Valley Hi Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodstock, Illinois.
- Location
- 2406 Hartland Road, Woodstock, Illinois 60098
- CMS Provider Number
- 145652
- Inspections on file
- 20
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Valley Hi Nursing Home during CMS and state inspections, most recent first.
The facility failed to maintain effective fall precautions and supervision for two high-risk residents. One resident with dementia, hospice status, severe weakness, lethargy, and known impulsivity was care planned as a fall risk requiring monitoring in the bathroom, yet CNAs assisted her to the toilet and then left her unattended despite staff knowledge that she would attempt to get up on her own if kept waiting; she was later found on the bathroom floor with a head laceration and was pronounced dead. Another resident with a high fall-risk score and a prior fall had a physician order and care plan for a bed mobility alarm, but surveyors observed the bed alarm not functioning because it was unplugged, with the cord on the floor, contrary to orders requiring the alarm to be in place and functioning every shift.
A resident, admitted for short-term rehab, eloped from the facility after an exit door alarm was triggered. Staff failed to verify the resident's presence in nearby rooms and did not adequately check the area outside the alarming door. The resident was found outside, confused but unharmed, indicating a lapse in the facility's protocol for responding to door alarms.
A facility failed to resolve a grievance from a resident's POA about a lack of communication. Despite the care plan requiring immediate notification of any falls or changes in condition, the POA was not informed of a fall until several days later. This ongoing communication issue led to significant distress for the POA.
The facility did not ensure food was served at a safe temperature, resulting in a resident with cognitive impairment sustaining full thickness burns after spilling hot soup measured at 181.7°F. Additionally, improper use of mechanical lifts during resident transfers led to multiple injuries, including a resident with severe cognitive impairment who sustained bruises on her face. The incidents were attributed to inadequate temperature monitoring, lack of documentation, and failure to adhere to food safety and transfer protocols.
The facility failed to ensure that opened, multi-dose vials of medication, including inhalers and gels, were labeled with expiration dates and failed to discard an expired medication. This deficiency was observed in five residents who were prescribed various medications. The Director of Nursing confirmed that all medications need to be dated when opened, but the facility's policy lacked specific guidance on this matter.
The facility failed to screen for and offer the COVID-19 vaccine to four residents, as evidenced by the lack of documentation in their records. The Infection Preventionist confirmed that residents should be screened upon admission, but this was not done for the residents in question.
A resident's non-pressure sacral wound was not treated as ordered. The resident reported having a wound, and staff were observed applying cream, but no dressing was present. The Wound Care Nurse applied barrier cream instead of the prescribed Hydrogel and bordered foam dressing. The LPN confirmed that wounds should always have a dressing if ordered and that nurses are responsible for replacing it if missing.
The facility failed to maintain a catheter drainage bag below the bladder level for a resident during a transfer and bed bath, risking urine backflow and potential complications. The resident has a history of quadriplegia, diabetes mellitus type 2, chronic kidney disease, and neuromuscular bladder dysfunction.
The facility staff failed to ensure a resident took all medications during administration. An LPN left a cup of MiraLAX on the resident's table, which remained untouched. The DON confirmed that staff should stay with residents during medication administration and not leave medications unattended.
The facility failed to ensure PRN anti-anxiety medications had a duration/end date for two residents. One resident had an active order for lorazepam since July 2023, and another since February 2024, both without a stop date. The DON confirmed that PRN psychotropic medications should have a 14-day stop date, as per the facility's policy.
The facility failed to serve pureed barbecue beef brisket at safe temperatures to three residents. The cook recorded the food temperature at 130°F, below the required 135°F, and did not reheat it before serving. The Dietary Manager confirmed the need for food to be served above 135°F to prevent bacterial growth and foodborne illness, as per the facility's policy.
The facility failed to provide pureed barbecue beef brisket in a smooth, pudding-like consistency for three residents requiring a pureed diet. The Dietary Manager confirmed the food was stringy and not smooth, increasing the risk of choking.
A resident's neurologist recommended physical therapy for lower extremity strengthening and balance, with an order placed and noted by staff. However, the facility failed to initiate the PT evaluation and treatment until over two months later, despite the Rehab Coordinator's statement that therapy evaluations should begin within a week of being ordered.
The facility failed to ensure that binding arbitration agreements were explained in a manner residents could understand. One legally blind resident signed without the agreement being read to her, and another resident signed without understanding it. The facility lacked a policy on these agreements.
The facility failed to screen for and administer influenza and pneumococcal immunizations to two residents. One resident did not receive the influenza vaccine until several months after consent and had not received the pneumococcal vaccine despite eligibility. Another resident was not re-screened for pneumococcal vaccine eligibility in subsequent years after an initial refusal by their POA.
The facility failed to ensure resident care equipment was in safe working order, leading to two incidents. In one case, a mechanical lift malfunctioned and pressed onto a resident's shoulder. In another, a resident fell due to a malfunctioning wheelchair brake. Both incidents were documented, and maintenance was notified.
The facility failed to provide mechanical lift training to staff members, resulting in an incident where a resident bumped her head on a Hoyer lift. The Home Health Aide involved had not received the necessary training, and the LPN and DON confirmed the lack of training. The resident's care plan required total mechanical transfers, but the facility did not ensure proper training for the staff.
Failure to Maintain Effective Fall Precautions and Supervision for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain updated and effective fall precautions and supervision for residents at risk for falls, resulting in a fall with head injury for one resident and an inoperative fall-prevention device for another. One resident (R1), who had unspecified moderate dementia with behavioral disturbance, a history of falls, and was on hospice with documented severe tiredness, lethargy, worsening loss of strength, and impulsivity, was known by multiple staff to be a “big fall risk,” impulsive, and likely to get up without waiting for assistance if call lights were not answered promptly. Her care plan identified her as at risk for falls due to unsteady gait and balance, with interventions including staff monitoring while in the bathroom and observation for gait unsteadiness, but the Assistant DON acknowledged that bathroom-related fall interventions had not been updated despite R1’s recent decline and change in bathroom habits. On the morning of 1/1/26, incident reports and staff statements show that a CNA (V5) responded to R1’s call light and screaming for help, found her in bed, and assisted her with a walker to the bathroom, placing her on the toilet and then leaving the room to attend to other tasks. Another CNA (V11) confirmed that R1 was clumsy with the walker and that both CNAs left the room to check on other residents while R1 remained on the toilet. A third CNA (V8) stated that R1 was using the bathroom and the CNA left her to answer another call light when the fall occurred. Staff interviews, including with the CNA supervisor (V4), multiple RNs (V6, V12, V14, V10), and the hospice RN (V16), consistently described R1 as clinically fragile, weak, lethargic, impulsive, and not willing to wait for help, and indicated that staff needed to stay close or in the room when she was in the bathroom. Despite this, R1 was left unattended on the toilet, and shortly thereafter staff found her on the bathroom floor on her left side with a head laceration and a puddle of blood under her head; she was described as nonresponsive, cyanotic, dusky, and with agonal breathing before being pronounced dead. A second resident (R3), also identified as at risk for falls with a fall risk assessment score of 16 and a prior documented fall from bed, had a care plan intervention and physician order for a bed mobility alarm with instructions that staff ensure the alarm was in place and functioning properly every shift. During the survey, R3 was observed in bed with a bed alarm attached to the bed rail, but the alarm indicator lights were not on. When the CNA supervisor (V4) checked the device, the alarm cord was found on the floor under the bed and not plugged in; once plugged in, the alarm light flashed red, indicating it had previously been off. The facility’s Fall Risk Assessment and Prevention Program policy requires individualized interventions for residents at risk for falls and evidence of care plan review and update following each fall, but in R3’s case the ordered bed alarm was not in place and functioning as required at the time of observation.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to verify a resident had not eloped after an exit door alarm sounded and did not supervise the resident adequately to prevent elopement. The incident involved a resident who was cognitively intact and had been admitted for short-term rehabilitation following elective hip surgery. The resident was last seen in bed at 12:45 AM, and an alarm was triggered at 1:12 AM. Staff checked the door but did not see anyone outside due to darkness and silenced the alarm without verifying the resident's presence in nearby rooms. The resident was later found outside the facility, appearing confused but unharmed. Staff had not followed the facility's policy to check the immediate area outside the alarming door and verify the presence of residents in nearby rooms. The resident was brought back inside and assessed, showing no injuries. The incident highlighted a lapse in the facility's protocol for responding to door alarms and ensuring resident safety.
Failure to Resolve Grievance Regarding Communication
Penalty
Summary
The facility failed to resolve a grievance verbalized by a resident's POA regarding a lack of communication. The resident, who was cognitively impaired due to dementia and at risk for falls, experienced an unwitnessed fall in the bathroom. Despite the care plan indicating that the POA should be notified immediately of any falls or changes in condition, the POA was not informed of the fall until several days later. This delay in communication led to significant distress for the POA, who had previously expressed concerns about communication issues during a care plan meeting with the facility's administrators and DON. The POA had repeatedly communicated the need for immediate notification of any incidents involving the resident, yet the facility failed to adhere to this request. The incident report for the fall showed that the POA was not notified until much later, despite the facility's grievance policy stating that concerns should be addressed as quickly as possible. Interviews with facility staff confirmed that the POA's concerns about communication had been ongoing and that the facility had not taken prompt action to resolve these grievances, resulting in a deficiency in the facility's grievance resolution process.
Food Temperature and Mechanical Lift Safety Deficiencies
Penalty
Summary
The facility failed to ensure residents were served food at a safe temperature, leading to a resident (R273) sustaining full thickness burns on his right forearm and abdomen after spilling hot soup during a meal. The incident occurred when the soup was measured at 181.7 degrees Fahrenheit, well above the safe temperature range. The resident's cognitive impairment was not taken into account, as he continued to refuse to get up for meals, resulting in the burn incident. The lack of proper temperature monitoring and documentation, as well as the failure to follow established food safety policies, contributed to this serious safety issue. Additionally, the facility failed to safely transfer residents with a mechanical lift, resulting in multiple incidents where residents were injured during transfers. In one instance, a resident (R17) sustained a bruise below her left eye and on her forehead due to improper use of the mechanical lift. Despite the resident's severe cognitive impairment and the need for extensive assistance with activities of daily living, staff members were not cautious during transfers, leading to avoidable injuries. The facility's transfer and positioning policy emphasized the importance of extreme caution when using mechanical lifts, highlighting a clear deviation from established protocols.
Failure to Label and Discard Expired Medications
Penalty
Summary
The facility failed to ensure that opened, multi-dose vials of medication, including inhalers and gels, were labeled with expiration dates and failed to discard an expired medication. This deficiency was observed in five residents who were prescribed various medications. Specifically, an undated albuterol inhaler prescribed to one resident was found in a medication cart, and the LPN acknowledged that it should have been dated when opened. Another resident's Latanoprost eye drops were found opened and undated, and an albuterol inhaler prescribed to a third resident was found expired but not discarded. Additionally, an undated tube of Oragel prescribed to a fourth resident was found in the medication cart. The LPNs involved were unsure about the expiration dates of these medications once opened. The Director of Nursing confirmed that all medications need to be dated when opened to ensure proper expiration tracking, stating that most medications expire 28 days from opening, while inhalers expire 30 days from opening. The facility's Medication Pass Guidelines policy, dated April 2019, was reviewed and found to lack specific guidance on dating medications once opened and did not specify the expiration dates for oral gels or albuterol inhalers. This lack of proper labeling and discarding of expired medications led to the observed deficiencies in medication storage and management for the residents involved.
Failure to Screen and Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to screen for and offer the COVID-19 immunization to residents, as evidenced by the lack of documentation for four residents (R64, R38, R59, R65) out of a sample of 18. R64's records showed no documentation of receiving or being offered the COVID-19 vaccine from admission until a progress note on 3/19/24 indicated a message left for the power of attorney regarding consent. Similarly, R38's records indicated no screening or offer of the vaccine from admission until a progress note on 3/20/24 showed a discussion with the resident about the vaccine. R59 and R65 also had no documentation of being screened or offered the vaccine until 3/19/24, despite being admitted earlier. The Infection Preventionist (IP) confirmed that residents are supposed to be screened for the COVID-19 vaccine upon admission and educated about it if needed. However, the IP was unable to find any documentation that the four residents had been screened or offered the vaccine. The facility's COVID-19 Response Plan stated that the vaccine should be made available to all employees and residents who wish to receive it, but this was not followed for the residents in question.
Failure to Treat Non-Pressure Sacral Wound as Ordered
Penalty
Summary
The facility failed to ensure a non-pressure sacral wound was treated as ordered for one resident. On 3/18/24, the resident reported having a wound on her bottom, and staff were observed applying cream to the area. However, the resident had no dressing on her sacrum as required by the treatment order. The Wound Care Nurse confirmed the presence of an open wound and applied barrier cream instead of the prescribed Hydrogel and bordered foam dressing. The treatment order specified that the wound should be washed with soap and water, patted dry, and Hydrogel applied, followed by a bordered foam dressing every three days or as needed. The Licensed Practical Nurse stated that a wound should always have a dressing if ordered and that nurses are responsible for replacing it if missing.
Improper Positioning of Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure a catheter drainage bag was maintained below the level of the bladder for a resident reviewed for catheters. During a transfer using a mechanical lift, CNAs hung the resident's catheter bag on the sling strap above the resident and later placed it on the bed while providing a bed bath. This improper positioning of the catheter drainage bag was observed by surveyors. A CNA confirmed that the catheter drainage bag should be positioned lower than the bladder to prevent urine backflow, which could lead to infections and other complications. The resident's medical history includes quadriplegia, diabetes mellitus type 2, chronic kidney disease, and neuromuscular bladder dysfunction. The facility's Foley Catheter Care Policy also mandates that the urinary catheter drainage bag should be kept lower than the bladder.
Failure to Ensure Resident Took All Medications
Penalty
Summary
The facility staff failed to ensure a resident took all medications during medication administration. On 3/19/2024 at 8:29 AM, an LPN prepared medications for a resident, including dissolving MiraLAX in water. The LPN administered the pills but left the MiraLAX on the resident's breakfast table in the dining room. The resident did not drink the MiraLAX, and the LPN was observed talking to other residents on the opposite side of the dining room. At 8:51 AM, the surveyor noted the MiraLAX was still untouched. When questioned, the LPN stated that he normally leaves the MiraLAX with the resident and checks back later. The Director of Nursing confirmed that staff should stay with residents during medication administration and that medications should not be left unattended. The facility's Medication Pass Guidelines policy states that staff should watch the resident swallow all medications and not leave any medications with the resident to take later.
Failure to Ensure PRN Psychotropic Medications Had a Stop Date
Penalty
Summary
The facility failed to ensure PRN anti-anxiety (psychotropic) medications had a duration/end date for two residents. One resident had an active order for lorazepam since July 2023, to be administered every two hours as needed for anxiety, agitation, or restlessness, without a stop date. Another resident had an active order for lorazepam since February 2024, to be administered every four hours as needed for anxiety, also without a stop date. The Director of Nursing confirmed that PRN psychotropic medications should have a 14-day stop date, as per the facility's policy reviewed in March 2022.
Failure to Serve Pureed Food at Safe Temperatures
Penalty
Summary
The facility failed to serve pureed barbecue beef brisket at safe temperatures to three residents on pureed diets. On the specified date, the cook recorded the temperature of the pureed barbecue beef brisket at 130°F, which is below the required 135°F for safe serving. Despite confirming the temperature, the cook did not reheat the food to the necessary internal temperature of 165°F before serving. The facility's temperature log from the previous day showed a different temperature for the same food item. The Dietary Manager confirmed that food should be served at temperatures above 135°F to prevent bacterial growth and foodborne illness. The facility's policy from 2017 mandates that hot food items must be cooked, held, and served at a minimum of 135°F.
Improper Consistency of Pureed Food
Penalty
Summary
The facility failed to provide pureed barbecue beef brisket in a smooth, pudding-like consistency for three residents requiring a pureed diet. On the specified date, the lunch meal tickets for these residents indicated they received pureed barbecue beef brisket. However, upon evaluation of a test tray, the pureed barbecue beef brisket was found to be stringy and not smooth, requiring chewing. The Dietary Manager confirmed that the consistency was improper and not in line with the facility's policy for pureed diets, which mandates that pureed foods should be completely smooth and semi-solid, similar to mashed potatoes. This inconsistency in food preparation increases the risk of choking for residents on a pureed diet.
Delay in Physical Therapy Evaluation and Treatment
Penalty
Summary
The facility failed to evaluate a resident for Physical Therapy (PT) after receiving an order to start PT. The resident's neurologist recommended dedicated physical therapy for lower extremity strengthening and balance, with an order placed on 10/4/23. The order was noted by staff on 10/5/23, but no evaluation or treatment for PT was initiated until 12/15/23. The PT evaluation and plan of treatment were conducted on 12/23/23, resulting in a delay of over two months. The resident's daughter confirmed that therapy was not started when ordered, and the Rehab Coordinator acknowledged that therapy evaluations should begin within a week of being ordered, indicating a significant delay in care.
Failure to Properly Explain Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement was explained to residents in a form and manner they could understand. For one resident, who is legally blind, the agreement was not read to her, and she was unaware of what she was signing, believing it to be part of her admission paperwork. The concierge admitted to not reading the agreement to the resident and not knowing about her blindness. Another resident also signed the agreement without understanding it, thinking it was part of the admission paperwork. The facility did not have a policy on binding arbitration agreements, as confirmed by the administrator.
Failure to Administer Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to screen for and administer influenza and pneumococcal immunizations to two residents. Resident 64 was admitted to the facility and had consent forms signed by their POA for both vaccinations. However, the resident did not receive the influenza vaccination until several months later and had not received the pneumococcal vaccination despite being eligible. The medication administration records confirmed the delay and omission of the vaccinations. Resident 19 was also not properly screened for pneumococcal vaccination eligibility. Although the resident's POA initially refused the vaccine, the resident had not been re-screened for eligibility in subsequent years. The facility's Infection Preventionist acknowledged the lack of a process for annual re-screening of long-term residents for pneumococcal vaccines and admitted that the facility missed administering the flu vaccine to Resident 64. The facility's policies indicated that vaccinations should be offered and administered to all qualifying residents and re-offered annually to those who refuse, but these policies were not followed in these cases.
Failure to Maintain Safe Resident Care Equipment
Penalty
Summary
The facility failed to ensure resident care equipment was in safe working order, affecting two residents. In the first incident, a mechanical lift malfunctioned while transferring a resident to bed. After the transfer was completed, the lift began to self-lower and pressed onto the resident's right shoulder. The resident did not sustain any injuries. The incident was reported, and the lift was taken out of service for maintenance. Interviews with staff confirmed that the lift's motor malfunctioned, causing the incident. The facility's mechanical work order indicated that the lift was under warranty and was being repaired by the manufacturer. In the second incident, a resident fell while being transferred from the toilet to a wheelchair due to a malfunctioning wheelchair brake. The right lock of the wheelchair was ineffective, causing the chair to move during the transfer. The resident was guided to the floor and did not sustain any injuries. The incident was documented, and maintenance was notified to fix the wheelchair brake. The facility's maintenance logs confirmed that the brakes were readjusted and tightened the following day. The facility's policy establishes a Preventive Maintenance Program to ensure regular inspection and testing of equipment.
Failure to Provide Mechanical Lift Training
Penalty
Summary
The facility failed to provide mechanical lift training to staff members using lifts for residents requiring mechanical lifts for transfers. This deficiency was identified during an interview and record review, where it was found that a Home Health Aide had not received any training on the Hoyer lifts from the facility. The aide, along with a Certified Nursing Assistant, was involved in an incident where the Hoyer lift started to tip, causing the resident to bump her head on the lift. The Licensed Practical Nurse/Rehab Coordinator confirmed that the aide likely did not receive the necessary training, and the Director of Nursing acknowledged that staff using a Hoyer lift should be trained. The resident's care plan indicated a need for maximum assistance with activities of daily living and required total mechanical transfers, but the facility failed to provide in-service training on Hoyer lifts for the involved staff member.
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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