Accolade Healthcare Of Peoria
Inspection history, citations, penalties and survey trends for this long-term care facility in Peoria, Illinois.
- Location
- 5600 Glen Elm Drive, Peoria, Illinois 61614
- CMS Provider Number
- 145039
- Inspections on file
- 34
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Accolade Healthcare Of Peoria during CMS and state inspections, most recent first.
The facility failed to maintain safe and well-maintained resident rooms and hallways, including damaged and stained ceiling tiles, ripped wallpaper, exposed insulation and studs, and loose or detached baseboard trim in resident areas and corridors. One resident’s room had sagging, stained ceiling tiles and a damaged wall with exposed insulation, while another room shared by two residents had baseboard trim pulled away and lying in the main walking path between beds. Several hallway ceiling tiles were stained and cracked. A cognitively intact resident reported that wall damage in their room had not been repaired, and staff acknowledged prior roof leaks causing damage and the need for additional repairs, while also stating they were unaware of some of the existing hazards.
A wound nurse did not wear a protective gown while providing wound care to a resident with an unstageable pressure ulcer, despite clear signage and facility policy requiring Enhanced Barrier Precautions (EBP) including gown and glove use for such high-contact care activities.
The facility failed to comply with its policies on facial hair restraints and food labeling. A dietary aide was observed without a beard cover, and several food items in the walk-in freezer were not labeled or dated. The dietary manager was unsure of the beard coverage policy, and acknowledged that staff are responsible for labeling and dating food items.
The facility failed to revise care plans for several residents, resulting in deficiencies in addressing their specific medical and care needs. Care plans lacked nonpharmacological interventions for managing conditions such as depression, anxiety, and schizophrenia. Additionally, critical aspects of care, such as dialysis management and decision-making abilities, were not adequately documented, as verified by the Care Plan Coordinator.
The facility failed to provide appropriate indications for antipsychotic medications in several residents with dementia, lacking documentation of target behaviors and non-pharmacological interventions. Additionally, there were instances of duplicate drug therapy and inappropriate medication orders, highlighting a lack of proper assessment and documentation.
A facility failed to notify the State Agency of a new bipolar disorder diagnosis for a resident, which required a new PASRR. The resident was initially admitted with dementia and later diagnosed with bipolar disorder, but no new PASRR was completed. The administrator confirmed the oversight.
A facility failed to observe, assess, and document the care of a resident with a colostomy. The resident had a physician's order to monitor the colostomy, empty the pouch when one-third full, and change the appliance every three to five days. However, there was no documentation in the medical record regarding these actions. The administrator and care plan coordinator confirmed the absence of documentation for the colostomy's monitoring, assessment, or changes.
A facility failed to provide specific dialysis orders and care for a resident with End Stage Renal Disease. The resident's medical record lacked dialysis orders, a nephrologist, post-dialysis target weight, and care instructions for the dialysis port. Staff interviews revealed uncertainty about the resident's nephrologist and the absence of necessary documentation in the resident's chart.
A resident was found with a tipped-over medicine cup containing 11 pills on their bedside table, without any documented approval for self-administration. An LPN admitted to not staying with the resident to ensure medication consumption, contrary to facility policy. The DON confirmed the medications were the resident's morning doses, which included several prescribed drugs.
The facility failed to respond to call lights in a timely manner for two residents with mobility restrictions, leading to prolonged periods of discomfort and distress. One resident was left in a wheelchair with a back brace for an extended period, while another was left on the commode for two hours without assistance.
A resident with mobility restrictions following lumbar fusion surgery was repeatedly observed without access to a call light, leading to distress and prolonged periods without assistance. The facility's staff failed to adhere to the policy of placing call lights within reach, compromising the resident's ability to request help.
A resident who required rehabilitation services post-lumbar spine fusion surgery did not receive proper care due to the lack of physician orders for spinal precautions, improper use of a spine brace, and inadequate pain and indigestion management. The resident experienced significant discomfort and pain, and staff were not adequately trained on the use of the spine brace and spinal precautions.
A facility failed to implement necessary interventions to prevent pressure ulcers for a high-risk resident who had undergone lumbar fusion surgery. The resident was observed without heel protectors, left in a wheelchair without a pressure-relieving pad, and experienced significant pain due to improper care. Facility policies on repositioning and skin care were not followed, leading to inadequate prevention of skin breakdown.
The facility failed to ensure staff were competent in handling a resident's specialized equipment and spinal precautions following lumbar fusion surgery. The resident was repeatedly left in a wheelchair with a spine brace on, causing significant pain. Staff improperly used a mechanical lift without removing the brace and failed to follow prescribed spinal precautions, leading to severe discomfort and improper care.
The facility failed to ensure the right resident received IV hydration and micronutrient therapy, and did not obtain a physician's order. A trainee nurse administered an IV to the wrong resident, resulting in a bruise. The incident was due to improper verification of the resident's identity.
Failure to Maintain Safe and Well-Maintained Resident Rooms and Hallways
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in multiple resident rooms and hallways. One resident’s bathroom contained two ceiling tiles with a brown substance covering about one-quarter of each tile and one tile sagging from the ceiling. In the same room, the wall across from the bed had blue construction tape over ripped wallpaper extending from the floor to about four feet up, and a three-foot by six-inch section of wall had loose floor trim pulled away, with crushed or missing drywall exposing insulation and wood studs. Ceiling tiles in two separate hallways were also observed with brown substances and damage: one hallway tile was more than half covered in a brown substance and cracked down the center, and two tiles on another hallway were more than half covered in a brown substance down the center. In another room shared by two residents, one wall’s baseboard trim was partially detached, with approximately two feet of trim pulled away and lying on the floor in the center aisle between the foot of both beds and the wall, in the path used by staff and residents to access beds and supplies. The affected residents included individuals with severe cognitive impairment and high fall risk. One resident’s MDS documented Alzheimer’s dementia, severe cognitive impairment, use of a manual wheelchair, and dependence for care, with a care plan identifying high fall risk. Another resident’s MDS documented non-Alzheimer’s dementia, severe cognitive impairment, wheelchair use, and dependence for care, also with a care plan identifying high fall risk. A cognitively intact resident in a room with damaged wall and prior leak-related work reported that the wall on their side had not been fixed and expressed a desire for repair so they would not get sick. Facility staff interviews revealed that a project manager acknowledged a prior roof leak requiring drywall and baseboard replacement in one room due to mold and stated another resident room needed similar work. The maintenance assistant described a roof line leak from an air/heat unit above two rooms that caused damage to walls, trim, and ceiling tiles, confirmed that one resident’s room still needed wall/trim/ceiling tile repairs, and admitted unawareness of the detached trim in the shared room and the damaged ceiling tiles in the hallways, despite the job description for the Maintenance Director requiring ensuring all aspects of the facility are in a good state of repair.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency occurred when a wound nurse failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during wound care for a resident with an unstageable pressure ulcer on the left buttock. The resident was under daily wound care orders, and a sign on the resident's door indicated that EBP, including the use of gown and gloves for close contact care, was required. Despite this, the wound nurse performed the wound care without donning a protective gown, as observed by surveyors. The facility's policy, dated 10/21/22, specifies that gown and glove use is mandatory during high-contact activities such as wound care for residents requiring EBP.
Failure to Follow Food Safety and Hair Restraint Policies
Penalty
Summary
The facility failed to adhere to its policy regarding the use of facial hair restraints in the kitchen and the proper labeling and dating of food items. During an observation, a dietary aide was seen washing dishes without a beard cover, contrary to the facility's Hair Restraints Policy, which mandates that all dining services staff wear hair restraints, including beard guards, in food production and dishwashing areas. The dietary aide was unaware of the requirement to cover his beard, and the dietary manager was also uncertain about the policy regarding beard coverage. Additionally, during an inspection of the facility's walk-in freezer, several food items, including a bag of frozen mixed vegetables and multiple bags of hot dog buns and sliced loaf bread, were found without labels or dates. The facility's Food Storage Policy requires all food items to be labeled with the name of the food and the date by which it should be sold, consumed, or discarded. The dietary manager acknowledged that the responsibility for labeling and dating food items lies with the staff who open the boxes or containers, and confirmed that the items should have been labeled and dated.
Deficiencies in Care Plan Revisions for Residents
Penalty
Summary
The facility failed to revise care plans for six residents, leading to deficiencies in addressing their specific medical and care needs. For Resident 9, the care plan lacked documentation of nonpharmacological interventions for managing depression and paranoid schizophrenia, despite being on multiple medications for these conditions. Similarly, Resident 110's care plan did not include nonpharmacological interventions for anxiety and depression, even though the resident was prescribed medications for these diagnoses. Resident 265, who has end-stage renal disease and a dialysis catheter, had a care plan that did not address critical aspects such as emergency contacts, target weight, or specific dialysis orders. The care plan also failed to include an assessment of the dialysis port, which is essential for managing the resident's condition. Resident 94, with an ileostomy, had a care plan that inaccurately included interventions for constipation and did not reflect the resident's current needs or goals, such as the potential reversal of the colostomy. Resident 415's care plan was incomplete, lacking nonpharmacological interventions for anxiety and depression, and did not specify the resident's decision-making abilities. Similarly, Resident 22's care plan did not include nonpharmacological interventions for managing behaviors associated with dementia, bipolar disorder, and other psychiatric conditions, despite being on antipsychotic medication. These omissions indicate a failure to provide comprehensive and individualized care plans for the residents, as verified by the Care Plan Coordinator.
Inadequate Justification and Documentation for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide appropriate indications for the use of antipsychotic medications in several residents diagnosed with dementia. Specifically, seven residents were identified as receiving antipsychotic medications without proper justification or documentation of target behaviors. For instance, one resident was prescribed Risperdal for dementia with behaviors, yet their care plan did not reflect any behavioral disturbances. Another resident was given Olanzapine for dementia with mood disorder, but the consent form lacked details on the indication for use or target behaviors. Additionally, the facility did not identify or implement non-pharmacological interventions for two residents receiving antidepressant medications. These residents' medical records lacked documentation of alternative methods attempted before resorting to pharmacological treatments. The Director of Nursing confirmed the absence of non-pharmacological interventions and acknowledged that such documentation should have been present. The report also highlights instances of duplicate drug therapy and inappropriate medication orders. For example, one resident was started on Quetiapine, an antipsychotic, for depression, which the Director of Nursing admitted was inappropriate. Another resident's care plan did not align with their behavior tracking report, which showed no recent behaviors warranting the prescribed antipsychotic medication. These deficiencies indicate a lack of proper assessment and documentation in the administration of psychotropic medications.
Failure to Notify State Agency of New Bipolar Diagnosis
Penalty
Summary
The facility failed to notify the appropriate State Agency of a new diagnosis of bipolar disorder for a resident, identified as R81, which was necessary for a new Pre-admission Screening and Resident Review (PASRR). R81 was admitted with a primary diagnosis of dementia with other behavioral disturbances, and the initial PASRR indicated no need for a Level II determination. However, the resident's medical records later showed a diagnosis of bipolar disorder added on two separate occasions, first on December 12, 2022, and then as bipolar/hypomanic on May 12, 2023. Despite these updates, there was no documentation or evidence that a new PASRR was completed following the addition of the bipolar diagnosis. The facility administrator confirmed that the State Agency should have been notified to conduct a new screening based on the updated diagnosis.
Failure to Document Colostomy Care
Penalty
Summary
The facility failed to observe, assess, and document the care of a resident with a colostomy. The resident, identified as R94, has a diagnosis of ileostomy status and a physician's order to monitor the colostomy, empty the pouch when it is one-third full, and change the appliance every three to five days. However, there was no documentation in the resident's medical record, including the treatment administration record (TAR), medication administration record (MAR), or nurses' notes, regarding the monitoring, assessment, or changing of the colostomy. On September 4, 2024, the resident expressed a desire to have the colostomy reversed and showed the surveyor the colostomy. On September 6, 2024, the facility's administrator confirmed the absence of documentation for the resident's colostomy outputs. Additionally, the care plan coordinator verified that there was no routine documentation of the colostomy's monitoring, assessment, or changes in the resident's medical record.
Deficiency in Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide specific dialysis orders and care for a resident requiring dialysis services. The facility's dialysis protocol, revised in September 2023, mandates that nursing staff are responsible for monitoring the dialysis access site for signs of infection or bleeding and ensuring the resident's care plan reflects their dialysis needs. However, the medical record for a resident with End Stage Renal Disease and an acquired absence of a kidney lacked dialysis orders, a listed nephrologist, post-dialysis target weight, and instructions for caring for the dialysis port. Observations and interviews revealed further deficiencies. The resident had a right chest dialysis catheter port and confirmed being on dialysis. A Licensed Practical Nurse admitted to being unsure of the resident's nephrologist and acknowledged that all residents on dialysis should have specific orders and a target weight documented in their charts. Additionally, a Registered Nurse in Dialysis, contracted by the facility, stated that the facility does not have access to specific resident orders for dialysis and emphasized the importance of staff being aware of any concerns with dialysis access sites and knowing the nephrologist to contact in emergencies.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure proper medication storage and administration for a resident, leading to a deficiency. During an observation, a resident was found lying in bed with a medicine cup containing 11 pills on the bedside table. The cup had been tipped over, spilling approximately half of the pills onto the table. The resident was unable to identify the medications or state which pill was which. This incident occurred without any assessments or physician orders for self-administration of medications documented in the resident's medical record. A Licensed Practical Nurse (LPN) confirmed that they had given the resident their morning medications but did not stay to ensure all medications were consumed, which was against the facility's policy. The Director of Nursing verified that the medications in front of the resident were indeed their morning medications. The resident's Medication Administration Record listed several medications that were supposed to be administered that morning, including Escitalopram, Omeprazole, and Carbidopa-Levodopa, among others.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to ensure call lights were answered in a timely manner and responded to accommodate the residents' needs for two residents with mobility restrictions. Resident R3, admitted for rehabilitation services post-lumbar fusion surgery, was observed on multiple occasions in pain and discomfort, waiting for assistance after activating the call light. On one occasion, R3 was left in a wheelchair with a back brace for an extended period, causing significant distress. Despite repeated attempts to get help, including contacting their healthcare power of attorney, R3's needs were not promptly addressed by the staff. Similarly, Resident R4, admitted for rehabilitation services related to a right lower leg fracture, reported being left on the commode for two hours without assistance. R4, who requires substantial help with toileting hygiene due to mobility issues, expressed frustration and distress over the lack of timely response from the staff. These incidents highlight the facility's failure to provide timely and adequate care to residents with significant mobility restrictions, leading to prolonged periods of discomfort and distress. The observations and interviews with the residents and their representatives indicate a pattern of neglect in responding to call lights, which is critical for residents who depend on staff assistance for their daily needs and pain management.
Failure to Ensure Call Lights Were Accessible for Resident with Mobility Restrictions
Penalty
Summary
The facility failed to ensure call lights were available for resident use, specifically for a resident with mobility restrictions following lumbar fusion surgery. The resident, who required substantial assistance with mobility and was at high risk for falls, was observed multiple times without access to a call light. On one occasion, the resident's call light was draped over the bed and unreachable while the resident was in a wheelchair. The resident's roommate had to activate the call light on their behalf. Despite the roommate's efforts, the resident remained unattended for an extended period, leading to distress and discomfort. The resident's healthcare power of attorney confirmed that the resident had called them in distress due to being left in a wheelchair with a brace on for an extended period. The power of attorney had to contact the front desk to ensure the resident was attended to. The facility's administrator acknowledged that staff should ensure call lights are within reach of residents before exiting the room. This deficiency highlights a failure to adhere to the facility's policy of placing call lights within reach, compromising the resident's ability to request assistance when needed.
Failure to Provide Resident-Centered Care and Proper Use of Spine Brace
Penalty
Summary
The facility failed to provide resident-centered care for a resident who required rehabilitation services following a lumbar spine fusion surgery. The resident's hospital transfer papers and therapy evaluations specified the need for a spine brace during ambulation and transfers, as well as spinal precautions to avoid bending, lifting, or twisting. However, the facility did not have physician orders for spinal precautions, and the care plan lacked interventions related to the spine brace and spinal precautions. The resident was observed multiple times wearing the spine brace while seated in a wheelchair, contrary to the specified instructions, causing discomfort and pain. Additionally, the resident's pain and indigestion were not adequately assessed or managed, and the medication administration record lacked documentation of treatment for indigestion. The resident experienced significant pain and discomfort due to improper use of the spine brace and inadequate pain management. The resident was observed grimacing and expressing that the brace was causing pain and nausea. Despite the resident's complaints and visible discomfort, staff did not promptly address the issues. The resident's healthcare power of attorney also reported concerns about the resident being left in the wheelchair with the brace on for extended periods and staff performing actions that were not appropriate for the resident's condition. Further observations revealed that staff were not properly trained on the use of the spine brace and spinal precautions. A physical therapist noted that staff should have been using the log roll technique and removing the brace while the resident was in the wheelchair and during mechanical lift transfers. The facility's policies on transfers and pain management were not followed, leading to inadequate care and increased pain for the resident. The lack of staff education and proper documentation contributed to the deficiencies in the resident's care.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure interventions were implemented to prevent the development of pressure ulcers or worsening of wounds for a resident (R3) who was at high risk for pressure ulcers. R3 had a lumbar fusion surgery and required a spine brace while up and ambulating, but not while in bed or a chair. Despite being identified as high risk with a Braden Scale score of 12 and having a care plan that included frequent repositioning, the facility did not consistently implement these interventions. On multiple occasions, R3 was observed without heel protectors and without a pressure-relieving pad in the wheelchair. Additionally, R3 was left in a wheelchair with the brace on for extended periods, causing significant pain and discomfort. The resident's dressing was also found improperly positioned, failing to cover the surgical incision adequately. The facility's policies, including the Formulized Turning and Positioning Program and the Preventative Skin Care policy, were not followed. These policies required residents at moderate to high risk for pressure ulcers to be turned, toileted, and repositioned every two hours or as needed. Despite these guidelines, R3 was left in the same position for extended periods and did not receive the necessary interventions to prevent skin breakdown. The resident's healthcare power of attorney also reported that R3 was left in pain and without proper care, further highlighting the facility's failure to adhere to its own policies and care plans.
Failure to Ensure Staff Competency in Handling Specialized Equipment and Spinal Precautions
Penalty
Summary
The facility failed to ensure staff were competent to care for a resident (R3) who required specialized equipment and spinal precautions following a lumbar fusion surgery and spinal stenosis. R3's hospital transfer papers and subsequent evaluations documented the need for a spine brace to be worn during transfers and ambulation, but not while in bed or a chair. Despite these instructions, R3 was observed multiple times in a wheelchair with the spine brace on, causing significant discomfort and pain. R3's care plan and physician's orders lacked documentation of spinal precautions and proper application of the spine brace, leading to improper handling and increased pain for R3. On one occasion, R3 was left in a wheelchair with the spine brace on, causing pain and discomfort. The call light was unreachable, and R3's roommate had to assist in calling for help. When staff finally arrived, they improperly used a mechanical lift without removing the spine brace, further exacerbating R3's pain. Additionally, a Certified Nurse Aide admitted to putting the brace on incorrectly. R3 was left in bed with the call light out of reach and reported severe pain and indigestion. The dressing covering R3's back incision was found to be improperly applied, and staff used incorrect techniques that involved twisting motions, contrary to the prescribed spinal precautions. Interviews with staff and R3's healthcare power of attorney revealed that staff were not adequately educated on the use of the spine brace and spinal precautions. The physical therapist confirmed that staff should have been using the log roll technique and removing the spine brace during transfers. The facility's policy on transfers required proper training for staff on the use of mechanical lifts, which was not adhered to in R3's case. The lack of staff education and adherence to prescribed precautions led to significant pain and improper care for R3.
Failure to Ensure Proper IV Therapy Administration
Penalty
Summary
The facility failed to ensure the right resident received IV access hydration and micronutrient therapy, and did not obtain a physician's order for the administration of IV hydration and micronutrient therapy for one resident. An incident occurred where an IV therapy company inserted an IV into the wrong resident's wrist, resulting in the resident receiving approximately 300 ml of a nutrition solution. The resident, who was not supposed to receive the IV, pulled it out, causing a bruise on the right wrist. The incident was due to a mix-up by a trainee nurse who did not properly verify the resident's identity before administering the IV. The incident report and interviews revealed that the trainee nurse asked the resident her name, but did not verify her first and last name, birthdate, or picture in the medication administration record. The Director of Nursing and the preceptor nurse were informed of the mistake after the IV was administered. The facility's guidelines require contacting a physician or nurse practitioner for specific orders before administering IV hydration and micronutrient therapy, which was not done in this case. The resident's progress notes documented the bruise, and the resident's Power of Attorney was informed of the incident the following day.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
