Westminster Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomington, Illinois.
- Location
- 2025 East Lincoln Street, Bloomington, Illinois 61701
- CMS Provider Number
- 145400
- Inspections on file
- 20
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Westminster Village during CMS and state inspections, most recent first.
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.
The facility failed to provide adequate feeding assistance, implement nutritional recommendations, evaluate nutritional supplement intakes, notify the physician of significant weight loss, and ensure significant weight loss was evaluated by a dietitian for two residents. This resulted in severe weight loss for both residents, with one losing 16.65% of their weight over six months and the other losing 15.6% in two months.
The facility failed to label opened prepared foods with the date and time in the refrigerator, potentially affecting all 90 residents. The Dietary Manager could not determine how long the items had been in the refrigerator and decided to discard them.
The facility failed to obtain orders for oxygen, store, change, and label oxygen and nebulizer tubing per policy, and provide routine cleaning of a humidifier for several residents. Observations revealed uncovered and undated nebulizer equipment, outdated humidification bottles, and oxygen tubing on the floor, with no proper documentation or adherence to facility policies.
The facility failed to implement enhanced barrier precautions (EBP) as recommended by the CDC, affecting five residents. Staff did not wear gowns during urinary catheter care and wound treatments, and there was no EBP signage or PPE available in the rooms of affected residents. The Director of Nursing/Infection Preventionist admitted that the facility did not have an EBP policy in place.
The facility failed to assess the ability of three residents to self-administer medications, resulting in unauthorized medications being found at their bedsides. None of the residents had documented orders or assessments for self-administration, despite the facility's policy requiring such measures.
A resident experienced a fall and was later found to have multiple rib fractures, but the facility failed to investigate the cause of the injuries as required by their Abuse Policy. The DON and Assistant DON were unaware of the fractures until weeks later, indicating a lapse in communication and policy adherence.
A resident's care plan meeting was missed, with the last meeting documented several months ago. The facility's staff acknowledged the oversight, citing a large caseload as a contributing factor.
A resident reported swelling in their right elbow, but the facility failed to document the condition or ensure the resident was evaluated by a physician. Despite the resident's complaints and a nurse's observation, there was no follow-up or proper documentation in the medical record.
The facility failed to complete comprehensive wound assessments for two residents with new pressure injuries. Both residents, who required substantial assistance, had physician's orders for wound care but lacked proper documentation and timely updates to their care plans. The facility's policy did not specify staff responsibilities for initial wound assessments, leading to a lack of awareness and proper care.
The facility failed to secure oxygen canisters and properly implement fall interventions for two residents. Unsecured oxygen cylinders were found near a resident's doorway, and the resident's bed and chair alarms were not consistently connected to alarming devices. Fall investigations were incomplete, lacking documentation on the resident's activities prior to falls and staff interviews.
The facility failed to perform complete urinary catheter care, prevent cross-contamination, and maintain dignity and infection control for three residents. Issues included incomplete cleaning, improper glove use, and uncovered urinary collection bags touching the floor.
The facility failed to complete or accurately complete psychotropic medication assessments, quantify behaviors to justify the use of psychotropic medication, and attempt nonpharmacological interventions for two residents. One resident's medical record lacked proper assessments and behavior quantification, while another resident's record did not include nonpharmacological interventions or responses.
The facility failed to document and offer/administer Pneumococcal and Influenza vaccines for three residents, despite having a policy in place. The Assistant Director of Nursing confirmed that the required consent/declination forms were missed.
The facility failed to offer and document COVID-19 vaccination boosters for two residents. One resident's record showed no documentation of education or booster administration, while another's record lacked any vaccination history or status. The Assistant Director of Nursing confirmed that the required documentation was missed for both residents.
The facility failed to use the appropriate assistive device for a resident at high risk for falls, resulting in the resident slipping from a sit-to-stand lift and sustaining a dislocated shoulder. Despite the care plan indicating the need for a sling type mechanical lift, staff used a sit-to-stand lift, leading to the injury.
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 Provide Adequate Nutritional Care
Penalty
Summary
The facility failed to provide adequate feeding assistance, implement nutritional recommendations, evaluate nutritional supplement intakes, notify the physician of significant weight loss, and ensure significant weight loss was evaluated by a dietitian for two residents. Resident R5 experienced a severe weight loss of 16.65% over six months. Despite documented interventions in R5's care plan, there was no evidence of new nutritional interventions after 12/18/23, and significant weight loss was not reported to or evaluated by a physician. Observations showed R5 often struggled to eat without assistance, and staff did not consistently offer the prescribed nutritional supplements or provide necessary feeding assistance. Resident R21 experienced a 15.6% severe weight loss in two months. The facility did not document that R21's significant weight loss was reported to or evaluated by a physician. Additionally, R21 was not consistently provided with the prescribed nutritional supplement, receiving a less nutritious version instead. This discrepancy was not identified or addressed by the dietitian or nursing staff, contributing to R21's continued weight loss. Both residents' care plans included interventions to address their nutritional needs, but these were not consistently implemented or monitored. The facility's failure to follow through with dietary recommendations, provide necessary feeding assistance, and communicate significant weight changes to physicians resulted in severe weight loss for both residents. Observations and interviews with staff and family members highlighted the lack of consistent assistance and monitoring, further contributing to the residents' nutritional decline.
Failure to Label Opened Prepared Foods
Penalty
Summary
The facility failed to label opened prepared foods with the date and time in the refrigerator, which has the potential to affect all 90 residents. On 4/08/24 at 9:00 AM, cole slaw, whipped topping, and sour cream were observed in the refrigerator without labels indicating the date and time they were opened. The Dietary Manager stated that they could not determine how long these items had been in the refrigerator since they were not labeled and decided to discard them. The facility's midnight census as of 4/8/24 was documented as 90.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to obtain orders for oxygen, store, change, and label oxygen and nebulizer tubing in accordance with facility policy, and provide routine cleaning of a humidifier for several residents. Specifically, a humidifier was found in a resident's room without documentation in the medical record or routine cleaning/care. The resident was unsure of the machine's use, and the Director of Nursing (DON) was unaware of its presence, stating that the family brought it in and maintained it. Additionally, nebulizer equipment for another resident was found uncovered and undated, with droplets of medication still present, and there were no documented orders for routine changing of the equipment. Another resident was observed wearing oxygen with an outdated humidification bottle and unlabeled tubing, despite physician orders to change the equipment weekly. Lastly, another resident's oxygen tubing and nasal cannula were found on the floor, with the tubing dated but no storage bag provided, and there were no orders for oxygen administration or routine changing of the equipment in the medical record. The facility's policies for oxygen and nebulizer therapy were not followed, as evidenced by the lack of proper labeling, storage, and routine changing of equipment. The DON confirmed that oxygen and nebulizer tubing should be changed weekly, labeled with a date, and stored in a bag when not in use. However, the observations and interviews revealed that these practices were not consistently implemented, leading to deficiencies in respiratory care for the residents involved. The facility's failure to adhere to its own policies and obtain necessary physician orders contributed to the identified deficiencies in respiratory care management.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as recommended by the CDC, affecting five residents reviewed for EBP. Certified Nursing Assistants (CNAs) V11 and V15 provided urinary catheter care to Resident 31 without wearing gowns and without EBP signage on the door. Resident 31's care plan indicated the need for contact isolation due to MRSA colonization. Similarly, Resident 97, who had an indwelling urinary catheter, did not have EBP signage on the door, and CNAs V11 and V15 did not wear gowns during catheter care. The Director of Nursing/Infection Preventionist admitted that the facility did not have an EBP policy in place yet, although EBP signage was available. Residents 149, 150, and 33 also did not have EBP signage on their doors, and no PPE was available upon entering their rooms. Resident 149 had a urinary catheter and a pressure area on the right buttock, while Resident 150 had Stage II pressure ulcers on both buttocks. In both cases, the staff did not wear gowns during wound treatments. Similarly, Resident 33 had open pressure ulcers on both buttocks, and staff did not wear gowns during wound treatments or catheter care. The lack of EBP signage and PPE availability, along with the staff's failure to wear gowns, were consistent across all observed cases.
Failure to Assess Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess the ability of three residents to self-administer medications. During observations, surveyors found bottles of saline nasal spray and artificial tears at one resident's bedside and bathroom, two tubes of Diclofenac on another resident's nightstand, and a bottle of Flonase and three tablets of medication on a third resident's overbed table. None of these residents had documented orders to self-administer these medications or to keep them at the bedside. Additionally, the residents' medical records lacked assessments of their ability to self-administer medications, despite the facility's policy requiring such assessments and physician orders for bedside medication storage. One resident had moderate cognitive impairment, another had severe cognitive impairment, and the third had moderate cognitive impairment. Interviews with staff confirmed that the residents did not have the necessary orders for self-administration or bedside storage of the medications found. The facility's policy mandates that residents must be assessed and deemed appropriate for self-administration, have a written physician order, and store medications in a manner that prevents access by other residents. The policy also requires that unauthorized medications found at the bedside be reported and returned to the resident's representative, which was not followed in these cases.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident (R16) who was reviewed for accidents. According to the facility's Abuse Policy, injuries of unknown source should be investigated within two hours of notification, and the results should be reported to the Illinois Department of Public Health within five days. R16 experienced a fall on 3/14/2024 and was later found to have multiple rib fractures on 3/17/2024 after being transferred to the hospital. However, there was no documentation that the cause of R16's rib fractures was identified or investigated by the facility. The Director of Nursing (DON) and Assistant DON were unaware of R16's rib fractures until 4/9/2024, indicating a lapse in communication and failure to follow the facility's policy. The DON confirmed that an investigation would have been conducted if they had been notified. The Assistant DON speculated that the rib fractures might not be related to the fall since a chest x-ray on 3/14/2024 did not show any fractures, and suggested that the fractures could be due to R16's coughing. The Administrator began an investigation into the rib fractures on 4/9/2024, but this was after the deficiency had already occurred.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings for a resident (R21) as required. R21 stated that the facility does not have care plan meetings with her or her family. The medical record shows that R21 was admitted to the facility and had Minimum Data Sets completed on two occasions. However, the last documented care plan meeting for R21 was on 12/28/23, and no subsequent meetings were held within the required quarterly timeframe. The Social Services Director (SSD) and the Assistant SSD confirmed that R21's care plan meeting was missed and was only scheduled after the oversight was realized. The MDS/Care Plan Coordinator admitted to having a large caseload of 95 residents and acknowledged that R21's care plan meeting was overlooked. The facility's policy mandates care plan reviews and updates at least quarterly, but this was not adhered to in R21's case.
Failure to Document and Follow Up on Change in Condition
Penalty
Summary
The facility failed to document and follow up on a change in condition for one resident who reported swelling in their right elbow. The resident, who is cognitively intact, stated that the swelling started about three weeks ago and had informed the nurses about it. Despite the resident's complaints, there was no documentation in the medical record regarding the swelling or any evaluation by the physician. A registered nurse noticed the swelling and left a note for the physician but did not document the condition in the resident's medical record. The Director of Nursing confirmed that any changes in a resident's condition should be documented in the progress notes, which was not done in this case. The facility's policy on changes in a resident's condition requires that significant changes be reported to the physician and documented in the resident's medical record. However, in this instance, the resident's complaint and the nurse's observation were not properly recorded, and there was no follow-up to ensure the resident was evaluated by the physician. The physician was eventually contacted and ordered an elastic bandage wrap, but this was after the surveyors identified the deficiency.
Failure to Complete Comprehensive Wound Assessments
Penalty
Summary
The facility failed to complete a comprehensive wound assessment for two residents with new pressure injuries. Resident R150, who was cognitively intact and required assistance for ADLs, developed two Stage II pressure ulcers. Despite having physician's orders for wound care, there was no comprehensive wound assessment documented. R150 expressed discomfort and reported being left in a wheelchair for extended periods, which exacerbated her condition. The staff did not assist her in moving to a more comfortable recliner, as she requested. Similarly, Resident R149, who was also cognitively intact and required substantial assistance for transfer and toileting, developed a pressure ulcer on the right buttock. The treatment was initiated, but no comprehensive wound assessment was documented, and the care plan was not updated until a week later. The facility's policy did not specify the staff responsible for initial wound assessments, leading to a lack of proper documentation and awareness of the residents' conditions. The Assistant Director of Nursing and the Care Plan Coordinator were unaware of the pressure ulcers until much later, indicating a communication breakdown within the facility.
Failure to Secure Oxygen Canisters and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure oxygen canisters were secure and to thoroughly investigate falls, care plan, and implement fall interventions for two residents. On two separate occasions, unsecured, free-standing oxygen cylinders were observed near a resident's doorway. The Director of Nursing confirmed that the oxygen cylinders were not stored appropriately and should have been placed in the oxygen storage room. The facility's policy on oxygen therapy mandates that oxygen be used and stored safely to ensure resident and staff safety. Additionally, the facility did not properly manage fall interventions for a resident who was at high risk for falls. The resident's bed alarm was not connected to an alarming device on multiple occasions, and the chair alarm was inconsistently used. The resident had a history of falls, including unwitnessed and witnessed falls, but the fall investigations were not thorough. The investigations lacked documentation on the last time the resident was checked on, toileted, or if alarming devices were in place during the falls. There was also no evidence that staff were interviewed regarding these falls. The Assistant Director of Nursing confirmed that the fall investigations could be improved and acknowledged that the bed and chair alarms should have been documented in the resident's care plan and tasks. The facility's policies on falls and fall risk management require staff to identify causes and resident-centered interventions to prevent falls and minimize complications, as well as to monitor the efficacy of alarm use. However, these protocols were not adequately followed in this case.
Deficiencies in Urinary Catheter Care and Infection Control
Penalty
Summary
The facility failed to perform complete urinary catheter care, prevent cross-contamination during catheter care, and maintain the urinary collection bag in a dignity bag and off the floor for three residents. For one resident, the CNAs did not check or cleanse the creases between the thighs and genitals after a bowel movement, despite performing other aspects of catheter care. Another resident's catheter care was compromised when a CNA did not change gloves after removing the resident's shoes and failed to retract the foreskin and clean the penis. Additionally, a resident's urinary collection bag was observed uncovered, touching the floor, and without a dignity cover in the dining room and during transport out of the dining room. The facility's Nursing Patient Care Policy & Procedure requires hand hygiene, glove application, cleansing of the suprapubic and pubic area, and retraction of the foreskin for uncircumcised males during catheter care. The policy also mandates that urinary drainage bags be kept off the floor and covered for dignity and infection control. The Director of Nursing/Infection Preventionist confirmed that the observed practices did not align with the facility's policy, indicating a failure to adhere to established protocols for catheter care and infection prevention.
Failure to Complete Psychotropic Medication Assessments and Nonpharmacological Interventions
Penalty
Summary
The facility failed to complete or accurately complete psychotropic medication assessments, quantify behaviors to justify the use of psychotropic medication, and attempt nonpharmacological interventions for two residents. Resident R5 was admitted with diagnoses including Anxiety Disorder, Major Depressive Disorder, Delusional Disorder, and Paranoid Personality Disorder. The medical record for R5 documented multiple psychotropic medications but lacked proper assessments, behavior quantification, and nonpharmacological interventions. Additionally, there was no assessment for the increased dose of Escitalopram. The Assistant Director of Nursing confirmed these deficiencies during the review. Resident R14 had diagnoses of Anxiety, Depression, and Dementia and was prescribed multiple psychotropic medications. The psychoactive medication assessment for R14 documented behaviors of anxiety and constantly yelling out but did not include any nonpharmacological interventions or responses to such interventions. The Care Plan Coordinator confirmed the absence of documentation for nonpharmacological interventions or responses. The facility's policy requires specific behavior documentation and assessments on admission and quarterly, which were not followed in these cases.
Failure to Document and Administer Vaccinations
Penalty
Summary
The facility failed to maintain documentation of immunization status and offer/administer Pneumococcal and Influenza vaccines for three residents out of five reviewed in a sample of 31. The facility's policy, dated April 2024, mandates that residents be offered these vaccines based on CDC guidelines, with the Nursing Department responsible for ensuring administration and documentation. However, the records for three residents (R31, R21, R26) did not show that these vaccines were offered or administered. Specifically, R31's record showed previous vaccinations but no documentation of recent offers, R21's record lacked any immunization information, and R26's record showed an outdated vaccination with no recent offers documented. During an interview, the Assistant Director of Nursing (V3) confirmed that the process involves offering vaccines on admission and reviewing hospital records for immunizations. V3 acknowledged that the consent/declination form was missed for the three residents in question and could not provide documentation showing that the vaccines were offered on admission. This lapse in following the facility's policy and CDC guidelines led to the deficiency noted in the report.
Failure to Offer and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer and administer COVID-19 vaccination boosters to two residents, R31 and R21, as required by their policy. R31's medical record showed that they received a COVID-19 vaccine on 5/3/2022 and were admitted to the facility on an unspecified date. However, there was no documentation that education regarding the COVID-19 vaccination was provided to R31, nor was there any record of a COVID-19 booster being offered or administered. Similarly, R21's medical record did not document that COVID-19 vaccinations were offered or given, nor did it include any vaccine history or status. R21 was admitted to the facility on an unspecified date and had diagnoses of Pneumonia, Anemia, and Cerebral Infarction. During an interview, the Assistant Director of Nursing (V3) stated that Flu, Pneumonia, and COVID vaccines are offered upon admission and that hospital records are reviewed for immunizations. V3 acknowledged that the form for documenting consent or declination of vaccinations was missed for both R31 and R21. The facility's policy, revised in January 2024, mandates that the latest COVID-19 immunizations be made available to all residents upon admission unless medically contraindicated or already immunized. The policy also requires documented consent or refusal of the COVID-19 vaccine, which was not provided for R31 and R21.
Inappropriate Use of Assistive Device Leads to Resident Injury
Penalty
Summary
The facility failed to utilize the safest assistive devices for a resident (R1) who was at high risk for falls. R1, who had multiple diagnoses including chronic kidney disease, congestive heart failure, muscle weakness, and unsteadiness on feet, was moderately cognitively impaired and dependent on assistive devices for mobility and hygiene. Despite R1's care plan and physical therapy notes indicating the need for a sling type mechanical lift for transfers, the staff used a sit-to-stand lift, which was not appropriate for R1's condition. This inappropriate use of the sit-to-stand lift led to R1 slipping from the device and sustaining a dislocated shoulder, which required medical intervention in the form of a closed reduction at the emergency room. On the day of the incident, the registered nurse (V6) and two certified nurse aides (V8 and V9) attempted to clean R1 after a bowel movement using a sit-to-stand lift, despite R1's documented need for a sling type mechanical lift. During the process, R1, who was too weak, slipped out of the sit-to-stand lift and was eased to the floor by the CNAs. R1 complained of pain in the right shoulder, which was later confirmed to be a dislocation requiring emergency medical treatment. The incident was corroborated by interviews with the involved staff and a review of R1's medical records and care plan, which clearly indicated the necessity of using a sling type mechanical lift for all transfers due to R1's high fall risk and physical limitations.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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