Warren Barr South Loop
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 1725 South Wabash, Chicago, Illinois 60616
- CMS Provider Number
- 145632
- Inspections on file
- 58
- Latest survey
- October 1, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Warren Barr South Loop during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of confusion was sent to a methadone clinic appointment without the required escort after the scheduled escort called out unexpectedly. Facility staff were unable to communicate the need for an escort in time, and the LPN on duty was not informed of the requirement. A CNA supervisor, untrained as an escort, accompanied the resident but did not participate in the appointment, resulting in the resident attending without proper supervision as required by facility policy.
A resident with cognitive impairment and multiple complex medical needs developed a stage 2 pressure ulcer that was identified by a wound care NP, but the recommended treatment was not ordered or documented in the electronic health record or TAR. Additionally, the care plan was not updated to address the new wound, despite facility policy requiring such updates. Interviews with the LPN and DON confirmed the lack of documentation and care plan revision.
Surveyors found that several residents were living in rooms with broken thermostats lacking temperature indicators and, in one case, a dresser that was dirty, missing a handle, and had drawers that would not close. The Maintenance Director and a resident's POA confirmed these issues, and staff were unable to determine or control room temperatures, resulting in an environment that did not meet homelike standards.
A resident with end stage renal disease did not receive hemodialysis services three times weekly as ordered by the physician, with missed and undocumented treatments due to transportation issues and lack of communication. Nursing staff and the DON were unable to confirm or provide documentation that the required dialysis sessions occurred, and the physician was not notified of the missed treatments.
The facility failed to ensure proper labeling and dating of food items and did not enforce appropriate hair covering for kitchen staff, potentially affecting all 153 residents. The Food Service Director was observed without proper hair coverings, and several food items in the walk-in cooler were found unlabeled and potentially spoiled. Facility policies emphasize the importance of food labeling and personal hygiene, but these were not adhered to.
The facility failed to follow infection control policies, lacking proper signage and PPE for residents on isolation, including a COVID-19 positive resident. Two residents requiring Enhanced Barrier Precautions did not have appropriate signage or isolation carts. Additionally, the facility lacked policies for distributing information on shingles and screening for HIV, Hepatitis B, and C.
The facility failed to ensure appropriate use of side rails for several residents, leading to potential safety risks. One resident was observed with three half side rails up, despite their assessment indicating the use of only two. Another resident had both legs squeezed between two side rails while trying to eat, contrary to their assessment. Additionally, the facility neglected to evaluate side rail use quarterly for two residents, with one assessment overdue and another incomplete.
The facility failed to properly label and store medications, including inhalers and insulin pens, leading to potential cross-contamination and expired medication use. Additionally, a vial of acetylcysteine solution was improperly stored at a cognitively impaired resident's bedside, risking unauthorized access and medication errors. The DON confirmed the need for secure storage and proper labeling.
A resident receiving a pureed diet struggled with their meal due to inappropriate consistency, containing food particles and skin. The facility's failure to prepare pureed food correctly affected 19 residents. Staff confirmed that pureed food should be smooth, but improper preparation led to the presence of particles, posing a choking hazard.
The facility failed to provide prescribed therapeutic diets for several residents, leading to dietary interventions not being followed. One resident did not receive the prescribed double portion of protein and other dietary items, while another received incorrect liquid consistency, resulting in a choking episode. Errors in diet orders were due to communication issues between the electronic health record and kitchen systems, affecting residents with specific dietary needs.
A facility failed to properly document a resident's code status, resulting in conflicting orders of Full Code and DNR. The resident, diagnosed with dementia and adult failure to thrive, had a care plan indicating Full Code, but physician orders showed DNR. Staff were unable to locate the resident's POLST form, and there was confusion about the resident's actual code status. An audit did not find the POLST form, and the nurse supervisor changed the code status to Full Code in the records.
A facility failed to conduct a quarterly restraint assessment for a resident with sheepskin restraints to prevent trach pulling. The care plan was outdated, and the last assessment was from several months prior, despite policy requiring quarterly evaluations. The Restorative Nurse confirmed the missed assessment.
The facility failed to set low air loss mattresses to the correct weight settings for two residents, one with a stage 4 sacral wound and another at high risk for pressure ulcers. The incorrect settings compromised the mattresses' effectiveness in relieving pressure and aiding wound healing. The Wound Care Coordinator confirmed the discrepancies, noting the importance of proper settings based on residents' current weights.
A facility failed to enforce its smoking policy, allowing a resident with a downgraded smoking status to keep cigarettes and a lighter in a room with an oxygen tank, creating a fire hazard. Staff were unaware of the violation, and the presence of smoking materials in the room posed a significant risk to both residents involved.
The facility failed to follow its policies for medication administration and disposal, leading to deficiencies in pharmaceutical services. A resident did not receive medications as ordered, with prepared medications left at the bedside. Additionally, controlled substances were not properly disposed of, with discrepancies in narcotic count sheets and compromised blister packets found in medication carts. The DON confirmed that procedures were not followed, risking medication errors and diversion.
A resident received a meal containing ham, contrary to their documented dietary restrictions against pork and beef, leading to a deficiency. Despite the resident's clear preferences and the Registered Dietitian's notes, the meal served did not align with the resident's needs, violating the facility's policy on food preferences.
The facility failed to administer influenza and pneumococcal vaccines in a timely manner for three residents. Despite obtaining consents in September, the vaccines were administered with significant delays, and one resident did not receive the pneumococcal vaccine at all. The Director of Nursing could not explain the delays, and no documentation was provided to account for the issues.
A resident with a history of stroke, muscle wasting, and hypertension experienced a delay in receiving a COVID-19 vaccine, despite having signed an informed consent. The vaccine was administered nearly three months after consent was given. The facility's policy involves conducting clinics or obtaining vaccines from a pharmacy, but no documentation was provided to explain the delay.
Two residents with significant medical and cognitive impairments were found with uncombed, tangled, and matted hair due to the facility's failure to provide necessary grooming and hygiene care. Despite care plans indicating the need for assistance with ADLs, staff did not consistently perform hair care tasks, leading to poor grooming and hygiene. Observations and staff interviews confirmed the deficiency in adhering to the facility's policies on shower and hygiene.
A facility failed to investigate an alleged abuse incident involving a resident who was reportedly hit in the face. The resident's sister reported the incident to the ADON, who claimed to have informed the Administrator, but the Administrator stated he was not informed. The DON also had no knowledge of the incident. The facility's policy requires immediate reporting and investigation of abuse allegations, which was not followed in this case.
A resident with cognitive impairment and a history of burns was found with multiple wounds and burns, reportedly from spilled hot water. The facility failed to assess and document the source of the injury or rule out abuse. Staff were unaware of any incidents, and the resident's care plan did not address her preference for hot water or include safety interventions. The deficiency was compounded by a lack of communication and delayed investigation.
A resident with a history of falls and high fall risk sustained a frontal lobe hematoma after attempting to get out of bed unassisted. The care plan, which included being up for meals and having a bed alarm, was not followed. Staff interviews revealed that the resident was not assisted out of bed in the morning as required, and the facility's investigation into the incident was incomplete.
A resident with complex medical conditions developed a sacral pressure ulcer that worsened significantly, but the family was not informed of the changes. Despite the facility's policy requiring notification of significant changes, the family discovered the deterioration independently. Staff interviews confirmed the expectation to notify the physician and family, which was not met.
A facility failed to provide adequate respiratory care for a resident with a tracheostomy, leading to multiple incidents of dislodgement and ultimately the resident's death. The facility did not follow physician orders or update the care plan promptly, resulting in insufficient monitoring and care. The respiratory therapist and nursing staff failed to perform scheduled suctioning and monitoring, and there was confusion regarding the use of restraints.
A resident with a tracheostomy repeatedly pulled it out due to inadequate restraint measures. The facility failed to update the care plan promptly after the first incident, and the necessary double strap restraints were not implemented until days after the second incident, despite being part of the care plan. The facility did not follow its policy for person-centered care plans.
A facility failed to provide proper wound care for three residents, resulting in a Staph bacteremia for one resident and inadequate documentation for others. Dressings were not changed as ordered, and treatment orders were not accurately transcribed. The facility's policy for prompt identification and documentation of skin breakdown was not followed, leading to significant health issues.
A resident suffered a finger fracture after hitting it on a bed rail, which was used without proper assessment or a physician's order. The facility failed to conduct a bed rail assessment or discuss risks and benefits with the resident. Staff acknowledged the need for such assessments and orders, but none were completed. The facility's documentation confirmed the oversight, and the lack of a policy on side rails contributed to the issue.
A resident with reduced mobility developed severe pressure ulcers due to the facility's failure to implement preventive measures and timely nutritional interventions. Despite recommendations from a Wound Nurse Practitioner, there were delays in dietary assessments and essential treatments. The resident's condition worsened, leading to hospitalization for sepsis.
A facility failed to ensure a resident received enteral nutrition feedings via G-tube per physician orders. The LPN turned off the feeding pump prematurely and discarded the feeding container without proper verification, resulting in the resident not receiving the prescribed amount of enteral nutrition.
Two residents reported being sexually abused by a CNA, who inappropriately applied lotion to their private parts. Both residents, who have intact cognition, expressed feeling violated and fearful. Staff members corroborated the residents' accounts, and the incidents were reported to the police and IDPH.
The facility failed to provide reasonable access to telephones for five residents, impacting their ability to communicate with family and friends. The Maintenance Director found that the phones in these residents' rooms were not working, and staff did not follow the protocol to check and report non-working phones daily. One resident reported his phone had been non-functional for three weeks, and another expressed frustration over missed communications with family and church members.
Resident Sent to Methadone Clinic Without Required Escort Due to Communication and Staffing Failures
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of confusion was sent to a methadone clinic appointment without the required escort. The resident's medical record indicated diagnoses including encephalopathy, opioid abuse, and cancer, and the Minimum Data Set documented a BIMS score of 12/15, reflecting moderate cognitive impairment. Staff interviews confirmed that the resident was known to be forgetful, sometimes disoriented, and at risk of getting lost or harmed if left unsupervised in the community. Facility policy and a list of residents on methadone both specified that this resident required an escort for safety and to ensure the secure return of controlled substances. On the day of the appointment, the scheduled escort called out due to an emergency shortly before the resident's transportation arrived. The work clerk attempted to notify nursing staff that an escort was needed, but was unable to reach anyone by phone and ultimately learned the resident had already left without an escort. The LPN on duty, who was an agency nurse working his first shift at the facility, was not informed during shift handoff that the resident needed an escort and was unfamiliar with the facility's communication systems. The CNA who prepared the resident for the appointment also did not have information about the need for an escort. When the resident arrived at the clinic, a CNA supervisor who was not trained as an escort accompanied the resident but did not enter the clinic or participate in the appointment, as he was unsure of his responsibilities. The facility's policy required that, in the absence of a family member or representative, staff must escort residents with cognitive impairment or those receiving methadone to appointments. The lack of communication, inadequate handoff, and failure to ensure a trained escort resulted in the resident attending the appointment without appropriate supervision.
Failure to Follow Wound Care Recommendations and Update Care Plan
Penalty
Summary
The facility failed to follow the wound care specialist's recommendations for treating a resident's pressure ulcer and did not update the comprehensive care plan to address a new skin alteration. The resident, who was cognitively impaired and dependent on staff for activities of daily living, had multiple hospital admissions and re-admissions. Upon re-admission, a wound care nurse practitioner identified a stage 2 pressure ulcer on the resident's left lateral leg and recommended specific treatment. However, there was no evidence that a treatment order was entered into the electronic health record, nor was there documentation in the Treatment Administration Records (TAR) that the recommended wound care was provided. Interviews with facility staff, including the wound care LPN and the Director of Nursing, revealed that the wound care team may not have been made aware of the resident's wound, and no treatment orders or documentation could be found for the wound in question. Additionally, the resident's care plan was not revised to reflect the new skin alteration, contrary to facility policy, which requires care plans to be updated based on current resident conditions. Facility policies also mandate prompt identification, documentation, and treatment of skin breakdown, as well as timely updates to care plans, but these procedures were not followed in this case.
Failure to Maintain Homelike Environment Due to Broken Thermostats and Unclean Furniture
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment for three residents. Observations revealed that multiple resident rooms had broken thermostats with no temperature indicators, making it impossible for residents or staff to determine or control the room temperature. Additionally, one resident's dresser was found to be missing a handle, had drawers that would not close, and was dirty with hardened paste on its surface. These issues were confirmed through interviews with the resident's power of attorney and the Maintenance Director, who acknowledged the problems and the lack of temperature markings on the analog thermostats. The facility's policies require that the environment be maintained in a homelike condition and that malfunctioning equipment be reported and addressed by the maintenance department. However, the observed deficiencies indicated that these policies were not followed, as the maintenance and housekeeping issues persisted until brought to the attention of staff during the survey. The Maintenance Director was unable to determine the temperature settings in the affected rooms and had to perform immediate, on-the-spot repairs and cleaning, further demonstrating the lack of ongoing maintenance and attention to resident comfort.
Failure to Ensure Hemodialysis Services Provided as Ordered
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease and multiple comorbidities, including dependence on renal dialysis, was not provided with hemodialysis services three times weekly as ordered by the physician. Documentation revealed that the resident missed a scheduled dialysis session due to a transportation issue, and there was no evidence in the electronic health record that the physician was informed of the missed treatment. Additionally, there was no documentation confirming whether the resident received dialysis on the rescheduled date or on the following scheduled dialysis day. Nursing staff interviewed were unable to verify or locate records indicating that the resident received the required treatments on those days. The facility's policy required that dialysis communication and assessments be completed and documented for each dialysis session, and that the physician be notified if a session was missed or refused. However, review of the resident's records showed no dialysis assessments, progress notes, or communication for the dates in question. The Director of Nursing confirmed the absence of documentation and was unable to explain why the resident missed dialysis or whether the treatments were provided as ordered.
Deficiency in Food Safety and Personal Hygiene Practices
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items and did not enforce appropriate hair covering for kitchen staff, which could potentially affect all 153 residents receiving food prepared in the facility's kitchen. During an initial kitchen tour, the Food Service Director (V11) was observed without any hair coverings, including a hairnet or beard/mustache covering. Upon noticing the surveyor, V11 left the kitchen and returned with a beard protector that did not cover his mustache and was still not wearing a hairnet. V11 acknowledged the requirement for all kitchen staff to wear hairnets and beard guards to prevent hair from contaminating food. Further inspection of the kitchen revealed several food items in the walk-in cooler that were not labeled or dated, including an opened package of deli ham, sliced American/Swiss cheese, sausage links, and bacon. V11 admitted that these items should have been labeled with the date they were opened and a use-by date, typically within seven days, to prevent serving spoiled food to residents. Additionally, a large box of defrosted cheese omelets was found with brown spots, indicating spoilage. V11 stated that the omelets were defrosted upon delivery and should have been cooked from a frozen state, as per the manufacturer's guidelines. The facility's policies and signage emphasize the importance of proper food labeling and personal hygiene to prevent foodborne illnesses. The policies require that Time/Temperature Controlled for Safety (TCS) foods be labeled with a use-by date no more than seven days from preparation or opening. Despite these guidelines, the facility failed to adhere to its own standards, as evidenced by the unlabeled and potentially spoiled food items and the lack of proper hair coverings for kitchen staff.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures, resulting in several deficiencies. Specifically, the facility did not have the correct transmission-based precaution signage for two residents, R151 and R290. R151, who tested positive for COVID-19, did not have a droplet precaution sign outside their room, and staff failed to wear appropriate personal protective equipment (PPE) when entering the room. The staffing coordinator, V8, entered R151's room with a regular mask instead of an N95 and did not perform hand hygiene after exiting the room. Additionally, the facility did not place an isolation cart outside R290's room, who was on contact isolation for Clostridium Difficile (C. DIFF). The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents R16 and R181, who had conditions warranting such precautions. R16, who had enteral feeding and a sacral wound, did not have EBP signage or an isolation cart set up. Similarly, R181, who had an open wound with red-colored drainage, did not have EBP signage or an isolation cart. The Director of Nursing, V2, acknowledged that residents with open wounds or medical devices should be placed on EBP, but this was not done for R16 and R181. Furthermore, the facility lacked policies and procedures for distributing information about the risks associated with shingles and how to protect residents against the varicella-zoster virus. There were also no policies for HIV, Hepatitis B, and Hepatitis C screening or Hepatitis B immunization. The facility did not provide evidence of offering education on the Shingles vaccine to several residents, including R151. The Director of Nursing admitted that the facility could provide Shingles vaccine information upon request but did not have a policy for distributing it to all newly admitted residents.
Inappropriate Use of Side Rails and Lack of Quarterly Evaluations
Penalty
Summary
The facility failed to ensure the appropriate use of side rails for several residents, leading to potential safety risks. For instance, one resident was observed with three half side rails up, despite their assessment indicating the use of only two half-length rails for assistance. This resident was cognitively impaired and required staff assistance with activities of daily living (ADLs). Another resident was found with both legs squeezed between two half side rails while trying to eat lunch, although their assessment and consent specified the use of only two half-length rails. This resident also had cognitive impairments and needed staff assistance with ADLs. Additionally, a third resident was observed with all four half side rails up, contrary to their assessment and care plan, which indicated the use of only two half-length rails. This resident was severely cognitively impaired and required staff assistance with ADLs. The facility's Restorative Nurse confirmed that side rail assessments are conducted for all residents to prevent entrapment and determine proper use, and that no resident should have more than two half-length side rails. However, the facility failed to adhere to these guidelines, as evidenced by the observations and interviews. The facility also neglected to evaluate the use of side rails quarterly for two residents. One resident's side rail assessment was overdue, and the facility could not provide a recent assessment. Another resident's assessments were incomplete, and the facility admitted to missing the required evaluations. The facility's policy mandates quarterly evaluations of side rail use, but this was not consistently followed, leading to deficiencies in ensuring resident safety.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling, leading to several deficiencies. During an inspection, it was observed that a resident's Arnuity Ellipta inhaler was not labeled with the date it was opened, which is necessary to determine its expiration. Additionally, insulin pens for multiple residents were either not dated or not stored in individual clear bags, which is required to prevent cross-contamination. The Director of Nursing confirmed that medications should be labeled with the opening and expiration dates and stored individually to maintain infection control. Another significant issue was the improper storage of medication at a resident's bedside. An unopened vial of acetylcysteine solution was found at the bedside of a cognitively impaired resident, which should have been securely stored in the medication room. The Respiratory Manager acknowledged that leaving medication at the bedside could lead to other residents accessing it, potentially causing medication errors. The Director of Nursing reiterated that medications should not be left at the bedside and should be stored securely to prevent unauthorized access.
Inappropriate Pureed Food Consistency
Penalty
Summary
The facility failed to prepare pureed food in the appropriate diet consistency form, which has the potential to affect 19 residents receiving pureed diets. During an observation, a resident was seen struggling with their meal, which was supposed to be pureed but contained food particles and skin that the resident could not chew. The resident's meal ticket indicated a Cardiac-Pureed diet, and the resident expressed difficulty in eating the meal due to its inappropriate consistency. The Food Service Director confirmed that the pureed food should be smooth with no lumps, as the presence of particles poses a choking hazard. Interviews with facility staff revealed that the issue arose from improper preparation of the pureed ham, where the skin was not removed before pureeing. The Training Chef and the Speech Language Pathologist both emphasized that pureed food should have a smooth, applesauce-like consistency without detectable particles. The Regional Director of Operations acknowledged the oversight and noted that the skin should have been removed prior to pureeing. The facility's policy on food preparation mandates that food be prepared in a manner that meets residents' needs, but this was not adhered to in this instance.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to provide therapeutic diets and dietary interventions as prescribed by the physician and Registered Dietitian for four residents. One resident, who had a diagnosis of hypertension, type 2 diabetes mellitus, and other conditions, did not receive the prescribed double portion of ground ham, soup, fortified pudding, milk, and Mrs. Dash seasoning packet. The resident expressed dissatisfaction with the missing items and noted that sometimes he does not receive the prescribed items. The Registered Dietitian had documented the need for these dietary interventions to address the resident's severe protein-calorie malnutrition and pressure ulcer. Another resident, with a diagnosis of malignant neoplasm of the prostate and other conditions, did not receive the prescribed nectar thick liquids and instead received thin liquids, which led to a choking episode. The resident's diet order had been updated to include nectar thick liquids, but this change was not reflected in the kitchen's computer system, resulting in the resident receiving the incorrect diet. The Registered Dietitian confirmed that the physician's order did not transfer correctly to the kitchen system, causing the error. Additional deficiencies were observed with two other residents. One resident, on a cardiac-pureed diet, received the wrong type of meat and did not receive the prescribed whole milk or double portions of fruits and vegetables. Another resident, on a renal diet, received ham instead of the prescribed hamburger patty, which was inappropriate due to the high sodium content of ham. The Food Service Manager acknowledged the errors and emphasized the importance of following the diet orders as prescribed by the physician.
Failure to Properly Document and Identify Resident's Code Status
Penalty
Summary
The facility failed to properly identify and document a resident's code status, leading to conflicting orders for the resident's advanced directives. The resident, who had medical diagnoses of dementia and adult failure to thrive, was documented as having a Full Code status in their care plan, which was intended to be clearly identified in the medical record. However, the physician orders at the time indicated a DNR (Do Not Resuscitate) status, which was entered by a former facility nurse. This discrepancy resulted in two conflicting code statuses for the resident. The facility's staff, including nurses and the Director of Nursing, were unable to locate the resident's POLST form in the electronic medical records or in hard copy, and there was confusion among the staff regarding the resident's actual code status. An audit conducted by the facility did not find the POLST form, and the nurse supervisor eventually changed the resident's code status in the electronic records to Full Code. Attempts to contact the responsible party and the nurse who entered the DNR order were unsuccessful. The facility's Advance Directives policy requires that an Advance Directive form be completed and maintained, but the facility failed to provide the resident's POLST form as required.
Failure to Conduct Quarterly Restraint Assessment
Penalty
Summary
The facility failed to adhere to its policy of assessing a resident's need for restraints at least quarterly. A resident, identified as R99, had an active order for bilateral sheepskin restraints to prevent the resident from pulling their tracheostomy tube. The resident's care plan was not updated to reflect the use of the sheepskin restraints, as it still mentioned the use of bilateral soft wrist restraints. During the survey, it was observed that the resident was using the sheepskin restraints, but the facility had not completed the required quarterly restraint assessment. The facility's policy, last revised in August 2024, mandates that restraint assessments be conducted quarterly, during significant changes, and as needed. However, the most recent restraint assessment available for R99 was dated August 2024, and no updated assessment was provided despite requests from the surveyor. The Restorative Nurse confirmed that the resident was due for a restraint assessment in early February 2025, but it was not completed. This oversight indicates a failure to comply with the facility's own policy regarding restraint assessments.
Incorrect Mattress Settings for Residents with Pressure Ulcer Risks
Penalty
Summary
The facility failed to ensure that low air loss mattress devices were set to the correct weight settings for two residents, one with a current pressure ulcer and another at high risk for developing pressure ulcers. Resident 56, who has a stage 4 sacral wound, was observed on a low air loss mattress set to 120 pounds, despite their current weight being 84 pounds. The Wound Care Coordinator confirmed that the mattress should have been set between 80 to 90 pounds to relieve pressure on the wound effectively. This incorrect setting could compromise the intended purpose of the mattress in aiding wound healing. Similarly, Resident 66, who is at high risk for skin breakdown due to a history of pressure injuries, was found on a mattress set to 180 pounds, while their current weight was 136 pounds. The resident expressed discomfort, stating the mattress felt too firm, akin to lying on a wood block. The Wound Care Coordinator acknowledged that the mattress should have been set to 135 pounds. Both residents require staff assistance with positioning in bed, and the facility's policy mandates the use of specialized air mattresses for residents with stage 3 and 4 pressure sores to control moisture, heat, and friction.
Failure to Enforce Smoking Policy Creates Fire Hazard
Penalty
Summary
The facility failed to adhere to its smoking policy and smoking assessment protocols, resulting in a potential fire hazard. During an observation, it was noted that a resident, R110, who was previously downgraded to a dependent smoking status due to non-compliance, was found to have cigarettes and a lighter in her room. This was despite the presence of an oxygen tank in the shared room with another resident, R141, who was on hospice care and required oxygen for shortness of breath. The presence of smoking materials in a room with oxygen poses a significant fire risk, which was not mitigated by the facility's staff. Interviews with facility staff revealed a lack of awareness and enforcement of the smoking policy. The Registered Nurse, V13, was unaware of the lighter in the room and acknowledged the fire hazard, while the Psychiatric Rehabilitation Services staff, V14, confirmed that even residents allowed to smoke independently should not have lighters in rooms with oxygen. The Social Service Director, V16, admitted to being informed about the smoking materials only after the observation and acknowledged the safety risk. The Director of Nursing, V2, reiterated the danger of having lighters in rooms with oxygen, highlighting the risk to both residents involved.
Medication Administration and Disposal Deficiencies
Penalty
Summary
The facility failed to adhere to its policies and procedures for medication administration and disposal, resulting in deficiencies in pharmaceutical services for several residents. One resident did not receive medications according to the physician's order, as observed when prepared crushed medications were left at the bedside, which were supposed to be administered via a gastrostomy tube. The Licensed Practical Nurse acknowledged that the medications should not have been left at the bedside, as this could lead to medication errors and prevent the resident from receiving the intended benefits. Additionally, the facility did not properly dispose of controlled substances, as evidenced by compromised blister packets found in the medication carts. For two residents, the narcotic count sheets did not match the actual medications present, and the medications were not disposed of according to the facility's policies. The Director of Nursing confirmed that discontinued controlled medications should not be stored in the medication carts and should be properly disposed of with a witness present. The facility's failure to follow its own policies for medication storage, labeling, and disposal was further highlighted by the discrepancies in the narcotic count sheets and the improper handling of controlled substances. The Director of Nursing acknowledged that the facility's procedures were not followed, which could lead to potential medication errors and diversion of controlled substances.
Failure to Follow Resident's Dietary Preferences
Penalty
Summary
The facility failed to adhere to a resident's documented food preferences, resulting in a deficiency during a dining observation. On February 18, 2025, a surveyor observed a resident, identified as R81, receiving a lunch tray that included ham with gravy, despite the resident's clear preference and dietary restriction against consuming pork or beef due to indigestion. The resident expressed confusion and concern about the meal, noting that the meal ticket did not list ham as part of the meal and reiterated that the kitchen staff was aware of their dietary restrictions. Further investigation revealed that the Registered Dietitian, identified as V31, had documented R81's food preferences in the resident's progress notes on September 26, 2024, indicating that R81 should not receive pork or beef. The facility's menu management system and the resident's meal tracker were supposed to reflect these preferences, but the meal served did not align with the resident's documented needs. The facility's policy mandates that individual dining preferences, including food dislikes and intolerances, be identified and recorded within 48 hours of admission, yet this protocol was not followed in this instance.
Delayed Administration of Vaccines
Penalty
Summary
The facility failed to administer influenza and pneumococcal vaccines in a timely manner for three residents. The Director of Nursing (V2) explained that the facility holds immunization clinics if there are enough residents consenting to the vaccines, otherwise, they order the vaccines from the pharmacy. However, there were delays in administering the vaccines to residents R93, R118, and R151. R93 signed the consent for the influenza vaccine on 9/18/2024 but did not receive it until 11/15/2024. R118 signed the consent on 9/17/2024 and received the vaccine on 10/25/2024. R151 signed the consent on 10/3/2024 and received the vaccine on 12/12/2024. Additionally, R151 consented to the pneumococcal vaccine on 1/06/2025 but had not received it by the time of the survey. The facility's policies for influenza and pneumococcal vaccinations, last revised on 9/16/2024, state that vaccines should be offered and administered seasonally or as soon as they become available. The Director of Nursing was unable to provide a reason for the delay in vaccine administration and mentioned that the Infection Preventionist, who might have more information, was out of the country. The facility did not provide any documentation or correspondence related to the delay in vaccine administration before the conclusion of the survey.
Delayed COVID-19 Vaccination Administration
Penalty
Summary
The facility failed to administer a COVID-19 vaccination in a timely manner for a resident identified as R118. R118's medical history includes diagnoses of cerebral infarction, muscle wasting, muscle atrophy, hypertension, and seizures. The resident's informed consent for the COVID-19 vaccine was signed on October 22, 2024, but the vaccine was not administered until January 17, 2025. This delay in vaccination was identified during a survey, where it was noted that the facility's policy is to conduct COVID-19 clinics when there are enough consenting individuals, or otherwise obtain vaccines from the pharmacy for individual administration. During interviews, the Director of Nursing and acting Infection Preventionist (V2) acknowledged the delay but could not provide a specific reason for it, suggesting that the facility might have reached out to the pharmacy and found the vaccine unavailable. The facility's COVID-19 Vaccination Policy, last revised in July 2024, states that the facility will promote and provide vaccinations whenever available and consented to. However, no documentation or correspondence explaining the delay was provided by the facility before the survey concluded.
Failure to Provide Adequate Grooming and Hygiene Care
Penalty
Summary
The facility failed to ensure that residents who are unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming. Specifically, two residents, identified as R1 and R6, were observed with uncombed, tangled, and matted hair. Both residents have significant medical conditions and cognitive impairments, making them dependent on staff for personal hygiene and grooming. Despite the care plans indicating the need for assistance with ADLs, including personal hygiene, the facility did not adequately provide these services. R1 was observed with matted hair and a mattress that emitted a foul odor, suggesting inadequate hygiene care. R1's family member reported concerns about the lack of bathing and hair care, which were not addressed promptly by the staff. Observations by surveyors and interviews with staff confirmed that R1's hair was not combed or washed regularly, leading to a matted and unkempt appearance. The staff admitted to not performing hair care tasks, and the resident's condition was not adequately addressed until after the surveyor's intervention. Similarly, R6 was observed with tangled and matted hair, with brown particles and dry scalp. Staff interviews revealed that hair care was not consistently provided, and the resident's hair was not combed or washed as required. The facility's policies on shower and hygiene, as well as the restorative nursing program, were not followed, resulting in the residents' poor grooming and hygiene. The lack of adherence to these policies contributed to the deficiency in providing necessary ADL care for the residents.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to follow its policy to investigate an allegation of abuse involving a resident, identified as R4, who was reportedly hit in the face on the morning of 11/6/2024, prior to discharge. R4's sister, V3, reported the incident to the Assistant Director of Nursing (ADON), V4, who claimed to have informed the Administrator, V1, but V1 stated he was not informed. The Director of Nursing (DON), V2, also claimed to have no knowledge of the incident. The facility's policy requires immediate reporting of abuse allegations to the Administrator and submission of a final investigation report to the Illinois Department of Public Health (IDPH) within five working days. However, V3 reported not receiving any follow-up on the incident, indicating a failure in the facility's abuse reporting and investigation process.
Failure to Assess and Document Resident's Injury Source
Penalty
Summary
The facility failed to properly identify and assess a resident for the source of an injury in a timely manner, which led to a deficiency. The resident, an elderly female with a history of third-degree burns, weakness, and osteomyelitis, was found to have multiple wounds and burns. The resident reported that hot water was spilled on her, but there was no documentation or assessment to confirm the source of the injury or rule out abuse. The resident's cognitive impairment and language barrier further complicated the situation, as she was unable to clearly communicate the cause of her injuries. The facility's staff, including the Director of Nursing, Licensed Practical Nurse, and Certified Nursing Assistant, were interviewed, and none reported being aware of any incidents involving hot water or burns. The resident's skin and wound evaluations documented blisters and burns on various parts of her body, but there was no documentation of the resident explaining the source of the injury or if abuse was ruled out. The resident's care plan did not address her preference for hot water or include risk and safety interventions. The facility's failure to assess and document the source of the resident's injuries, as well as the lack of communication among staff, contributed to the deficiency. The resident's cognitive impairment and language barrier were not adequately considered in the assessment process, leading to a lack of clarity regarding the cause of her injuries. The facility did not initiate an investigation until after the resident's grandson visited, indicating a delay in addressing the issue.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to follow care plan interventions to provide adequate supervision for a resident, identified as R2, who was at high risk for falls. R2, who had a history of falls and was categorized as a high fall risk, attempted to get out of bed unassisted and sustained a frontal lobe hematoma leading to an intraparenchymal hemorrhage. The care plan for R2 included being up in common areas for meals and having a bed alarm to alert staff when attempting to get up unassisted. However, on the morning of the incident, R2 was still in bed around 8:15 AM, despite breakfast being served at 8:00 AM, and the bed alarm was not mentioned as having alerted staff. Interviews with staff revealed that R2 was a maximum assist resident and should have been a priority to be assisted out of bed in the morning. The Falls Coordinator, V10, stated that R2's fall interventions were not followed, as R2 was not up for breakfast in the common area as per the care plan. The Certified Nursing Assistant, V11, found R2 in a precarious position with her feet against the radiator and her back against the bed, indicating an attempted fall. The staff did not witness the fall, and there was no documentation of the nurse assigned to R2 being interviewed for the incident investigation. The facility's investigation into the fall incident was incomplete, lacking interviews from the nurse assigned to R2. The facility's policy for fall occurrences states that residents identified as high risk for falls should have interventions in place, and these interventions should be reevaluated and revised as necessary. However, the failure to ensure R2 was up for breakfast and the lack of a complete investigation into the incident highlight deficiencies in the facility's adherence to its policies and care plan interventions for fall prevention.
Failure to Notify Family of Pressure Ulcer Deterioration
Penalty
Summary
The facility failed to notify a resident's responsible party of changes in the resident's pressure ulcer condition. The resident, who was admitted with multiple complex medical conditions including cardiac arrest, encephalopathy, and chronic kidney disease, developed a sacral pressure ulcer that worsened significantly over time. Despite the deterioration of the wound, which was initially identified as a stage 3 pressure ulcer and later reclassified as an unstageable deep tissue injury, the family was not informed of these changes. The resident's care plan included specific instructions for skin care and monitoring, highlighting the high risk for skin impairment due to the resident's medical history and condition. The wound care nurse and other staff members documented the progression of the wound, noting significant changes in size, exudate, and tissue condition. However, there was no documentation of family notification regarding the worsening condition of the wound, despite the facility's policy requiring such communication. Interviews with staff members, including the wound care nurse practitioner and the director of nursing, revealed that the expectation was to notify the physician and the resident's representative of any changes in wound appearance. However, this notification did not occur, as confirmed by the resident's family member, who discovered the wound's deterioration independently. The facility's policies on notification for change of condition and skin care regimen emphasize the importance of informing family members of significant changes, which was not adhered to in this case.
Failure to Provide Adequate Respiratory Care for Resident with Tracheostomy
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident with a tracheostomy, as per the physician's orders and care plan interventions. The resident, who had a history of respiratory failure and required a tracheostomy for oxygenation, experienced multiple incidents of tracheostomy dislodgement. Despite these incidents, the facility did not implement effective interventions or closely monitor the resident to prevent further occurrences. The care plan was not updated promptly after the initial incident, and there was a lack of physician orders for necessary restraint changes. On several occasions, the resident's tracheostomy was dislodged, leading to emergency situations where the resident required hospital transfers. The facility staff, including the respiratory therapist and nursing staff, failed to provide consistent monitoring and care as required. The respiratory therapist did not perform scheduled suctioning and monitoring, and there was a significant gap in documentation of respiratory care. Additionally, the nursing staff did not document vital signs as ordered, and there was confusion regarding the use and documentation of restraints. The lack of adherence to physician orders and care plan interventions resulted in the facility staff being unaware of the resident's tracheostomy dislodgement, ultimately leading to the resident's death. The facility's policies on tracheostomy care and monitoring were not provided upon request, indicating a possible lack of established protocols. The deficiency highlights the facility's failure to ensure the safety and well-being of a resident with critical respiratory needs.
Failure to Implement Individualized Care Plan for Resident with Tracheostomy
Penalty
Summary
The facility failed to provide an individualized or person-centered care plan for a resident who had an order for restraints due to pulling out his tracheostomy. This deficiency was identified when the resident, who was admitted with a tracheostomy providing oxygen at 28 percent due to respiratory failure, pulled out his tracheostomy twice. The first incident occurred the day after admission, and the second incident happened three days later. Despite these incidents, the care plan did not address the issue of the resident pulling out his tracheostomy until after the second occurrence. The facility's response to the incidents was inadequate, as the care plan instructed a change from soft restraints to double strap sheep skin limb holders, but there was no physician order documented until several days later. The Restorative Nurse/Supervisor admitted that the double strap restraints were not implemented until they were available, which was six days after the second incident. During this period, no other interventions were documented to prevent further incidents. The facility's policy required person-centered care plans, but this was not adhered to in the case of this resident.
Inadequate Wound Care and Documentation in LTC Facility
Penalty
Summary
The facility failed to provide appropriate wound care for three residents, leading to significant health issues. For Resident 1, the facility did not follow the prescribed wound care orders, resulting in a Staph bacteremia and a foul odor from a sacral pressure ulcer. The wound care coordinator did not change dressings as required, and the treatments documented in the Physician Order Sheets were incongruent with the actual orders. The resident's sacrum dressing was found to be saturated and disintegrating, and the odor in the room was noted by multiple staff members. Resident 2's treatment was also inadequately documented, with scheduled dressing changes left blank on the Treatment Administration Record (TAR). The Director of Nursing confirmed that the notes were not properly recorded in the progress notes, indicating a lack of adherence to the facility's documentation policy. This failure to document and administer wound care as ordered could potentially lead to further complications for the resident. Resident 3's initial wound assessment was delayed, and the care plan did not include specific treatment orders. The sacral wound was noted to have a mild odor, indicating a change in condition that was not addressed. The facility's policy requires prompt identification and documentation of skin breakdown, but this was not followed, leading to inadequate care for the residents involved.
Failure to Assess and Manage Bed Rail Use Leads to Resident Injury
Penalty
Summary
The facility failed to properly assess and manage the use of bed rails for a resident, identified as R11, which resulted in an injury. R11 was observed with a soft cast on his left hand due to a nondisplaced fracture of the middle phalanx of his left middle finger, which he reported occurred after hitting it on the bed rail. Despite using the bed rails to assist with mobility, R11 stated he was never shown how to use them safely nor informed about the potential risks. The facility did not conduct a bed rail assessment, obtain a physician's order for the bed rails, or discuss the risks and benefits with R11, as required. The facility's staff, including the LPN, DON, ADON, and Restorative Nurse, acknowledged the necessity of a physician's order and a bed rail assessment for the use of bed rails. However, it was revealed that no such assessment or order was completed for R11. The Restorative Nurse admitted that the side rail assessment, which should have been conducted upon admission and periodically thereafter, was missed for R11. This oversight was confirmed by the facility's documentation, which lacked any record of a side rail assessment or physician's order for R11. The facility's job descriptions for various nursing roles emphasize the importance of following established safety precautions and ensuring person-centered care, yet these protocols were not adhered to in R11's case. The absence of a policy on side rails further contributed to the oversight. The failure to perform a bed rail assessment and obtain the necessary physician's order, along with the lack of communication regarding the risks and benefits of bed rails, directly led to R11's injury.
Failure in Pressure Ulcer Care Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, leading to the development and worsening of pressure injuries. The resident, who had anoxic brain damage and reduced bed mobility, was initially admitted with intact skin. However, after being readmitted from the hospital, preventive measures such as the application of skin moisture barriers were not ordered or implemented as per the facility's policy. This oversight contributed to the resident developing three unstageable pressure ulcers by the end of May. Despite recommendations from the Wound Nurse Practitioner for a nutritional consult due to the risk of wound complications, there was a significant delay in the resident being assessed by a dietitian. The resident was not seen by the dietitian until 18 days after the pressure injuries were identified, and essential nutritional interventions such as multivitamins, zinc sulfate, and protein supplements were not provided in a timely manner. This delay in nutritional support likely contributed to the deterioration of the resident's condition. Furthermore, the facility failed to carry out orders for laboratory testing and antibiotic therapy as recommended by the Wound Nurse Practitioner. The resident's condition worsened, with the wounds becoming malodorous and the resident developing a fever, indicative of infection. Ultimately, the resident was transferred to the hospital with a diagnosis of sepsis, highlighting the severe impact of the facility's failures in providing appropriate pressure ulcer care and prevention.
Failure to Administer Enteral Nutrition Per Physician Orders
Penalty
Summary
The facility failed to ensure a resident received enteral nutrition feedings via G-tube per physician orders. The surveyor observed the resident lying in bed with the enteral feeding pump turned off and the feeding tube not connected. The enteral feeding container, labeled with the date 04/05/2024, had approximately 500ml left, indicating that the feeding was not administered as per the physician's order, which specified that the feeding should continue until the full volume of 980ml was reached. The Licensed Practical Nurse (LPN) on duty admitted to turning off the feeding pump at approximately 10 AM but could not recall the remaining volume at that time. The LPN also discarded the feeding container without proper documentation or verification, which was later retrieved from the biohazard bin by the Director of Nursing (DON), confirming the remaining volume was approximately 520ml. The physician's order for the resident specified that the enteral feeding should be administered at a rate of 70ml/hr starting at 7 PM and should not be turned off until the full volume was reached. The care plan also documented the need to give GT tube feeding and water flush as ordered. The facility's policy on enteral tube feeding care and physician orders emphasized the importance of following the physician's orders accurately. The LPN's actions of turning off the feeding pump prematurely and discarding the feeding container without proper verification led to the deficiency, as the resident did not receive the prescribed amount of enteral nutrition.
Failure to Protect Residents from Sexual Abuse by CNA
Penalty
Summary
The facility failed to ensure that two residents, R1 and R2, remained free from abuse, resulting in both residents being sexually abused by a Certified Nursing Assistant (CNA), identified as V3. R1, a resident with multiple medical conditions including acute and chronic respiratory failure and anxiety disorder, reported that V3 applied lotion to his private parts inappropriately and played with them, despite R1's protests. R1 also mentioned a previous incident where another unnamed CNA was rough with him during ADL care. R1's BIMS score indicated intact cognition, and he expressed feeling violated and upset by V3's actions. R2, another resident with conditions such as muscle wasting and HIV disease, also reported inappropriate behavior by V3. R2 stated that V3 stroked his private parts while applying skin breakdown prevention cream, which was not a standard practice. R2 expressed fear of retaliation from V3 and was visibly emotional while recounting the incident. R2's BIMS score also indicated intact cognition, and he stated that he felt safe at the facility as long as V3 did not provide care to him. Multiple staff members, including other CNAs and an LPN, corroborated the residents' accounts. They reported that R2 had complained about V3's rough handling and inappropriate behavior. The facility's policy on abuse and neglect clearly defines abuse and outlines the expectations for professional care, which were not met in these instances. The incidents were reported to the police and the Illinois Department of Public Health (IDPH), and V3 was escorted out of the building pending investigations.
Failure to Provide Reasonable Access to Telephones
Penalty
Summary
The facility failed to provide reasonable access to the use of a telephone for five residents, which impacted their ability to receive and make calls without being overheard. During a tour of several residents' rooms, the Maintenance Director (V18) and the surveyor found that the phones in the rooms of five residents were not working, as there was no dial tone and calls could not be made or received. V18 acknowledged the importance of working phones for residents to communicate with family and friends and stated that staff should check daily to ensure phones are operational and report any issues to maintenance for repair. However, this protocol was not followed, leading to the deficiency. One resident (R10) reported that his phone had not been working since he arrived at the facility three weeks prior, preventing him from making or receiving calls. Another resident (R11) expressed frustration that her phone was not working, and she was unable to communicate with her family and church members. A CNA (V23) confirmed that there were no phones in the hallways and that the only alternative for residents with non-working phones was to use the nursing station phone. The facility's policy on maintenance, dated 7/28/2023, states that all resident care equipment and the building environment should be maintained by the maintenance department, and any malfunctioning equipment should be reported to maintenance, which was not adhered to in this case.
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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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