Spring Creek
Inspection history, citations, penalties and survey trends for this long-term care facility in Joliet, Illinois.
- Location
- 777 Draper Avenue, Joliet, Illinois 60432
- CMS Provider Number
- 146172
- Inspections on file
- 34
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Spring Creek during CMS and state inspections, most recent first.
The facility failed to implement ordered nutritional interventions and double-portion meals for a resident with significant weight loss and for two additional residents. A resident identified as at risk for compromised nutritional status, with a goal to prevent further weight loss, was repeatedly not given the ordered double portions and had inconsistent meal intake documentation, with only a limited number of entries over a month and no recorded intake after a certain date. The resident was observed thin and frail, was not served lunch while sleeping in the dining room, and later received only a peanut butter and jelly sandwich. Serial weights showed substantial fluctuations and an additional 10.3% loss in one month, while the RD, aware of the history of significant weight loss and low BMI, continued existing supplements without new recommendations and relied on nursing staff for accurate weights and intake records.
Surveyors identified that housekeeping staff left an unsecured cleaning cart in a resident hallway containing mislabeled and improperly stored chemical products, while nursing staff failed to use required gait belts and appropriate assistance levels when transferring a resident with hemiplegia, repeated falls, and altered mental status. Two CNAs transferred a resident with hemiplegia and moderate cognitive impairment using a mechanical lift over fall mats that remained in place beside the bed, contrary to facility expectations. In addition, two high-fall-risk residents with multiple recent falls were repeatedly observed in specialized high-back chairs or wheelchairs without care-planned safety interventions, including non-slip seating material and appropriate leg or foot supports, and one was left in clearly unsafe, slouched, or cross-seat positions without staff repositioning despite posted communication about their high fall risk.
Surveyors found multiple open medications and biologicals on a medication cart without required open dates, including anticonvulsants, laxatives, and antacids, as well as an unlabeled, uncovered container of white powder identified as thickener. Facility leadership acknowledged that all opened medications should be dated and labeled per policy. In addition, a resident with COPD, dementia, and other conditions had nebulizer medication stored at the bedside and self-administered treatments without an order for self-administration or bedside storage. Another resident had an unidentified pill in a medication cup at bedside, and a different resident had prescribed nasal spray stored in an unlocked in-room refrigerator, contrary to the facility’s policy that medications be securely stored and accessible only to authorized staff.
Surveyors found multiple food safety and sanitation issues in the kitchen affecting all residents receiving dietary services. An open bag of dry beans, expired hard-boiled eggs, an open bucket of beef base, and a bucket of chicken base stored under a sink were observed, along with pans of cake placed within splashing distance of a sink. Red sanitizer buckets in use tested at 400 ppm, and serving utensils and mixing bowls stored for use were visibly soiled with dried food and residue. The Dietary Manager acknowledged that food should be sealed and dated, that outdated food should be discarded, that food should not be stored under or near sinks, and that dirty utensils can cause cross-contamination, and these practices were inconsistent with facility policies on sanitary food preparation, labeling, storage, and sanitizer use.
Staff failed to follow the facility’s infection prevention policies, including Enhanced Barrier Precautions (EBP) and hand hygiene, during care for several residents. An RN and an LPN provided g-tube care and enteral feedings to multiple residents who had EBP signage and care plans requiring gown and gloves for device care, but they wore only gloves. In a separate incident, a CNA provided incontinence care to a resident without performing hand hygiene, used the same towel and washcloth repeatedly on perineal and buttock areas, and touched room items and a roommate’s stuffed bear with soiled gloves before leaving the room. The DON confirmed that EBP, proper incontinence care, and hand hygiene are required by facility policy to prevent infection.
A resident with severe cognitive impairment and multiple psychiatric and neurological diagnoses, known to have behaviors that intrude on others’ privacy, was observed sitting on the floor in a common area with pants down and genitalia exposed outside an incontinence brief. A social services director was seated at the nurses station with his back to the resident and was texting the DON while the resident remained undressed, and only after a CNA exited the elevator and alerted him was the resident assisted to stand, at which time genital exposure was still evident. Facility records and the MDS documented the resident’s behavioral symptoms, and the facility’s dignity policy required staff to promote and protect bodily privacy during care and treatment, which was not maintained in this incident.
A cognitively intact resident with multiple chronic conditions, including hemiplegia, morbid obesity, diabetes, major depressive disorder, and polyosteoarthritis, requested $40 from his personal funds account but did not receive the money for an extended period. The assistant administrator, who was the only person designated to access the bank, confirmed the resident had sufficient funds and had made the request weeks earlier but had not yet gone to the bank. This delay occurred despite a facility policy stating that the facility will hold, safeguard, and manage residents’ personal funds upon request.
A cognitively intact, continent resident with multiple medical conditions who uses a motorized wheelchair and requires assistance with toileting reported that a CNA refused to toilet her or change her menstrual pad after she requested toileting and a shower during her period, telling her to go in her pants. The resident reported this to the Administrator, and the DON stated she personally heard the CNA refuse to toilet the resident and later informed the Administrator. Documentation of the CNA’s discharge cited refusal to toilet a resident and other work issues. The Administrator, serving as abuse coordinator, did not report this allegation to the state agency and stated that refusing to toilet an alert, oriented, continent resident was not abuse, despite facility policy defining abuse to include deprivation of necessary goods and services and requiring timely investigative reporting.
Surveyors found that nursing staff failed to notify the NP/MD when a resident refused scheduled morning medications due to nausea and later received multiple ordered drugs, including gabapentin, outside the facility’s one-hour administration window without provider direction or documentation. Staff interviews, including with the NP, RN, LPN, and DON, confirmed that the expected practice was to administer antiemetic medication, reassess, and contact the provider if doses could not be given within the ordered time frame, but this did not occur. In a separate case, a resident independently managed a CGM device, reported glucose readings to staff, and received insulin and other interventions based solely on those readings, even though there was no physician order for CGM use, no assessment of the resident’s competency, no care plan interventions, and staff lacked instructions or knowledge of the device despite an existing facility CGM policy requiring an order and adherence to manufacturer guidelines.
A resident dependent on staff for care received g-tube feedings from unlabeled bags, including a clear bag connected to a water bag, while an open bottle of nutritional formula sat at the bedside. On repeated observations, the g-tube site had brown, thick, adherent drainage and no dressing, despite orders to clean the site with normal saline daily and as needed. A wound nurse stated nurses should assess and clean tube sites, and an RN acknowledged she could not identify the formula being infused because the bag was not labeled, even though the care plan required use of clinical standards, infusion as ordered, and regular checks of the tube site for drainage.
A resident with multiple chronic conditions did not receive several medications in accordance with physician orders or within the facility’s defined administration window, leading to a medication error rate above 5%. An RN delayed 9 AM doses due to nausea and administered Amantadine, Docusate, and Gabapentin together around early afternoon, outside the 8–10 AM window, and a daily multivitamin ordered for 9 AM was not actually given despite being signed off. Review of the POS, MAR audit, and interviews with an LPN, DON, and NP confirmed that medications were to be given within one hour of scheduled times and that prescriber clarification was required when doses were outside this window, which did not occur.
A resident with a history of respiratory complications and quadriplegia experienced severe shortness of breath and abnormal vital signs. Despite repeated requests from the resident and abnormal clinical findings, an LPN delayed calling 911 and instead sought routine ambulance transport, contrary to facility policy and staff expectations. When EMTs arrived, the resident was in significant distress and required immediate intervention.
A resident with a tunneled PICC line did not receive dressing and cap changes as ordered, with documentation showing missed or falsely recorded interventions. An LPN admitted to documenting dressing changes that were not performed and lacked training on central line care, while the DON confirmed only RNs should perform these tasks. The facility's policy for dressing changes and documentation was not followed.
A resident with quadriplegia and dependent on staff for eating was left unsupervised with a hot cup of coffee, resulting in 1st and 2nd degree burns. Despite recommendations against straw use and the need for supervision, the resident was allowed to drink from a straw, leading to the injury.
The facility failed to staff RNs for 8 consecutive hours daily, as required. On several occasions, no RNs were present for the required duration, confirmed by staff interviews and schedule reviews. The Administrator was unaware of these lapses, which could affect all residents.
The facility failed to obtain physician orders and conduct assessments for residents self-administering medications brought from home. Observations revealed medications at residents' bedsides without proper authorization or care plans, despite residents being cognitively intact. The DON confirmed no residents were assessed for self-administration, contrary to facility policy requiring assessments and orders for such practices.
Two residents with hemiplegia and contractures were not provided with necessary splints and palm protectors as prescribed. Despite physician orders and care plans, the required devices were not consistently applied, potentially worsening their conditions. Staff acknowledged the oversight and the need for proper documentation of any refusals.
The facility failed to prevent fall injuries and smoking hazards for several residents. A resident was pushed in a wheelchair without footrests, another was in a room with an exposed bed frame, and a third walked without skid-protection socks. Beds were left high without fall mats for residents at risk of falling. Additionally, a resident had smoking materials despite needing supervision, and her care plan was updated without a new assessment.
A resident with a G-tube was not properly managed, as staff failed to check tube placement and administer feeding at the correct rate. Despite orders for a 75 ml/hr rate, the feeding was consistently set at 70 ml/hr, and necessary residual checks were not performed. Staff interviews revealed outdated practices and non-adherence to facility policies, leading to a deficiency in care.
A medication error rate of 10% was identified when a nurse administered incorrect medications to a resident, failing to give Ezetimibe 10 mg as prescribed and incorrectly documenting it as given. The resident, with multiple diagnoses, was cognitively intact and had specific medication orders that were not followed.
The facility failed to ensure proper maintenance and monitoring of residents' personal refrigerators, leading to the presence of expired food items and lack of temperature control. Three residents were affected, with one having a refrigerator without a thermometer or temperature log, another with multiple expired food items, and a third with moldy fruit and expired dairy products. Housekeeping staff did not fulfill their responsibility to clean and monitor the refrigerators, posing a risk to residents' health.
A cognitively impaired resident suffered full thickness burns due to prolonged sun exposure, as the facility failed to provide adequate supervision. The resident, with a history of dementia and other medical conditions, was able to ambulate independently and frequently went outside. The facility did not have a system to monitor outdoor activities, and the patio door was left unlocked, allowing unsupervised access. Staff interviews confirmed the lack of supervision and absence of a policy for outdoor monitoring.
A resident with a history of knee prosthesis infection, hypertension, hypoglycemia, and hepatitis C was not provided access to $60 in their Trust Fund account after discharge. The Administrator confirmed the funds and promised a refund check, but the Director of Accounts Receivable verified that the money was still in the account and had not been sent.
The facility failed to protect residents from abuse, resulting in multiple altercations involving a resident with severe cognitive impairment who repeatedly entered other residents' rooms and took their belongings. This led to physical confrontations with two other residents, causing injuries and distress. Staff found it challenging to monitor the resident's behavior due to other caregiving responsibilities.
Failure to Implement Nutritional Interventions and Provide Ordered Double Portions
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow nutritional interventions for a resident with known significant weight loss, and failure to provide ordered double portions for multiple residents. One resident’s care plan, initiated on 11/03/2025, identified risk for compromised nutritional status with a goal of preventing further weight loss and an intervention to serve the ordered nutritional diet. Despite this, observations on 12/09/2025 showed the resident, who appeared thin and frail, was served only single portions of turkey, mashed potatoes, and mixed vegetables, even though the meal ticket specified double portions. The facility also failed to consistently document the resident’s meal intake, with the EMR showing only fifteen meal intake entries in the prior 30 days and the last recorded meal on 11/30/2025. On 12/10/2025, the same resident was observed sleeping in the dining room during lunch and was not served a meal during the meal service; staff stated they would later offer two peanut butter and jelly sandwiches and were unsure if the resident had eaten breakfast. The EMR confirmed no meal intake documentation after 11/30/2025. A standing weight obtained on 12/11/2025 was 131.8 lbs, compared with prior recorded weights of 159.2 lbs on 09/05/2025, 138.0 lbs on 10/14/2025, 147.0 lbs on 11/04/2025, and 145.7 lbs on 12/05/2025. The registered dietitian documented that the resident had a history of weight loss, significant weight loss over three and six months, and a BMI of 19.9, and noted that the resident was receiving a 240 ml nutritional supplement three times daily with no new recommendations. The dietitian later stated she suspected an error in the November weight, was aware of the family’s request for double portions, and was very concerned about the additional 10.3% weight loss in one month, indicating that closer monitoring of weights and intake might have prevented the significant weight loss. The facility also failed to serve ordered double portions for two additional residents reviewed for nutrition.
Failure to Control Environmental Hazards and Implement Safe Transfers and Fall-Prevention Measures
Penalty
Summary
The deficiency involves multiple failures to maintain a safe environment free from accident hazards and to provide adequate supervision and assistance to prevent accidents. Housekeeping staff left an unsecured cleaning cart in a resident hallway containing an 8 oz bottle labeled as dermal wound cleanser but actually filled with glass cleaner, a generic spray bottle containing bleach, and a quart bottle of pine cleaner. The housekeeper reported that she had retrieved the wound cleanser bottle from the trash and refilled it with glass cleaner after her original bottle broke, and that the generic spray bottle contained bleach. The cart had no locked compartment, and the facility’s housekeeping policy did not provide direction on proper storage or use of hazardous cleaning products. Safety Data Sheets for the chemicals described risks such as skin irritation, serious eye damage, respiratory irritation, and harm if swallowed. The facility also failed to ensure safe transfer techniques were used for a resident with significant physical and cognitive impairments. A CNA was observed transferring this resident from bed to a high-back wheelchair by placing a hand under the resident’s arm, holding the waistband of the pants, and pulling the resident to stand and pivot without using a gait belt. Interviews with the restorative nurse, restorative CNA, and DON confirmed that staff were expected to use gait belts for transfers and not to pull residents by their waistbands. The resident’s diagnoses included hemiplegia and hemiparesis affecting the right dominant side, chronic pain, failure to thrive, repeated falls, and altered mental status. The MDS showed the resident required substantial assistance for sit-to-stand and chair-to-bed transfers, and the care plan documented a history of falls related to poor safety awareness and impulsive behavior, with interventions specifying extensive assist by two staff and use of a mechanical lift with two staff for certain transfers. Additional deficiencies were identified in the use of fall mats and implementation of fall-prevention interventions. Two CNAs transferred a resident with hemiplegia and moderate cognitive impairment from a wheelchair to bed using a mechanical lift while fall mats remained down on both sides of the bed; the lift was rolled over the fall mat to position the resident in bed. The restorative nurse and DON stated that fall mats should be moved prior to transferring residents back to bed because they interfere with proper positioning of the lift base under the bed and present a tripping hazard. For two other residents at high risk for falls, the facility did not implement care-planned positioning and seating interventions. One resident of shorter stature, with a history of four falls in front of his wheelchair, was repeatedly observed in a specialized high-back chair without leg rests or footrests, leaving his legs dangling and unsupported and in slouched or unsafe positions, including sitting across the seat with legs over the armrest while nursing staff did not assist with repositioning. Another resident, also with four recent falls in front of a specialized high-back chair, was observed multiple times in a high-back chair or wheelchair without the care-planned non-slip seating material and with feet dangling due to missing footrests. Staff acknowledged that these residents were frequent fallers and that specific fall interventions, including non-slip devices and safe positioning, were expected to be implemented based on posted communication sheets and updated care plans.
Improper Medication Labeling and Insecure Storage of Drugs and Biologicals
Penalty
Summary
Surveyors identified that multiple medications and biologicals on a medication cart were not labeled or stored according to facility policy and professional standards. During an inspection of medication cart #3 with the ADON, open bottles of antacid/anti-gas for one resident, Levetiracetam (Keppra) solution for another resident, Lactulose solution for a third resident, and Valproate Sodium oral solution for a fourth resident were found without open dates. Several stock medications and biologicals on the same cart, including Geri-Tussin DM, Polyethylene Glycol 3350, and Reguloid, were also open without open dates. Additionally, a container holding approximately 1/4 cup of an unlabeled white powder, identified by the ADON as liquid thickener, was missing its snap-on lid and had no label or date. The ADON acknowledged that she does not date all medications when opened and stated that the white substance should have been properly contained. The DON stated that all open medications are required to have an open date and that all containers should be labeled to identify their contents, consistent with the facility’s Medication Storage policy, which requires dating when the manufacturer’s seal is broken and sets a 30-day expiration unless otherwise specified. Physician orders confirmed that the undated open medications on the cart were active orders for the respective residents, including Valproate Sodium for agitation/anxiety, Keppra for epilepsy, Lactulose for toxic encephalopathy, and Maalox Max for indigestion. The facility’s written policies also required medications and biologics to be stored safely, securely, and properly. Surveyors also observed failures in secure storage and control of medications at the bedside and in resident rooms. One resident with diagnoses including COPD, cataract, myopia, dementia, major depressive disorder, anxiety, and polyarthritis had a nebulizer machine and two unopened vials of Albuterol Sulfate for inhalation on the bedside table and reported independently adding the medication to the machine and administering treatments daily without nursing supervision. The DON stated there were no residents authorized to self-administer medications and that no medications should be stored at the bedside without an order; the resident’s orders did not include bedside storage. Another resident had a medication cup at bedside containing a small white pill marked “AC 145,” which she believed might be for high blood pressure; her orders included Chlorthalidone 25 mg daily for hypertension. A separate resident’s unlocked in-room refrigerator contained Fluticasone Propionate nasal spray ordered for nightly use, despite the facility’s policy that medication supplies are accessible only to licensed nursing, pharmacy personnel, or staff lawfully authorized to administer medications.
Improper Food Storage, Labeling, and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s dietary services affecting all 114 residents receiving dietary services, based on observations during a kitchen tour and staff interviews. In dry storage, surveyors observed a 25 lb bag of great northern beans left open to the air. In kitchen cooler #2, they found a facility container of hard-boiled eggs with an expiration date of 7/14/25 still present. A 30 lb bucket of beef base was observed open to air with the lid sitting loosely on top, and a 30 lb bucket of chicken base was being stored underneath the kitchen sink. Two silver facility pans containing yellow cake were placed on the counter within splashing distance of the kitchen sink. Two red sanitization buckets in use tested at 400 ppm, above the level later identified by the Dietary Manager as appropriate. Surveyors also observed that serving utensils stored in open bins were dirty with dried, crusted food, and two stacks of three silver mixing bowls under the food prep counter contained crumbs and a dried white substance. In a subsequent interview, the Dietary Manager stated that food should be sealed to prevent damage, contamination, and bacteria, and that dating food items is important to assure freshness, adding that outdated or misdated food needs to be discarded because it can cause sickness. The Dietary Manager acknowledged not knowing that food should not be stored under the sink or near the sink due to potential contamination from water, and stated that using dirty utensils will cause cross-contamination and sickness. The facility’s written policies required sanitary practices in food preparation, proper labeling and sealing of opened food items, appropriate storage of opened products in tightly covered containers, and following manufacturer recommendations for sanitizing solution concentration.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Device and Incontinence Care
Penalty
Summary
Surveyors identified that nursing staff did not follow the facility’s Enhanced Barrier Precautions (EBP) and PPE requirements when providing care to multiple residents with devices and wounds. One RN administered an enteral feeding via gastrostomy tube (g-tube) to a resident who had an EBP sign on the door and a care plan requiring EBP due to a g-tube, urinary catheter, and wound, but the RN wore only gloves. The same RN later assessed and flushed another resident’s g-tube, again with an EBP sign posted and a care plan requiring EBP for a g-tube and wound, while wearing only gloves. An LPN administered a bolus g-tube feeding to a third resident whose door displayed an EBP sign and whose care plan required EBP due to a g-tube, but the LPN also wore only gloves. The facility’s EBP policy required gown and gloves for high-contact resident care activities, including handling feeding tubes, and the DON stated staff were expected to adhere to EBP when rendering direct care. Surveyors also observed a CNA providing incontinence care to another resident without performing hand hygiene and while improperly using gloves and contaminated supplies. The CNA entered the room, closed the door, and donned gloves without hand hygiene, then removed a urine- and stool-soiled undergarment, turned off the call light with soiled gloves, and closed the privacy curtain, bumping the overbed table and knocking the roommate’s stuffed bear to the floor. The CNA picked up the bear with the same soiled gloves and then continued incontinence care, wiping under the resident’s reddened abdominal fold and vaginal area multiple times with the same towel, and wiping the buttocks and gluteal cleft multiple times with the same washcloth, before covering the resident, removing gloves, and leaving the room. The DON stated that not cleaning residents properly during incontinence care and touching environmental items with soiled gloves is an infection control concern and that staff should perform proper hand hygiene. Facility policies on incontinence care and hand hygiene required perineal/genital care to prevent infection and specified handwashing or alcohol-based hand rub use before and after glove use, after handling potentially contaminated items, and after direct resident care.
Failure to Maintain Resident Bodily Privacy in Common Area
Penalty
Summary
Surveyors identified a failure to maintain a resident's bodily privacy and dignity when a resident with severe cognitive impairment and multiple psychiatric and neurological diagnoses was observed partially undressed in a common area. On 12/11/25 at 10:14 AM, the resident was sitting on the floor in a common area across from the nurses station, in front of the elevator, with pants pulled down to the knees and the penis not contained in the incontinence brief. The Social Services Director was seated at the nurses station with his back to the resident and was texting the DON while the resident remained on the floor undressed. At 10:16 AM, a CNA exited the elevator, observed the resident on the floor, and alerted the Social Services Director; together they assisted the resident to stand, at which time the resident’s penis was fully exposed outside of the incontinence brief. The resident’s admission record showed multiple diagnoses including encounter for surgical aftercare, autistic disorder, epilepsy, dementia, schizophrenia, impulse disorder, and intellectual disabilities. The MDS dated 10/05/25 documented severe cognitive impairment and behavioral symptoms that intruded on the privacy of others and disrupted care or living arrangements. Progress notes dated 12/11/25 at 10:53 AM described the resident as being in and out of other residents’ rooms, unable to be redirected, pushing past staff, and laying on the floor exposing self. The facility’s Dignity policy, revised 01/25, stated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality, and that staff shall promote, maintain, and protect residents’ privacy, including bodily privacy during assistance with personal care and treatment procedures. Despite this policy and the known behavioral history, the resident was allowed to remain in a public common area with genital exposure until discovered by the CNA.
Failure to Provide Timely Access to Resident Personal Funds
Penalty
Summary
The facility failed to honor a resident’s right to manage his personal funds by not providing prompt access to requested money from his personal funds account. During observation, the resident, who was cognitively intact per an MDS dated 11/17/25 and had diagnoses including hemiplegia and hemiparesis, morbid obesity, diabetes, major depressive disorder, and polyosteoarthritis, reported that he had requested $40 from his personal funds account three weeks earlier from the Assistant Administrator/Human Resources and had never received it. In a subsequent interview, the Assistant Administrator/Human Resources confirmed that the resident had a $160 balance and had requested $40 approximately two weeks earlier, but she had not gone to the bank to obtain the funds and acknowledged that residents should not have to wait two weeks or more for requested money. The Assistant Administrator/Human Resources also stated she was the only person who could go to the bank to access residents’ funds. The facility’s Resident Personal Funds policy dated 05/14 stated that the facility manages residents’ personal funds when requested and that residents may choose to have the facility hold, safeguard, and manage their personal funds. Despite this policy and the resident’s request, the facility did not provide timely access to the resident’s personal funds, resulting in the deficiency.
Failure to Report Allegation of Abuse Involving Refusal of Toileting and Hygiene Care
Penalty
Summary
The facility failed to report an allegation of abuse to the state survey agency after a cognitively intact resident reported that a CNA refused to provide necessary toileting and hygiene care. The resident, who has diagnoses including Arnold Chiari Syndrome, craniofacial dysostosis, monocular exotropia, seizures, scoliosis, and dysthymic disorder, is usually continent of bowel and bladder, has limited use of extremities, uses a motorized wheelchair, and requires assistance with toileting and toilet hygiene per her care plan. She stated that when she requested toileting assistance and a shower because her menstrual period had started, the CNA told her to go to the toilet in her pants and did not change her menstrual pad. The resident reported this incident directly to the Administrator and stated the CNA later told her she would not have said that if she knew the resident was "in her right mind." The Administrator, who is identified as the abuse coordinator, acknowledged that he did not submit a report to the Illinois Department of Public Health after being informed that the CNA did not provide the requested shower and refused to change the resident’s menstrual pad. The DON stated that she heard the CNA refusing to toilet the resident and that she informed the Administrator of this refusal, although she did not recall when. Documentation in the CNA’s corrective action notice listed discharge for refusal to do work, including refusing to toilet a resident during her shift, taking long breaks, and attitude issues. Despite this, the Administrator stated that refusing to toilet an alert, oriented, continent resident is not abuse and confirmed that no report was made, contrary to the facility’s Abuse Prevention Program policy, which defines abuse to include deprivation of goods and services necessary to maintain physical, mental, and psychosocial well-being and requires accurate and timely investigative reports.
Failure to Notify Provider of Missed Medications and Unassessed Use of Resident-Managed CGM
Penalty
Summary
The deficiency involves the facility’s failure to follow provider notification requirements and medication administration parameters when ordered medications were missed, and failure to assess and obtain orders for the use of a continuous glucose monitoring (CGM) device. For one resident with diagnoses including atrial fibrillation, hypertension, schizophrenia, cognitive communication deficit, pain, and weakness, the RN reported that the resident refused her scheduled morning medications due to nausea and that Zofran was given. The RN then administered multiple medications, including amantadine, docusate sodium, and gabapentin, at approximately 1:05 PM, well outside the facility’s stated one-hour medication administration window for a 9 AM dose, without contacting the NP or MD for direction. Review of the physician order sheet confirmed these medications were ordered on twice-daily and three-times-daily schedules, and the medication administration audit showed the 9 AM gabapentin dose was documented at 1:16 PM and the 1 PM dose at 1:19 PM. There were no progress notes indicating the RN had notified the NP or MD about the missed or delayed doses. Interviews with clinical staff and leadership confirmed that the nurse did not follow expected procedures for missed or delayed medications. The NP stated she was not contacted about any medications not administered to this resident and explained that if a resident was nauseous, she expected antinausea medication to be given and then, if the resident still could not take medications within the 8–10 AM window for a 9 AM dose, the nurse should call the provider to clarify which medications to administer, as it was not up to the nurse to decide due to differing medication half-lives and potential toxicity. Other nursing staff, including an RN and an LPN, stated that if a resident could not take medications at the scheduled time, they would notify the doctor to determine whether to skip or make up the dose, and the DON stated the nurse should contact the doctor if medications are held past the due time because it could result in an overdose if the next dose was due around the same time. The facility’s medication administration policy required medications to be administered within one hour of prescribed times, and the change in condition policy required physician or NP notification when deemed necessary or appropriate in the resident’s best interest. A second deficiency involved the facility’s failure to obtain a physician’s order, perform an assessment, and develop care plan interventions for a resident’s use of a CGM system, despite having a facility policy on continuous glucose monitoring. The resident reported that she independently managed her CGM, obtained her own blood glucose readings, and informed staff of the results, and that staff did not check her blood glucose with facility equipment. An LPN stated that insulin and other interventions were provided based on the readings the resident reported from her CGM, and these readings and related interventions were documented in the EMR. The DON confirmed that the resident had a CGM, that staff obtained and documented glucose readings from the device, that the resident maintained and connected it herself, and that no competency assessment of the resident’s use of the CGM had been completed. The DON also stated staff did not have instructions or knowledge of how the device worked, and the Administrator confirmed there were no facility policies guiding assessment or nursing actions based on resident-managed CGM devices. Record review showed there was no physician order for self-directed CGM use, no care plan interventions, and no documented assessment of the resident’s use of the CGM, despite a facility CGM policy requiring a physician’s order and adherence to manufacturer instructions.
Failure to Follow G-Tube Orders, Label Feedings, and Maintain Tube Site
Penalty
Summary
The deficiency involves the facility’s failure to follow gastrostomy tube (g-tube) feeding orders, properly label feeding bottles and bags, and maintain the g-tube site for one resident dependent on staff for care. On multiple observations, the resident was receiving g-tube feedings via a pump with hanging feeding bags that were not labeled with the type of formula being infused, and a clear bag was connected to a water bag without labeling. An open bottle of the ordered nutritional product was observed at the bedside. On one occasion, the feeding pump alarm was beeping to indicate inactivity, and the alarm continued for at least 15 minutes without resolution. When an RN assessed the infusion, she stated she was unsure of the type of feeding being administered because the bag was not labeled, and acknowledged that feeding bags should be accurately labeled to ensure the correct formula is infused. The resident’s g-tube site was repeatedly observed with brown, thick, adherent drainage and without a dressing, despite an order to clean the g-tube site with normal saline daily and as needed. The wound nurse stated that nurses should be assessing and cleaning tube sites to prevent complications. The resident’s care plan directed nursing staff to use clinical standards of practice in managing the tube, including infusing feeding as ordered and regularly checking the tube site for drainage. These observations and staff statements show that the facility did not implement the ordered care and care plan interventions for g-tube feeding administration, labeling, and site maintenance for this resident.
Medication Administration Outside Time Window Resulting in Elevated Error Rate
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and within the facility’s defined medication administration window, resulting in a medication error rate of 10.53% (4 errors out of 38 opportunities), exceeding the required rate of less than 5%. One cognitively intact resident with diagnoses including atrial fibrillation, hypertension, schizophrenia, cognitive communication deficit, pain, and weakness did not receive medications as ordered. On a specified date, an RN delayed the resident’s scheduled 9 AM medications because the resident was nauseous and subsequently prepared and administered them at 1:05 PM, outside the facility’s one-hour window around the prescribed time. The RN then documented the medications as administered in the electronic record between 1:15 PM and 1:19 PM. Medication reconciliation and record review showed that Amantadine HCl and Docusate Sodium, each ordered twice daily at 9 AM and 5 PM, and Gabapentin 300 mg, ordered three times daily at 9 AM, 1 PM, and 5 PM, were all administered at 1:05 PM instead of at the ordered 9 AM time. The 1 PM dose of Gabapentin was also signed out at 1:19 PM. A daily multivitamin ordered once a day at 9 AM was not administered as ordered, despite being signed off in the record. Interviews with an LPN, the DON, and an NP confirmed that the facility’s medication administration window for 9 AM medications was 8 AM to 10 AM, and that medications given outside this window required contacting the physician or NP for clarification, which was not documented for this resident. The facility’s policy required medications to be administered according to physician orders and within one hour of prescribed times, which was not followed in this instance.
Failure to Ensure Timely Emergency Response for Resident in Respiratory Distress
Penalty
Summary
The facility failed to ensure a timely ambulance transfer for a resident experiencing respiratory distress. On the day in question, the resident, who had a history of acute respiratory failure with hypoxia, sepsis, quadriplegia, and repeated hospitalizations for shortness of breath, repeatedly requested to go to the emergency room due to shortness of breath and not feeling well. Despite the resident's abnormal vital signs—including low blood pressure, elevated heart rate, and low oxygen saturation—the LPN on duty initially called for a routine ambulance instead of 911. The ambulance dispatcher advised the nurse to call 911 due to the resident's critical condition, but the nurse attempted to contact other ambulance companies instead, delaying emergency care. When the EMT arrived approximately 20 minutes later, the resident was found gasping for air with further deteriorated vital signs and required immediate intervention. The EMT noted that the resident was unable to call 911 herself due to her paraplegia. Interviews with other nursing staff, the DON, and the NP confirmed that the facility's policy and standard practice required calling 911 immediately for acute respiratory distress and significant changes in vital signs. The facility's care plan for the resident also specified prompt response to respiratory complications and emergency needs, which was not followed in this instance.
Failure to Provide Proper PICC Line Care and Documentation
Penalty
Summary
The facility failed to provide proper care and maintenance for a resident's tunneled PICC (Peripherally Inserted Central Catheter) line. Upon admission to the hospital, the resident's PICC line dressing was found to be 22 days old, despite orders and facility policy requiring dressing changes every 7 days. Documentation in the resident's Medication Administration Record (MAR) indicated that dressing changes were performed on two dates, but the LPN who documented these changes later admitted that she did not actually perform the dressing changes and was unsure if an RN had done so. Additionally, there was no documentation of required PICC line cap changes in the MAR or Treatment Administration Record (TAR) for the month reviewed. Interviews with facility staff revealed a lack of clarity and training regarding central line care responsibilities and procedures. The LPN stated she had not received training on central line dressing changes and did not know the frequency for cap changes, believing these tasks were the responsibility of an RN. The DON confirmed that only RNs should perform central line dressing changes and acknowledged that staff needed reeducation on central line care. The facility's policy required dressing changes every 5-7 days and documentation of all interventions, which was not followed in this case.
Failure to Supervise Resident with Hot Liquids Results in Burns
Penalty
Summary
The facility failed to implement safety interventions and provide adequate supervision to prevent a resident from sustaining burns while drinking hot liquids. The resident, who has quadriplegia and is dependent on staff for eating, was left unsupervised with a hot cup of coffee that had no lid and was using a straw, despite recommendations against straw use due to aspiration risk. The resident suffered 1st and 2nd degree burns on her chest after the coffee spilled from the straw onto her chest. The incident occurred when a CNA warmed the resident's coffee in the microwave and returned it to her without a lid, allowing her to drink it unsupervised. The resident's care plan and previous swallow study explicitly advised against the use of straws and required supervision while drinking. The lack of adherence to these safety measures and the facility's policy on feeding and assisting residents led to the resident's injury.
Failure to Staff RNs for Required Hours
Penalty
Summary
The facility failed to staff Registered Nurses (RNs) for 8 consecutive hours, 7 days a week, as required. This deficiency was identified through a review of the facility's schedule and interviews with staff members. The schedule from September 28, 2024, through October 23, 2024, revealed that on several occasions, there were no RNs present in the facility for the required duration. Specifically, on September 29, October 13, and October 19, 2024, the facility did not have an RN on duty for 8 consecutive hours. The facility's policy mandates that an RN must be available for supervision for at least 8 consecutive hours daily, which was not adhered to on these dates. Interviews with staff, including the Director of Nursing (DON), Assistant Director of Nursing (ADON), and other RNs, confirmed that they did not work on the weekends unless necessary, and there was no documentation to show their presence on the specified dates. The Administrator acknowledged the requirement for RNs to be present for 8 hours daily but was unaware of the lapses in staffing. The facility's failure to meet the staffing requirement has the potential to affect all residents, as it compromises the supervision and care provided.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to obtain physician orders for medications brought from home and placed at the bedside, and did not complete self-administration of medication assessments for six residents. These residents were observed with various medications at their bedsides, including Lidocaine pain relief, antiacid tablets, nasal sprays, and eye drops, which they self-administered without proper assessment or orders. Despite being cognitively intact, as indicated by their BIMS scores, there were no documented assessments or care plans for self-administration of medications in their electronic medical records. The Director of Nursing (DON) acknowledged that medications brought from home should have orders and that residents need to be assessed for their ability to self-administer medications safely. However, the DON stated that no residents were currently assessed or authorized to self-administer medications. The facility's policy requires an assessment at admission or thereafter, with documentation and physician orders if self-administration is deemed appropriate. Additionally, medications kept at the bedside should be recorded on the medication record, and drug storage remains the responsibility of the nursing staff. One resident was found with a bisacodyl stimulant laxative at the bedside, which she took without informing her nurse, despite having no current order for it. The LPN confirmed that all medications should be administered by nursing staff, citing risks such as over-medicating and drug interactions. The facility's policy on medication storage emphasizes that medications should be stored safely and securely, accessible only by authorized personnel.
Failure to Apply Splints and Braces
Penalty
Summary
The facility failed to apply necessary splints and braces to two residents, R11 and R15, who required them to maintain or improve their range of motion. R11, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, was observed multiple times without the prescribed right resting hand splint. Despite having a physician's order and a care plan indicating the need for the splint to prevent further contracture, the splint was not applied during the observed times. The restorative nurse confirmed that the splint should have been on, as its absence could increase contraction. Similarly, R15, who had diagnoses including hemiplegia and contractures in both hands, was observed without the required palm protectors on several occasions. The physician's orders and care plan specified the need for bilateral palm protectors to manage muscle stiffness. The restorative nurse admitted that the palm protectors were not applied as required and noted that the night CNAs removed them without proper documentation or orders to do so. The Director of Nursing and other staff acknowledged that splints and protectors should be applied as ordered, and any refusal by residents should be documented.
Deficiencies in Fall Prevention and Smoking Supervision
Penalty
Summary
The facility failed to implement necessary interventions to prevent fall injuries and smoking hazards for several residents. One resident, who is blind and uses a wheelchair, was pushed by staff without footrests attached to his wheelchair, resulting in his feet hitting a raised section of concrete. Another resident with severe cognitive impairment was found in a room with an exposed metal bed frame, posing a potential injury risk. Additionally, a resident with severe cognitive impairment was observed walking without skid-protection socks, increasing her fall risk. The facility also failed to maintain appropriate bed heights and fall prevention measures for residents at risk of falling. One resident's bed was consistently left in a high position without fall mats, despite being at risk for falls and having a care plan that included fall mats as an intervention. Another resident, who preferred a high bed position, did not have fall mats in place as required by his care plan, and staff were unaware of the missing mats. Furthermore, the facility did not adequately assess and supervise a resident with smoking materials. A resident was found with a lighter and an aerosol spray can, despite a care plan indicating she required supervision when smoking. The facility's policy prohibits residents from keeping smoking materials if they are not safe to smoke independently, yet the resident's care plan was updated without a new smoking risk assessment.
Failure to Properly Administer G-tube Feeding
Penalty
Summary
The facility failed to properly manage the administration of G-tube feeding for a resident, identified as R15, who was admitted with conditions including hemiplegia, hemiparesis, dysphagia, and a gastrostomy. The Physician Order Sheet for R15 specified that the G-tube feeding should be administered at a rate of 75 ml/hr for 20 hours daily, with specific instructions to check tube placement and residuals before feeding. However, observations revealed that the feeding was consistently administered at an incorrect rate of 70 ml/hr, and the necessary checks for tube placement and residuals were not performed. On multiple occasions, staff members, including LPNs and the Assistant Director of Nursing, failed to adhere to the prescribed procedures for G-tube feeding. For instance, on one occasion, an LPN did not check the residual by aspirating the stomach contents before starting the feeding, and the feeding pump was set to an incorrect rate. Another LPN also failed to check the placement by checking for residual prior to flushing the G-tube with water. These actions were contrary to the facility's policy, which required checking for residuals to prevent potential complications such as regurgitation or aspiration. Interviews with staff, including the Director of Nursing, revealed a lack of adherence to the facility's policies and outdated practices being used, such as pushing air to check for tube placement. The Director of Nursing emphasized the importance of aspirating to check residuals and ensuring the feeding rate matched the physician's orders. The facility's policies clearly outlined the procedures for G-tube feeding and weight assessments, but these were not followed, leading to the deficiency in care for R15.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 10%, which exceeds the acceptable threshold of 5%. During a medication pass observation, a registered nurse administered incorrect medications to a resident. Specifically, the nurse gave one tablet of Folic Acid 1000 mcg, one tablet of Torsemide 20 mg, and one tablet of Soaanz (Torsemide) 60 mg, but failed to administer Ezetimibe 10 mg as prescribed. The nurse incorrectly signed the Medication Administration Record (MAR) indicating that Ezetimibe was given, despite the medication not being available. The resident involved, who was cognitively intact, had multiple diagnoses including hypertension, hyperlipidemia, lymphedema, and atrial fibrillation. The resident's medication orders for October 2024 included Ezetimibe 10 mg, Folic Acid 400 mcg, and Torsemide 60 mg, with Torsemide 20 mg having been discontinued in September 2024. The Director of Nursing confirmed that medications should be administered as prescribed and that discontinued medications should not be present in the medication cart. The facility's policy emphasizes the importance of administering medications according to physician orders and documenting any deviations appropriately.
Deficiency in Refrigerator Maintenance and Food Safety
Penalty
Summary
The facility failed to maintain proper food safety and hygiene standards in residents' personal refrigerators. Three residents were found to have expired food items and lacked temperature monitoring in their personal refrigerators. One resident had a refrigerator with no thermometer and no temperature log, and she reported that staff had never checked her refrigerator. Another resident had multiple expired food items, including milk and yogurt, and also lacked a thermometer and temperature log. The resident was unaware of the expired items until the surveyor pointed them out. A third resident's refrigerator contained old, moldy fruit and expired dairy products, and the refrigerator was cluttered and sticky. Despite the resident's inability to clean the refrigerator due to physical impairments, the housekeeping staff responsible for cleaning it had not done so. The Assistant Director of Nursing acknowledged the risk of illness from consuming expired food and confirmed that housekeeping was responsible for maintaining the cleanliness and safety of the refrigerators.
Lack of Supervision Leads to Resident's Sunburn
Penalty
Summary
The facility failed to provide adequate supervision to a cognitively impaired resident, resulting in prolonged sun exposure and subsequent full thickness burns to the resident's upper back and posterior neck. The resident, identified as having dementia, was able to ambulate independently and frequently went outside. However, the facility did not have a system in place to monitor or supervise the resident's outdoor activities, leading to the resident being exposed to the sun for an unknown duration. The resident's medical history included chronic obstructive pulmonary disease, Alzheimer's disease, fibromyalgia, basal cell carcinoma, chronic pain syndrome, and adjustment disorder with mixed anxiety and depressed mood. The resident was severely cognitively impaired and required assistance with activities of daily living. Despite these needs, the facility's care plan did not adequately address the supervision required to prevent the resident from wandering outside unsupervised. Interviews with facility staff revealed that the patio door was left unlocked, allowing residents to exit without staff knowledge. The Activity Assistant supervised the patio only during scheduled smoking breaks, and no staff were assigned to supervise the area at other times. The Director of Nursing confirmed that there was no investigation into the duration of the resident's sun exposure and no facility policy regarding outdoor supervision, contributing to the incident.
Failure to Provide Resident Access to Funds
Penalty
Summary
The facility failed to provide a resident access to their funds as requested. The resident, a male with a history of infection and inflammatory reaction due to an internal left knee prosthesis, hypertension, hypoglycemia, hepatitis C, and aftercare following joint replacement surgery, was admitted and later discharged from the facility. Approximately a month after discharge, the resident contacted the facility regarding his Trust Fund money. The Administrator confirmed that $60 remained in the resident's Trust Fund account and assured the resident that a refund check would be mailed. However, the Director of Accounts Receivable verified that the funds were still in the account and had not been sent to the resident. The resident's statement showed an ending balance of $60.04 on the date of discharge.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to keep residents safe from resident-to-resident abuse, resulting in multiple altercations involving residents R1, R2, and R3. On April 17, 2024, R1 was pushed by R2, causing R1 to fall and hit her head. R1 was sent to the emergency department and later released with no significant injuries. R1, who has moderate cognitive impairment and a history of repeated falls, reported feeling unsafe around R2 and preferred to stay in her bedroom to avoid further confrontations. R2, who has severe cognitive impairment and a history of wandering and taking other residents' belongings, was discharged for psychiatric care after the incident. Another incident occurred on February 26, 2024, when R2 struck R1 in the face and lip after a misunderstanding involving a stuffed animal. R1 did not require special treatment for the cut on her face. Staff members reported that R1 had previously threatened to give R2 a black eye if she entered her room, leading to an argument and subsequent physical altercation. R2's behavior of entering other residents' rooms and taking their belongings was noted by multiple staff members, who found it challenging to monitor her constantly due to other caregiving responsibilities. R2 was also involved in an incident with R3 on March 20, 2024, when R3 activated her call light and reported that R2 had slapped her on the right arm. Although no acute injury was noted, R3 experienced discomfort in the area. R3, who has moderate cognitive impairment and multiple medical diagnoses, remembered being hit by R2. Staff members confirmed that R2 was found in R3's bedroom but were unsure of her actions. These incidents highlight the facility's failure to protect residents from abuse and adequately monitor R2's behavior, leading to repeated altercations and a lack of safety for the affected 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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