The Haven Of St. Elmo
Inspection history, citations, penalties and survey trends for this long-term care facility in St Elmo, Illinois.
- Location
- 221 East Cumberland, St Elmo, Illinois 62458
- CMS Provider Number
- 145857
- Inspections on file
- 22
- Latest survey
- August 25, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Haven Of St. Elmo during CMS and state inspections, most recent first.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as observed and documented by surveyors.
The facility did not provide pharmaceutical services to meet residents' needs and failed to employ or obtain the services of a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident with diabetes did not receive prescribed sliding scale insulin or consistent blood glucose monitoring due to an unacknowledged physician order in the EHR, resulting in hyperglycemia and hospitalization. Nursing staff believed the order was discontinued, and the MAR showed missed insulin administrations over several days.
The facility did not provide enough nursing staff to meet resident needs, as evidenced by two residents experiencing delays in toileting assistance and incontinent episodes due to slow call light response. Staff interviews confirmed that CNA coverage was often inadequate, with non-certified personnel sometimes monitoring residents on specialized units. Review of staffing schedules showed shifts with fewer CNAs than required by the facility's own assessment, and leadership acknowledged that staffing levels and records were insufficient and inaccurate.
Several residents with cognitive capacity and documented care needs experienced delays in toileting assistance due to inadequate staffing, leading to incontinence episodes. Additionally, after a single resident sustained a burn while smoking, all residents who smoked were required to wear safety aprons and have their smoking materials locked away, regardless of individual risk assessments. These actions were implemented without individualized reassessment, resulting in a failure to respect residents' rights to dignity and self-determination.
Two residents who required staff assistance for toileting experienced delays in receiving help, resulting in incontinent episodes while waiting for staff to respond to call lights. Both residents were cognitively intact and had care plans specifying the need for timely toileting support. Staff and the DON confirmed that insufficient staffing, particularly on nights and weekends, led to these delays.
A resident with a diagnosis of dementia and moderate cognitive impairment did not have a care plan addressing dementia or related care needs. The resident was repeatedly observed sitting unengaged in the dementia unit, and staff confirmed the absence of dementia-specific interventions in the care plan, despite facility policy requiring such planning.
Staff did not follow enhanced barrier precautions for two residents with pressure ulcers, as LPNs and CNAs provided wound care using gloves and hand hygiene but failed to wear gowns during high-contact care activities, despite clear care plan instructions, physician orders, and posted signage requiring both gown and glove use.
Two shared resident rooms were found to be below the required 80 sq. ft. per resident, with measurements confirming insufficient space. Although residents did not voice concerns and no complaints were documented, the deficiency was identified through observation and measurement during the survey.
The facility did not provide the required 8 hours of RN coverage per day, 7 days a week, affecting all 43 residents. The administrator admitted to the lack of coverage and absence of a policy. An LPN confirmed frequent RN absences on weekends, and the nursing schedule for several months showed multiple dates without the required RN coverage.
The facility failed to provide prescribed mechanical soft diets to four residents with severe cognitive impairments and specific dietary needs. Despite documented dietary orders, residents were served meals that did not meet the required texture, such as unground meatloaf and unchopped vegetables. This oversight occurred over several days, with the Director of Nursing acknowledging the failure to follow dietary guidelines.
The facility failed to provide timely assistance with meals for three residents with severe cognitive impairments and other medical conditions. Despite care plans indicating dependency on staff for eating, residents were left without immediate help, consuming minimal food. Staffing challenges were noted, with only two CNAs available to assist multiple residents during meals.
A resident with GERD and other medical conditions experienced frequent vomiting and regurgitation during meals, which was observed by staff but not documented or reported to the physician. Despite staff awareness, the issue was not communicated to the DON, highlighting a failure in following the facility's policy for notifying physicians of changes in condition.
A resident with multiple diagnoses was prescribed psychotropic medications without documented attempts at gradual dose reductions (GDR) or rationale for not doing so. Despite reminders from the pharmacist, the facility lacked documentation from the physician regarding GDRs, violating facility policy that requires such reductions unless clinically contraindicated.
A facility failed to maintain aseptic technique during catheter care for a resident with a neurogenic bladder. A CNA placed a water basin and washcloths on a toilet lid and used a dropped squeeze bottle without disinfecting it, contrary to infection control policies. The Infection Preventionist confirmed these actions did not meet facility expectations.
The facility did not post the required daily nurse staffing data, including the facility's name, date, census, and staff hours, in a prominent place accessible to residents and visitors. The Administrator was unaware of this requirement, and an LPN confirmed the absence of posted data. This oversight could impact all 43 residents.
The facility did not meet the required minimum square footage per resident in two multiple occupancy rooms, affecting four residents. Measurements showed that the rooms did not provide the necessary 80 square feet per resident. Despite this, no concerns were raised by residents or their families, and observations indicated adequate space for residents' needs.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements for daily nursing staff coverage and supervision by a licensed nurse on every shift, as observed and documented by surveyors.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Administer Sliding Scale Insulin and Monitor Blood Glucose
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus and multiple comorbidities did not receive sliding scale insulin and appropriate blood glucose monitoring as ordered by the physician. The resident's Medication Administration Records (MAR) for several days showed no documentation of sliding scale insulin administration at scheduled times, despite an active physician order. The resident was also not consistently monitored for blood glucose levels during this period. Progress notes indicated that the sliding scale insulin order was not acknowledged in the electronic health record, leading nursing staff to believe it was discontinued, and as a result, the resident did not receive the prescribed insulin. This failure to administer insulin and monitor blood sugars resulted in the resident experiencing hyperglycemia, with blood sugar levels documented as high as 541, and ultimately being sent to the emergency room for evaluation and treatment. Interviews with nursing staff and the physician confirmed that the sliding scale insulin order was not confirmed in the system and was therefore not administered. The administrator acknowledged that orders should be reviewed and reentered correctly to ensure continuity of care, and that the resident should have received the sliding scale insulin as directed.
Insufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple reports from residents and staff, as well as a review of staffing schedules. Two cognitively intact residents with significant care needs, including assistance with toileting due to weakness, unsteadiness, and a history of falls, reported frequent delays in staff response to call lights, resulting in incontinent episodes while waiting for assistance. Both residents' care plans required staff support for toileting, with one requiring assistance every two hours or sooner upon request. Staff interviews corroborated these concerns, with CNAs and other personnel stating that there were not always enough staff to meet residents' needs in a timely manner. It was reported that call lights were not answered promptly and that non-certified staff, such as housekeepers, were sometimes assigned to monitor residents on the Alzheimer's unit due to staffing shortages. These non-certified staff members indicated they were not trained to provide care or handle resident behaviors and only performed basic monitoring while completing their regular duties. A review of staffing schedules and facility assessment tools revealed discrepancies between scheduled and actual staffing levels, with documented instances of only one or two CNAs present during certain shifts, despite the facility's own assessment indicating a need for more staff. The Director of Nursing and the Administrator both acknowledged that the number of CNAs on duty was insufficient to provide timely care, particularly on nights and weekends, and that staffing records were not always accurate.
Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
The facility failed to honor the rights of four residents to a dignified existence and self-determination, specifically regarding timely toileting assistance and the imposition of smoking restrictions. Two cognitively intact residents, both with documented needs for staff assistance with toileting, reported frequent delays in call light response, sometimes waiting up to thirty minutes for help. These delays resulted in incontinent episodes, as confirmed by both residents and staff, who acknowledged insufficient staffing, particularly on nights and weekends. Facility policy requires prompt response to call lights, but this was not consistently followed. Additionally, the facility implemented a blanket policy requiring all residents who smoke to wear plastic safety aprons and to smoke only under supervision, following an incident where one resident burned himself. Multiple residents, including those assessed as safe to smoke independently and with no history of burns, were required to wear the aprons and had their smoking paraphernalia locked away. These residents expressed discomfort and dissatisfaction with the new restrictions, stating they had not been reassessed individually after the incident and did not understand the need for the change. Staff interviews confirmed that the decision to require aprons and restrict smoking was made by facility administration after the burn incident, without individualized reassessment for each resident. Documentation showed that some residents' care plans and smoking safety screens did not indicate a need for adaptive equipment or supervision, yet the restrictions were applied universally. This resulted in a failure to respect residents' autonomy and dignity, as required by their rights.
Failure to Provide Timely Toileting Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide timely toileting assistance for two residents who required staff support for activities of daily living. One resident, with diagnoses including hypertension, repeated falls, pain, and kidney stones, was assessed as cognitively intact and required supervision or assistance for toilet transfer and hygiene. The resident's care plan specified the need for staff assistance due to general weakness and a history of falls. The resident reported that staff response to call lights could take up to half an hour, particularly on weekends, resulting in episodes of incontinence while waiting for help. Another resident, also cognitively intact and diagnosed with muscle wasting, lack of coordination, acute kidney failure, and chronic pain syndrome, required substantial assistance for toileting. The care plan directed staff to assist the resident to the restroom every two hours or sooner upon request. This resident reported frequent delays in staff response to call lights, leading to repeated incontinent episodes. Multiple staff members, including CNAs and the Director of Nursing, confirmed that staffing shortages, especially on nights and weekends, contributed to delays in answering call lights and providing timely toileting assistance.
Failure to Develop Dementia Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing the dementia diagnosis and related care needs for a resident with a documented history of dementia. The resident's admission record included multiple diagnoses, such as type 2 diabetes mellitus, dysphagia, major depressive disorder, dementia, and anxiety disorder. The Minimum Data Set (MDS) assessment indicated moderate cognitive impairment with a BIMS score of 12. Despite these findings, the resident's current care plan did not address dementia or any associated care needs. Observations over several days showed the resident sitting in the dementia unit dining room without any engagement or activities, and staff interviews confirmed fluctuations in the resident's cognitive status. The Care Plan Coordinator acknowledged that the care plan lacked any interventions or goals related to dementia care, and the facility's own policy required comprehensive evaluation and care planning for individuals with dementia. The deficiency was identified through record review, staff interviews, and direct observation.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions were followed for two residents with pressure ulcers. For one resident with a Stage 4 sacral pressure ulcer and an indwelling catheter, both the LPN and CNA provided wound care treatment using gloves and performed hand hygiene according to current standards, but did not wear gowns as required by the resident's care plan, physician orders, and facility policy. The care plan and signage outside the resident's room specifically instructed staff to don gowns and gloves during high-contact care activities, including wound care for chronic skin openings. Similarly, another resident with a Stage 3 pressure ulcer, a blister, and a laceration, was observed receiving wound care from an LPN and CNA who also failed to wear gowns during the procedure, despite the resident's care plan and physician orders indicating the need for enhanced barrier precautions. Both residents had clear documentation and signage indicating the requirement for gown and glove use during high-contact care, but staff did not adhere to these protocols during observed treatments.
Failure to Provide Required Square Footage in Shared Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in two multiple occupancy bedrooms, affecting four residents. Observations revealed that the rooms in question were shared by two residents each and contained beds, dressers, recliners, walking assistive devices, and over-bed tables, resulting in limited space for movement. Measurements taken by the Maintenance Director confirmed that the rooms were 154 sq. ft. (77 sq. ft. per resident) and 150.7 sq. ft. (75.4 sq. ft. per resident), both below the required 80 sq. ft. per resident for multiple occupancy rooms. Interviews with the affected residents indicated that none expressed concerns about the room size. The Administrator acknowledged that rooms 19-31 did not meet the 80 sq. ft. per resident requirement and that residents were not notified of this at admission. The facility's records confirmed the occupancy of these rooms, and no concerns were documented in Resident Council Minutes or during the survey interviews with residents or families. Despite the lack of complaints, the deficiency was identified based on direct measurement and regulatory requirements.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours per day, 7 days a week, as required. This deficiency was confirmed through interviews and record reviews. The facility's administrator acknowledged the lack of RN coverage and admitted there was no policy in place to ensure the required coverage. A Licensed Practical Nurse (LPN) reported that during the weekend of July 20-21, 2024, there was no RN on duty, and this was a frequent occurrence on weekends. The nursing schedule for May, June, and July 2024 showed multiple dates where the facility did not meet the required RN coverage, affecting all 43 residents residing in the facility.
Failure to Provide Prescribed Mechanical Soft Diets
Penalty
Summary
The facility failed to provide food with the prescribed mechanical soft texture for four residents, each with specific dietary needs due to their medical conditions. These residents, identified as having severe cognitive impairments and various diagnoses such as dementia, dysphagia, and Alzheimer's disease, were served meals that did not meet their dietary requirements. For instance, one resident with no teeth and at risk for dental complications was served unground meatloaf and unchopped broccoli, which they did not consume. Another resident, who had poor dental health and was at risk for dental complications, was also served meals that did not adhere to the mechanical soft texture requirement. This included unground meatloaf and large pieces of vegetables, which were not suitable for their dietary needs. Similarly, a third resident with neurocognitive disorder and muscle wasting was served meals that did not meet the prescribed texture, including unground meatloaf and unchopped vegetables. The facility's failure to adhere to the dietary orders was observed over several days, with meals consistently not prepared according to the mechanical soft texture guidelines. Despite having documented dietary orders and care plans specifying the need for mechanically altered diets, the facility did not follow these instructions, leading to residents being served inappropriate meals. The Director of Nursing acknowledged that the food should have been prepared according to the recipes and guidelines, which were not followed in these instances.
Failure to Provide Timely Assistance with Meals
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living, specifically eating, for three residents with severe cognitive impairments and other medical conditions. Resident 30, diagnosed with dementia, Alzheimer's disease, and other conditions, was observed on two occasions receiving her meal without assistance, resulting in her consuming less than 5% of her food. Despite her care plan indicating she is dependent on staff for eating, staff members delayed in providing the necessary assistance, and at one point, another resident attempted to help her. Similarly, Resident 33, with diagnoses including neurocognitive disorder and Parkinson's disease, was also left without immediate assistance during meal times, despite being documented as dependent for eating. Resident 21, with Alzheimer's disease and other health issues, experienced delays in receiving help with meals as well. The Director of Nursing acknowledged that residents should not wait 20 minutes or more for assistance and noted staffing challenges, with only two CNAs available to assist multiple residents needing help during meals.
Failure to Monitor and Report GERD Symptoms
Penalty
Summary
The facility failed to monitor and report episodes of vomiting and food regurgitation for a resident diagnosed with multiple conditions, including Alzheimer's disease, dementia, and Gastro-Esophageal Reflux Disease (GERD). The resident's care plan included monitoring and documenting signs and symptoms of GERD, but these episodes were not recorded in the electronic medical record, nor was the physician notified. Observations over several days showed the resident regurgitating food during meals, and staff members, including CNAs and an LPN, were aware of the issue but did not ensure it was documented or communicated to the physician. Interviews with staff revealed that the vomiting had been occurring for some time, with increased frequency in recent weeks. Despite this, the Director of Nursing was unaware of the situation, indicating a breakdown in communication within the facility. The Speech Language Pathologist had previously evaluated the resident and suggested that the issue might be related to GERD medication, recommending a barium study, but no referral was made. The facility's policy requires notifying the physician of changes in condition, which was not followed in this case.
Failure to Document Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R24, was free from unnecessary psychotropic medications. R24 was admitted with diagnoses including major depressive disorder, schizophrenia, insomnia, and nutritional anemia. The resident's medication regimen included Doxepin, Quetiapine, and Alprazolam, all of which required gradual dose reductions (GDR) as per facility policy. However, there was no documentation of attempted GDRs or any rationale or contraindication for not attempting GDRs for these medications in R24's medical record. The Director of Nursing (V2) acknowledged the lack of documentation from the Mental Health Family Nurse Practitioner (V13) regarding GDRs for the medications. The Pharmacist (V21) confirmed sending multiple reminders to the facility about the need for GDRs, but noted a gap in documentation from the physician. The facility's policy mandates that residents on psychotropic drugs should receive GDRs and behavioral interventions unless clinically contraindicated, with attempts encouraged at least twice yearly. Despite these requirements, the facility did not maintain the necessary documentation to support compliance with GDR protocols for R24.
Failure to Maintain Aseptic Technique During Catheter Care
Penalty
Summary
The facility failed to maintain aseptic technique during catheter care for a resident with a neurogenic bladder requiring an indwelling Foley catheter. The resident, who is cognitively intact, was admitted with multiple diagnoses including type 2 diabetes mellitus, urinary tract infection, chronic kidney disease, and flaccid neuropathic bladder. The facility's policy required catheter care per facility guidelines every 24 hours. However, during an observation, a CNA was seen placing a water basin and washcloths on a toilet lid in a hallway bathroom before using them for catheter care, which is against infection control practices. Additionally, the CNA dropped a squeeze bottle containing soap and water on the hallway floor and then placed it on the resident's bedside table without disinfecting the area or replacing the bottle. The Infection Preventionist Nurse confirmed that the facility's expectations were not met, as staff should not place supplies on potentially contaminated surfaces and should replace any items that become contaminated. The CNA involved had received training on catheter and perineal care upon hiring but did not adhere to the facility's infection control policies during the observed incident. The facility's policies on infection prevention and urinary catheter care emphasize the importance of aseptic techniques and routine hygiene to prevent infections, which were not followed in this case.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to prominently post the daily nurse staffing data, which includes essential information such as the facility's name, date, census, and the total number and actual hours worked per shift for both licensed and unlicensed staff responsible for resident care. This deficiency was observed on multiple occasions, including specific times on 7/21/2024, 7/22/2024, and 7/23/2024, where the Daily Nurse Staffing data sheet was not posted in a location readily accessible to residents and visitors. During an interview, the Administrator admitted to being unaware of the requirement to post this data, and a Licensed Practical Nurse confirmed that she had never seen the staffing data posted while working at the facility. This oversight has the potential to affect all 43 residents residing in the facility.
Facility Fails to Meet Room Size Requirements for Multiple Occupancy Rooms
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in two multiple occupancy rooms, affecting four residents. Observations and measurements conducted on 7/23/2024 revealed that the rooms shared by the residents did not meet the regulatory requirement of 80 square feet per resident. Specifically, the room shared by two residents measured 154 square feet, equating to 77 square feet per resident, while another room measured 150.7 square feet, equating to 75.4 square feet per resident. These measurements were confirmed by the Maintenance Director using a tape measure. During the survey, the facility's Administrator acknowledged that rooms 19-31 did not meet the required space per resident and were certified for double occupancy. Despite this, there were no concerns or negative feedback from the residents or their families regarding the room sizes, as documented in interviews and Resident Council Minutes from the past six months. The facility's Daily Census sheet confirmed that several residents resided in these non-compliant rooms. Observations during the survey indicated that adequate space existed to meet the medical and personal needs of the residents in these rooms.
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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