Thrive Of Lake County
Inspection history, citations, penalties and survey trends for this long-term care facility in Mundelein, Illinois.
- Location
- 850 E Us Highway 45, Mundelein, Illinois 60060
- CMS Provider Number
- 145460
- Inspections on file
- 55
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Thrive Of Lake County during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, osteoporosis, abnormal gait, and high fall risk, who required extensive assistance for bed mobility, fell from bed while a CNA was changing an incontinent brief with the bed in an elevated position. The CNA stood on the opposite side of the bed from the direction the resident was instructed to roll and reported the resident rolled off before she could intervene. A restorative nurse later stated staff should stand on the side toward which a resident is being turned to act as a barrier. The resident was sent to the hospital, where imaging showed a fracture deformity of a toe of indeterminate age.
A resident with severe cognitive impairment did not receive a lidocaine patch as ordered, with conflicting documentation and observation regarding its application and removal. Additionally, a nurse pre-poured medications for five residents into cups ahead of scheduled administration times, contrary to facility policy, increasing the risk of medication errors.
A resident with multiple medical conditions was found to have a new left hip fracture requiring surgery after being sent to the hospital. The DON assumed the fracture was old without confirming with hospital staff, did not interview all relevant staff or therapists, and the facility's incident report inaccurately described the injury. The facility did not follow its own abuse investigation policy, which requires interviewing all staff present during the period in question.
A resident's overpayment resulting from a change in Medicaid liability was not refunded in a timely manner. Despite the facility's policy requiring prompt processing, the refund process was not completed, and the resident's family did not receive the identified overpayment for nearly two years.
A resident with a history of falls and cognitive impairment fell and sustained pelvic fractures due to inadequate supervision in the dining room. The LPN and CNAs were occupied with other tasks, leaving the resident unsupervised despite her high fall risk. The fall was unwitnessed, and the resident's care plan had identified her as needing close monitoring.
A resident experienced unrelieved pain and sleep disturbances for three days due to the facility's failure to provide her prescribed muscle relaxer, tizanidine, despite multiple requests. The medication was eventually received and administered after a delay, with discrepancies noted between the resident's account and medication administration records. Staff interviews revealed issues with medication reordering and dispensing, contrary to the facility's policies on pain management.
The facility failed to properly store food items and maintain sanitary conditions in the kitchen, affecting all residents. Thickener was left uncovered, and sanitization levels were inadequate, increasing the risk of contamination. A cook was observed using contaminated gloves without changing them or performing hand hygiene, leading to potential cross-contamination. The facility lacked specific policies for glove use and hand hygiene in the kitchen.
The facility failed to serve food at an appetizing temperature, as meals were often delayed and served cold, leading to resident complaints. The Dietary Manager was aware of the issue but had not attended Resident Council meetings to address it. Logistical issues with food carts were cited as a reason for the lack of insulated covers on trays. CNAs, responsible for distributing trays, often had to reheat food, impacting their ability to provide other resident care.
The facility failed to implement proper infection control measures, including incorrect isolation signage for a resident with MRSA, inadequate PPE use by staff during high-contact care for residents under enhanced barrier precautions, and improper glove use during pericare. These deficiencies were confirmed by the facility's infection control staff.
A resident with severe cognitive impairment and other medical conditions was not provided with appropriate toileting assistance, as a CNA instructed her to relieve herself in her brief instead of offering a bedpan. The facility's policy emphasizes maintaining residents' dignity, which was not upheld in this instance.
A resident with severe cognitive impairment and hemiplegia was not safely transferred using a mechanical lift, as only one staff member was actively involved in the process, contrary to the facility's policy requiring two staff members. This deficiency was observed during a survey, highlighting a failure to adhere to safety protocols.
A resident with multiple health conditions, including severe malnutrition and chronic kidney disease, did not receive timely PICC line dressing changes and measurements as required. The facility's records showed the last dressing change was on 2/28, but by 3/13, the dressing was not intact and lacked a date or signature. The facility's policy mandates weekly dressing changes and proper labeling, which were not followed, as confirmed by the DON.
A facility was found to have a 6% medication error rate during a medication pass involving two residents. An LPN administered an incorrect dose of Zinc to a resident and failed to provide a prescribed Thiamine tablet. The facility lacked the prescribed Zinc 220 mg capsules, and there was no documentation of the discrepancy or communication with the provider. The DON confirmed that nurses should follow physician orders and document any issues.
A facility failed to complete prescribed treatments for a resident with an unstageable sacral pressure ulcer. The resident's treatment orders were changed to include cleansing with normal saline and applying Iodosorb/Calcium alginate and foam dressing three times a week. However, the Treatment Administration Record showed that 2 out of 11 treatments were not documented as completed. The wound nurse confirmed that treatments should be changed as ordered and documented.
A facility failed to notify a resident's POA about the initiation of treatment for a pressure injury. The resident was admitted with a pressure injury, and treatment orders were obtained the following day. However, the POA was not informed until the resident was in the emergency room. The facility's policy did not specify the need to notify a POA, contributing to the communication lapse.
Resident Falls From Bed During Incontinent Care Due to Improper Positioning and Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe provision of care and adequate supervision to prevent an accident for one resident identified as high risk for falls. The resident had Alzheimer’s disease, osteoarthritis, osteoporosis, abnormal gait and mobility, cognitive deficit, incontinence, and required extensive assistance for bed mobility. A fall risk evaluation completed on 12/9/25 identified the resident as high risk for falls. On 3/15/26 at 7:00 PM, while a CNA was changing the resident’s incontinent brief, the resident slid or rolled off the side of the bed and fell to the floor. The CNA reported that the bed was elevated to facilitate care, the brief was partially undone, and the resident was instructed to roll to the right side and grab the bed bar, at which point the resident rolled off the bed. The CNA stated she was positioned on the resident’s left side and did not have time to grab the resident as she fell to the right side. The LPN’s incident report and interview confirmed that only one staff member was present during the turning and changing, and that the resident fell off the right side of the bed while the CNA was working on the left side and pulling on lumpy sheets. The restorative nurse stated that staff should stand on the side of the bed toward which the resident is being turned to act as a barrier and help prevent rolling off the bed, and indicated that in this case the CNA should have been on the right side of the bed when the resident was turning. The resident’s daughter reported being told that the CNA pulled the sheet and the resident rolled off the bed, and stated that the CNA should have been standing in front of the resident rather than behind her. The resident was sent to the hospital for evaluation, and an X-ray of the left foot showed a fracture deformity of the second proximal phalanx of indeterminate age, with the physician unable to definitively link the fracture to this fall. The facility’s fall prevention policy states that each resident will receive services and care to ensure the environment remains as free from accident hazards as possible.
Failure to Administer and Store Medications According to Physician Orders and Facility Policy
Penalty
Summary
The facility failed to administer medication as ordered by a physician for one resident and did not ensure medications were stored in their original packaging prior to administration for five other residents. One resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, was found with a lidocaine patch stuck to her bed linens, dated from the previous day. The nurse responsible had not yet applied the new patch as scheduled, despite documentation indicating otherwise. The medication administration record specified the patch should be applied in the morning and removed at night, but this was not followed, and the nurse's statements conflicted with the documented times. Additionally, during a medication pass, a registered nurse was found to have pre-poured medications for five residents into cups labeled with room numbers, storing them in the medication cart drawer. The nurse stated this was done to expedite the medication pass due to a high resident load. The medications in the cups were scheduled for administration at later times, and the Director of Nursing confirmed that pre-pouring medications is against policy as it could lead to medication errors. Facility policy requires medications to be prepared and administered immediately, with proper documentation at each step, which was not adhered to in these instances.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident who was readmitted with multiple diagnoses, including acute respiratory failure, kidney failure, hypertension, and diabetes. The resident was sent to the hospital after refusing food and fluids and was found to have a new left femoral neck fracture, which required surgical intervention. The resident's family requested an investigation into the cause of the fracture, as there was no documentation of a fall or incident at the facility, and it was unclear if the injury occurred during care or another activity. The Director of Nursing (DON) assumed the fracture was old, referencing a four-year-old record of a different fracture, and did not contact hospital staff to clarify the nature of the injury. The DON also did not interview all staff or therapists who had cared for the resident during the relevant period. The facility's incident report inaccurately described the fracture as old, despite hospital records indicating it was new. The facility's abuse investigation policy requires interviews with all staff present during the period of the allegation, but this was not followed.
Failure to Timely Refund Resident Overpayment Due to Billing Error
Penalty
Summary
The facility failed to accurately bill and issue a timely refund for an overpayment to a resident who was under hospice Medicaid coverage from the beginning of 2023 until her passing in mid-2024. The resident's spouse experienced a financial change in 2023, which altered the Medicaid payment and the spouse's liability for the resident's bill. Despite this change, the facility continued to bill the spouse the same amount, resulting in an overpayment. Documentation in the resident's electronic medical record indicated that a business office employee identified the issue and began the process to correct the payment and initiate a refund, but there was no evidence that the process was completed or that the refund was issued. Interviews with facility staff revealed that the overpayment was recognized, and the refund amount was identified as $9,290.10. However, the process to issue the refund was not followed through, and the resident's power of attorney and family had not received the refund despite repeated attempts to resolve the matter, including involving an attorney. The facility's own policy required refunds to be processed and released within 10 business days, but this was not adhered to, resulting in a delay of nearly two years.
Resident Falls Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, resulting in the resident falling and sustaining fractures to her pelvis. On the day of the incident, the resident, who was known to frequently attempt to get up from her wheelchair, was left unsupervised in the dining room. The Licensed Practical Nurse (LPN) and Certified Nursing Assistants (CNAs) were occupied with other tasks, leaving the resident without the necessary one-on-one monitoring. The resident's fall was unwitnessed, and she was unable to describe the event due to her cognitive impairment. The resident had a history of falls and was identified as a high risk for falls due to impaired cognition and poor safety awareness. Her care plan highlighted her diagnoses, including vascular dementia and osteoporosis, which contributed to her fall risk. Despite these known risks, the facility's staff did not provide the required supervision, as outlined in the facility's fall prevention policy. The incident was reported by a hospice nurse who was present in the unit, and subsequent medical evaluations confirmed the resident sustained acute fractures from the fall.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R133, who experienced unrelieved pain and was unable to obtain restful sleep for three days. The resident reported not receiving her prescribed muscle relaxer, tizanidine, from the 8th to the 10th of March, despite requesting it multiple times. The staff informed her that the medication was ordered and would follow up with the pharmacy, but no follow-up was communicated to the resident. The medication was eventually received on the night of the 10th, and the resident was administered the medication on the morning of the 11th. The medication administration records for January, February, and March 2025 showed inconsistencies with the resident's account, as they indicated that tizanidine was administered on the 8th and 9th of March. However, the resident disputed this, stating she did not receive the medication during those days. Pain assessments during this period documented varying pain levels, with a peak pain level of 8 on the 10th of March. The resident's care plan included interventions to anticipate and respond immediately to any complaint of pain, which were not effectively implemented. Interviews with staff revealed that the medication was reordered on the 4th of March, but the facility's automated medication dispensing system did not include tizanidine. The Director of Nursing expected staff to reorder medications when a week's supply remained and to use the dispensing system if a medication was unavailable. The facility's policies on medication administration and pain management emphasized the importance of timely and effective pain management, which was not adhered to in this case.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and handling of food items, as well as maintaining sanitary conditions in the kitchen, which affected all residents. During a kitchen tour, it was observed that a pitcher containing thickener was left uncovered, and a large box of thickener in the dry storage room was also left open, exposing the contents to potential contamination. The Dietary Manager acknowledged that the thickener should be covered to prevent cross-contamination, yet the issue persisted throughout the day. Additionally, the facility did not maintain proper sanitization levels in the food preparation area. A red bucket used for sanitizing was found with dingy water and a stained rag, and when tested, the sanitization level was inadequate. The Dietary Manager confirmed that the sanitizing solution was not effective, which could increase the risk of foodborne illness. The facility's policy required proper sanitization to prevent outbreaks, but this was not adhered to during the survey. Furthermore, a cook was observed handling food with contaminated gloves, failing to change them or perform hand hygiene after touching his clothing. The cook continued to prepare meals and handle clean utensils with the same gloves, leading to potential cross-contamination. The facility lacked a specific policy for glove use and hand hygiene in the kitchen, and the existing handwashing policy did not adequately address the observed deficiencies.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
The facility failed to serve food at an appetizing temperature to residents, as observed during a survey. Residents reported that meals were often served late, with dinner being delayed by an hour on some occasions, resulting in cold food. This issue was a recurring complaint in Resident Council meetings, yet the Dietary Manager had not attended these meetings to address the concerns. The Dietary Manager admitted to being aware of the complaints but cited logistical issues with the current food carts as a reason for the lack of insulated covers on some trays. The facility had ordered new carts to resolve this issue, but they had not yet arrived. During the survey, it was observed that the process of preparing and delivering meals was disorganized and slow, with the final plate being prepared over an hour after the first. The CNAs were responsible for distributing the trays to residents, but they reported not having enough time to do so promptly, often needing to reheat food in microwaves. This task took away from their other resident care duties. The dietary staff did not assist in passing trays, and the lack of insulated covers on some trays contributed to the food being served cold, leading to daily complaints from residents.
Infection Control Deficiencies in PPE Use and Isolation Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place for several residents. For one resident, identified as R465, the facility did not post the correct isolation precautions. Initially, an enhanced barrier precautions (EBP) sign was posted, which was later changed to contact isolation, as the resident had a serious MRSA infection and surgical wounds. The error was acknowledged by the Director of Nurses/Infection Control Preventionist, who confirmed that contact isolation was necessary due to the severity of the infection. In another instance, two staff members, a Licensed Practical Nurse (LPN) and a Certified Nurse Aide (CNA), failed to wear gowns while providing care to a resident under enhanced barrier precautions. The resident, R157, had a history of infections and required gowns and gloves during high-contact care activities. Despite the posted precautions, the staff only wore gloves, which was against the facility's policy for EBP, as confirmed by the Director of Nurses/Infection Control Preventionist. Additionally, a Licensed Practical Nurse (LPN) did not adhere to the enhanced barrier precautions while providing g-tube care to another resident, R16. The LPN wore gloves but failed to don a gown, which was required due to the potential for contamination during the procedure. The Assistant Director of Nursing/Infection Control Nurse confirmed that the failure to wear a gown could lead to cross-contamination. Furthermore, a Certified Nursing Assistant (CNA) did not change gloves or perform hand hygiene appropriately during pericare for resident R80, leading to potential cross-contamination. The facility's policies on glove use and handwashing were not followed, as confirmed by the Assistant Director of Nursing.
Failure to Maintain Resident Dignity During Personal Care
Penalty
Summary
The facility failed to maintain a resident's dignity during personal care, specifically for a resident with severe cognitive impairment, dementia, hemiplegia, and chronic pain, who was dependent on staff for toileting. On March 11, 2025, the resident expressed the need to use the bathroom, and a CNA along with a social services staff member assisted her into bed using a mechanical lift. Instead of providing a bedpan or assisting the resident to the toilet, the CNA instructed the resident to relieve herself in her brief, promising to clean her up afterward. The resident was later heard calling for help. The CNA admitted uncertainty about the availability of bedpans on the unit and acknowledged the resident's need for a bowel movement. The Assistant Director of Nursing and the Director of Nursing both confirmed that residents should be offered a bedpan if they cannot use the toilet, emphasizing the importance of maintaining residents' dignity. The facility's policy on dignity, dated November 2011, states that care should be provided in a manner that maintains and enhances each resident's dignity and respect.
Failure to Safely Transfer Resident Using Mechanical Lift
Penalty
Summary
The facility failed to transfer a resident safely, which was observed during a survey. The resident, identified as R66, has severe cognitive impairment, dementia, hemiplegia, and chronic pain, and is dependent on staff for transfers. On the day of the incident, R66 requested to go to the bathroom, and a CNA and a Social Services staff member were involved in transferring her using a mechanical lift. However, the Social Services staff member was not near the resident during the transfer, contrary to the facility's policy requiring two staff members to be present and actively involved in the transfer process. Interviews with various staff members, including the Assistant Director of Nursing, a Restorative Nurse, and the Director of Nursing, confirmed that the facility's policy mandates two staff members to be present during mechanical lift transfers for safety reasons. The care plan for R66 also specifies that two staff members should assist with mechanical lift transfers. Despite this, the Social Services staff member was not actively involved in guiding the resident during the transfer, which is a deviation from the established protocol and contributed to the deficiency.
Failure to Maintain PICC Line Dressing and Measurement
Penalty
Summary
The facility failed to ensure the proper administration and maintenance of a PICC line for a resident, identified as R15, who was part of a sample of 32 residents reviewed for PICC line care. R15 had multiple diagnoses, including severe protein-calorie malnutrition, Guillain-Barre Syndrome, and chronic kidney disease, and required TPN for nutrition and hydration. The facility's records indicated that the dressing for R15's PICC line was supposed to be changed every seven days, with the last recorded change on 2/28/25. However, during an observation on 3/13/25, it was found that the dressing was not intact, and there was no date or signature on it, indicating it had not been changed as required. Further investigation revealed that the facility's Treatment Administration Record (TAR) showed the dressing change and measurement of the external catheter length were due on 3/7/25, but no nurse had signed off on completing these tasks. The facility's policy required that PICC line dressings be changed weekly or when the dressing becomes moist, loosened, or soiled, and that the dressing be labeled with the date of change and the initials of the nurse. The Director of Nursing confirmed the importance of these procedures for infection control and proper PICC line placement, highlighting the facility's failure to adhere to its own policies and procedures.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility was found to have a medication error rate of 6%, exceeding the acceptable threshold of 5%. This was observed during a medication pass involving two residents, where one resident, identified as R264, did not receive their prescribed Thiamine 100 mg tablet. Additionally, the resident was administered an incorrect dose of Zinc, receiving 225 mg instead of the prescribed 220 mg. The LPN responsible for the medication pass, V7, failed to locate the correct Zinc dosage and did not check the medication room or consult a nursing manager for the correct medication. Instead, V7 improvised by administering four 50 mg tablets and half of a fifth tablet, resulting in an incorrect total dosage. Further investigation revealed that the facility did not have the prescribed Zinc 220 mg capsules in stock, and there was no documentation in the resident's progress notes regarding the medication discrepancy or any communication with the provider to address the issue. The Director of Nursing (DON) confirmed that nurses are expected to follow physician orders and document any deviations or issues in the progress notes. The facility's policy requires that any discrepancies between the Medication Administration Record (MAR) and the medication label be checked against orders before administration, and any unadministered medication should be recorded with a reason and the physician notified.
Failure to Complete Prescribed Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that treatments were completed as prescribed for a resident with an unstageable sacral pressure ulcer. The resident's wound physician progress note documented a reopened unstageable pressure ulcer with 100% necrotic eschar tissue. Treatment orders were changed to cleanse with normal saline and apply Iodosorb/Calcium alginate and foam dressing three times a week and as needed. However, the Treatment Administration Record (T.A.R.) showed that 2 out of 11 treatments were not documented as completed. The wound nurse confirmed that treatments should be changed as ordered and documented on the T.A.R. The facility's wound policy states that any resident with a wound should receive treatment and services consistent with their goals of treatment.
Failure to Notify POA of Pressure Injury Treatment
Penalty
Summary
The facility failed to immediately notify the power of attorney (POA) for a resident regarding the initiation of treatment for a pressure injury. The resident, identified as R1, was admitted to the facility with a pressure injury on the coccyx, which was noted as present on admission. The wound care nurse, V4, assessed the resident on the day following admission and obtained treatment orders for the pressure injury. However, V4 did not inform the POA, V5, about these treatment orders. V5 only became aware of the pressure injury and its treatment when the resident was in the emergency room several days later. The facility's policy on change in resident condition did not specify the requirement to notify a POA, which contributed to the communication lapse. Despite a care conference held three days after the treatment orders were obtained, where V5 participated, there was no clear documentation or recollection of informing V5 about the wound care. The registered nurse, V8, acknowledged that new wound care treatment orders should be treated as a change in condition, necessitating immediate notification of the POA, which was not done in this case.
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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