger of an explosion or injury if the cylinder were to fall. Additionally, the facility failed to use a gait belt during the transfer of a resident, increasing the risk of falls and injury. A CNA was observed transferring a resident by pulling on the waistband of the resident's pants instead of using a gait belt, contrary to the facility's Safe Resident Handling policy. The resident, who was a high fall risk and required two-person assistance, was not transferred safely, as confirmed by staff interviews. The facility's policy mandates the use of gait belts for transfers, yet this was not followed, compromising the resident's safety.
Improper Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure a resident received oxygen therapy consistent with physician orders, as observed during a survey. A resident, identified as R15, was seen in the dining room with a nasal cannula improperly positioned, with one prong in the right nostril and the other on the cheek. The portable oxygen delivery device connected to the cannula was flashing a warning message indicating 'no breathing detected, please check cannula.' Despite this, the CNA present did not understand the message and continued feeding the resident without notifying the nurse. The resident's respiratory rate was elevated at 32 breaths per minute, indicating potential respiratory distress. When the surveyor informed the RN about the issue, the RN switched the resident's oxygen source to a portable tank but did not check the oxygen saturation level or ensure the nasal cannula was correctly positioned. The resident's medical history includes chronic obstructive pulmonary disease, respiratory failure, and cognitive communication deficit, requiring continuous oxygen therapy. The facility's policy mandates that oxygen therapy be administered per physician orders and that staff should address any issues with oxygen delivery immediately. The Director of Nursing confirmed that the staff should have assessed and corrected the nasal cannula positioning to ensure proper oxygen delivery.
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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