Allure Of Geneseo
Inspection history, citations, penalties and survey trends for this long-term care facility in Geneseo, Illinois.
- Location
- 704 South Illinois Street, Geneseo, Illinois 61254
- CMS Provider Number
- 145789
- Inspections on file
- 23
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Allure Of Geneseo during CMS and state inspections, most recent first.
Surveyors found that the facility’s Dietary Manager did not hold the Food Handler Certification or Certified Food Protection Manager certification required by the facility’s own job description. Review of the job description confirmed that such certification is a qualification for the role, and facility census records showed that 62 residents were in the facility. During a kitchen tour, the Dietary Manager stated that since being hired several months earlier, he had not obtained the required certification, creating a deficiency related to ensuring sufficient staff with appropriate competencies and skill sets in the food and nutrition service.
The facility failed to follow its antibiotic stewardship and infection surveillance policies by not consistently applying McGeer criteria, not completing required infection assessment forms, and not accurately tracking infections and culture data. Multiple residents received antibiotics for pneumonia, sepsis, skin infections, and UTIs, yet their infections were often missing from the infection logs, and culture results—when obtained—were not reliably recorded or trended. In several UTI cases, antibiotics were started based only on urinalysis or without any culture, and documentation in the infection reports conflicted with progress notes regarding whether cultures were completed and which organisms were identified.
A resident with dementia, insomnia, and a history of falls was prescribed quetiapine (Seroquel) 25 mg at bedtime for “dementia with behavioral disturbance,” despite the facility’s psychotropic policy requiring specific, documented indications and the drug reference stating it should not be used in elderly patients with dementia-related psychosis. The MDS showed the resident was cognitively intact with no documented behaviors, while the care plan listed psychotropic use for dementia with behavioral disturbance and insomnia. Staff described the resident as mainly exit seeking with lack of safety awareness, usually easily redirected, and requiring supervision at night. The DON acknowledged that antipsychotics should not be used in dementia patients and felt the resident was appropriate for dose reduction, but there was no clear, appropriate indication documented for the ongoing antipsychotic use.
A resident with multiple urologic conditions, including BPH, urinary retention, prostate cancer, hematuria, and a history of UTIs, had an indwelling urinary catheter and was on Enhanced Barrier Precautions. Surveyors observed the urinary drainage bag hanging from the bed frame, uncovered and facing the hallway, despite facility policy requiring catheter bags to be covered with privacy bags. During observed catheter care, a CNA performed hand hygiene and used PPE but did not retract the foreskin while cleansing the uncircumcised penis, contrary to facility expectations later confirmed by the administrator and DON. These actions resulted in a failure to provide appropriate catheter care and to maintain the resident’s privacy and dignity.
Staff failed to follow infection prevention and control practices during wound and catheter care for two residents on Enhanced Barrier Precautions. In one case, nurses performed sacral pressure ulcer treatment using the same pair of gloves from room entry through removal of soiled materials, wound cleansing, medication application, and placement of a clean dressing, without changing gloves or performing hand hygiene between dirty and clean tasks. In another case, CNAs provided catheter and incontinence care with an untied gown, reused contaminated gloves to handle clean washcloths and water, discarded stool-contaminated water and urine into the resident’s sink, placed a urine container on the bedside table, changed gloves multiple times without hand hygiene, and left the room without disinfecting the bedside table or bathroom sink.
A resident with severe cognitive impairment and multiple health conditions experienced new onset pain that was not properly assessed, documented, or communicated to the provider. Nursing staff administered pain medication without a thorough assessment and failed to notify the provider in a timely manner, resulting in a delay in identifying a femur fracture. The facility did not follow its policy for notification of significant changes in condition.
The facility did not follow its policy for labeling and dating opened food items, as observed in the reach-in cooler where a bag of shredded cheese and a salad bag were undated. Additionally, the walk-in cooler had dust and debris on the fan covers and surrounding areas. The Dietary Manager confirmed these issues, which could impact all 63 residents.
A facility failed to maintain a resident's dignity by not ensuring her clothing was clean and free of debris. The resident, who was severely cognitively impaired, was observed with dried food debris on her pants. Her husband expressed concern about the lack of clothing protectors during meals, leading to frequent soiling. The facility administrator confirmed that staff should change soiled clothing after meals.
A resident with chronic heart failure and edema did not receive physician-ordered compression stockings, as staff failed to apply them. Observations showed significant bilateral pitting edema, and the resident confirmed the stockings were not put on by staff. The facility's RN/Administrator verified the existence of the order, highlighting a lapse in care.
The facility failed to provide adequate range of motion exercises and contracture care for three residents. One resident with a contracted hand did not receive therapy or devices, another resident's splint was inconsistently applied, and a third resident did not receive restorative exercises after therapy discharge. The facility's staff acknowledged deficiencies in care planning and execution.
A facility failed to change and properly store a resident's nebulizer mask and tubing every 72 hours and oxygen tubing weekly, as per its policies. The nebulizer mask was found undated and unbagged, and the oxygen tubing was undated. A nurse confirmed these lapses, indicating non-compliance with the facility's respiratory care protocols.
An LPN failed to disinfect a shared glucometer between uses on three residents with diabetes, contrary to the facility's infection control policy. The glucometer was used consecutively on residents requiring regular blood glucose monitoring without being cleaned, as confirmed by the LPN.
The facility failed to provide written notices of transfer to residents and their representatives, as required. Two residents were transferred to a hospital without receiving the necessary documentation. The administrator confirmed the lack of a process to ensure these notifications are given.
The facility failed to provide bed hold policy notices to residents or their representatives during hospital transfers, as required by their policy. This was confirmed through interviews and record reviews, revealing a lack of documentation in residents' medical records and an ineffective process to ensure compliance.
Dietary Manager Lacks Required Food Safety Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager possessed the required Food Handler Certification or Certified Food Protection Manager certification as specified in the facility’s Dietary Manager job description. The undated job description states that Food Handler Certification or Certified Food Protection Manager certification is required for the position. CMS Form 671, signed by the Administrator, documents that 62 residents reside in the facility. During the initial kitchen tour, the Dietary Manager reported that since being hired in October 2025, he had not yet obtained the required certification, resulting in a deficiency related to employing sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service, including a qualified dietitian. This failure was identified through record review of the job description and facility census information, as well as an interview with the Dietary Manager confirming the lack of required certification since the start of his employment. The report notes that this deficiency has the potential to affect all 62 residents residing in the facility.
Failure to Implement Antibiotic Stewardship and Infection Surveillance
Penalty
Summary
The deficiency involves the facility’s failure to implement its antibiotic stewardship and infection surveillance programs as required by its own policies. The Infection Surveillance policy required collection of data to identify infections, including infection site, pathogen, signs and symptoms, resident location, and tracking of all resident infections, as well as use of laboratory reports, antibiotic use, and culture results. The Antibiotic Stewardship Program policy required use of McGeer criteria to define infections, completion of assessment and data collection forms, and measurement of antibiotic use by monthly prevalence, antibiotic starts, and/or days of therapy. Despite these policies, the facility did not consistently complete McGeer forms, did not consistently obtain or document culture results, and did not consistently include infections and culture data on the Monthly Report of Resident Infections. For multiple residents who received antibiotics, there was no documentation that McGeer criteria were applied or that required surveillance forms were completed. One resident received Levaquin for pneumonia, another received antibiotics for sepsis secondary to a UTI with a documented Proteus mirabilis urine culture, and another received Ciprofloxacin for a UTI with a urine culture showing >100,000 cfu/mL Escherichia coli; none of these cases had McGeer forms completed, and several were not entered on the Monthly Report of Resident Infections. Additional residents received antibiotics for a thigh abscess, UTIs treated with Ciprofloxacin, Rocephin, Keflex, Ampicillin, Bactrim DS, and Macrobid, yet their records similarly lacked McGeer forms, and their infections or culture results were either omitted or incompletely documented on the Monthly Report of Resident Infections. In some cases, urine cultures were obtained but the organism and results were not incorporated into the infection logs, and in other cases antibiotics were started without any urine culture being completed prior to treatment. One resident’s progress notes documented that urology advised starting Ampicillin for a positive urinalysis and later confirmed that the current antibiotic was sensitive to the culture, but the Monthly Report of Resident Infections stated no urine culture was completed and did not list an organism. Two other residents received antibiotics for UTIs without any urine culture obtained before treatment, and their infections were not captured on the Monthly Report. During interview, the Chief Nursing Officer acknowledged that infection surveillance was not thoroughly conducted, did not meet the required criteria for antibiotic use, and that culture results were not obtained or reviewed to track and trend infections.
Inappropriate Use of Antipsychotic Medication Without Clear Indication
Penalty
Summary
The deficiency involves the facility’s failure to provide an appropriate indication for the use of an antipsychotic medication for one resident. Facility policy on psychotropic medications states that such drugs are to be used only when nonpharmacological interventions are clinically contraindicated, to treat specific, diagnosed, and documented conditions, and not as chemical restraints. The drug reference used by the facility lists quetiapine (Seroquel) as an antipsychotic indicated for schizophrenia, with certain off-label uses, and specifies it is not to be given to elderly patients with dementia-related psychosis. The resident in question was admitted with diagnoses including unspecified dementia with other behavioral disturbance, cognitive communication deficit, insomnia, and a history of falls. The MDS assessment documented that the resident was cognitively intact and had no behaviors, while the care plan documented that the resident was on psychotropic medications for dementia with other behavioral disturbance and insomnia. Physician orders dated at admission documented Seroquel 25 mg at bedtime for dementia with behavioral disturbance. During interviews, an RN described the resident’s behaviors mainly as exit seeking and lack of safety awareness, noting that the resident was usually easily redirected and required supervision, especially at night. The DON stated that the resident had been “good” since admission, with dementia and lack of safety awareness as the primary issues, and indicated a belief that the resident was appropriate for dose reduction to discontinue Seroquel. The DON agreed that antipsychotic medications should not be used in dementia patients but did not clearly state that the indication for Seroquel in this case was inappropriate. Overall, the documentation and staff interviews did not establish an appropriate, specific, and documented indication for the antipsychotic medication consistent with facility policy and the drug reference.
Failure to Provide Proper Catheter Care and Maintain Privacy for a Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to follow its catheter care policy and to maintain privacy and dignity for a resident with an indwelling urinary catheter. The facility’s undated catheter care policy states that residents with indwelling catheters are to receive appropriate catheter care, with dignity and privacy maintained, and specifies that privacy bags will be available and catheter drainage bags will be covered at all times while in use. During observation, the resident’s urinary collection bag was hanging on the bed frame facing the hallway, visibly showing pink-tinged urine, and was not covered by a dignity/privacy bag as required by the policy. The resident involved was admitted with diagnoses including hematuria, chronic kidney disease, benign prostatic hyperplasia with lower urinary tract symptoms, urinary retention, presence of urogenital implants, prostate cancer, and a history of UTIs, and had an indwelling urinary catheter ordered for urinary retention. The care plan documented that the resident was on Enhanced Barrier Precautions due to the indwelling catheter. During observed catheter care, the CNA performed hand hygiene, donned gloves and a gown, and cleansed the resident’s penis; however, the resident was uncircumcised and the CNA did not retract the foreskin during cleansing, contrary to the facility’s policy and accepted practice as later confirmed by the administrator and DON. The CNA also acknowledged that the catheter bag should have been covered, confirming the failure to provide appropriate catheter care and to maintain privacy and dignity for this resident.
Failure to Follow Hand Hygiene and PPE Protocols During Wound and Catheter Care
Penalty
Summary
The deficiency involves failures in infection prevention and control practices, specifically improper hand hygiene, glove use, and PPE use during care of residents on Enhanced Barrier Precautions. Facility policies require changing gloves and performing hand hygiene between clean and dirty tasks, when moving from one body part to another, and during wound care after removing soiled dressings and after cleansing the wound. Policies also require gowns to be fastened in the back and wound care to be performed in a manner that decreases potential for infection and cross-contamination. For one resident with severe cognitive impairment, morbid obesity, type 2 diabetes with hyperglycemia, and an unstageable sacral pressure ulcer, nurses performed sacral wound treatment while on Enhanced Barrier Precautions. The RN entered the room wearing gown, gloves, and mask, used her gloved hands to move the bed, and then proceeded directly to wound cleansing without changing gloves. Another RN, also wearing her initial pair of gloves, handled clean gauze, applied saline, and prepared a cotton swab with Santyl, handing these items to the first RN, who continued to use the same gloves throughout the procedure. The clean abdominal dressing was also handled and applied while both nurses continued to wear their original gloves placed upon room entry, without any glove change or hand hygiene between dirty and clean steps of the wound care. For another resident on Enhanced Barrier Precautions due to an indwelling urinary catheter, two CNAs performed catheter and incontinence care without adhering to PPE and hand hygiene standards. One CNA’s gown was not tied while providing care. After cleaning stool from the catheter with washcloths, the CNA used the same contaminated gloves to wet new washcloths in a pan of water, then emptied the stool-contaminated water into the resident’s bathroom sink, removed gloves, and donned new gloves without hand hygiene. The CNA then cleansed the resident’s bottom, removed a soiled brief, and again changed gloves without hand hygiene. The second CNA emptied urine from the catheter bag into a plastic container, placed the container on the bedside table, and then emptied it into the bathroom sink. Both CNAs removed PPE and exited the room without performing hand hygiene, and the bedside table and bathroom sink were not disinfected after being used for contaminated materials.
Failure to Assess, Document, and Notify Provider of New Onset Pain
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with severe cognitive impairment and multiple comorbidities, including generalized osteoarthritis, dementia, and a history of right lower femur fracture. The resident, who was dependent on staff for most activities of daily living, experienced new onset pain that was not properly assessed, documented, or communicated to the provider in a timely manner. On the evening when the resident first exhibited significant pain, the nurse administered acetaminophen but did not perform or document a thorough pain assessment, nor did she notify the provider of the new onset pain. The following day, another nurse was alerted to the resident's pain, conducted an assessment, and identified pain in the right leg with movement, which was not typical for the resident. The nurse changed the resident's transfer method to accommodate the pain and attempted to notify the provider, but did not ensure that the provider received the notification before the end of her shift. The provider was not made aware of the situation until the next day, when an X-ray was ordered, ultimately revealing a right lower femur fracture. Throughout this period, there was a lack of documentation regarding the initial pain episode and insufficient communication with the provider about the resident's change in condition. The facility's policy required notification of significant changes in a resident's condition, but this was not followed. The delay in assessment, documentation, and provider notification contributed to a delay in identifying the cause of the resident's pain and in initiating appropriate interventions.
Failure to Date Opened Food Items and Maintain Kitchen Cleanliness
Penalty
Summary
The facility failed to adhere to its Labeling and Dating policy, which requires that leftovers and opened food items be clearly labeled with the date they are to be discarded. During an inspection, it was observed that the walk-in cooler had multiple areas with dust and debris on the fan covers and surrounding walls and ceiling. Additionally, in the reach-in cooler, a large bag of shredded mild cheddar cheese and a large opened salad bag with browning lettuce were found without any indication of the date they were opened. The Dietary Manager confirmed these observations and acknowledged that the items should have been labeled with the date they were opened. This deficiency has the potential to affect all 63 residents currently residing in the facility.
Failure to Maintain Resident Dignity by Ensuring Clean Clothing
Penalty
Summary
The facility failed to maintain a resident's dignity by ensuring that clothing attire was clean and free of debris for a resident who was severely cognitively impaired. During an observation, the resident was found sitting in a high back wheelchair with dried, crusted debris on the lap of her pants. The resident's husband expressed concern that the facility was not using clothing protectors during meals, as he frequently found the resident wearing dirty pants with food spills. He noted that the pants worn on a previous day were similarly soiled. The facility administrator acknowledged that staff should change a resident's clothing if it becomes soiled after a meal.
Failure to Apply Physician-Ordered Compression Stockings
Penalty
Summary
The facility failed to apply physician-ordered compression stockings for a resident with a known history of acute/chronic heart failure, atrial fibrillation, chronic kidney disease, and edema. The resident's physician order sheet and care plan both specified the need for compression stockings to be worn on the bilateral lower extremities in the morning and removed at bedtime to manage edema. However, observations on multiple occasions revealed that the resident was not wearing the compression stockings as ordered, and the resident reported that staff did not put them on her. On two separate days, the resident was observed with significant bilateral pitting edema in the lower extremities, and the compression stockings were not in place. The resident's feet and legs were not elevated, which could have contributed to the worsening edema. The facility's registered nurse and administrator confirmed the existence of the physician's orders for the compression stockings, yet they were not applied as required, indicating a failure in following the prescribed care plan for the resident.
Deficiencies in Range of Motion and Contracture Care
Penalty
Summary
The facility failed to provide adequate range of motion exercises and contracture alleviation devices for three residents, leading to deficiencies in their care. One resident, who had a history of cerebrovascular accident and muscle weakness, was observed with a contracted left hand that had not been addressed in her care plan. Despite having an active range of motion program documented, she did not receive any therapy or devices to manage her contracture since her admission. The facility's Chief Nursing Operations director confirmed the lack of a formal therapy evaluation and the absence of specific interventions for the resident's contracted hand. Another resident, with a history of hemiplegia following a cerebral infarction, was supposed to wear a splint on his left hand to prevent worsening contractures. However, the resident reported that the splint was not consistently applied, and staff confirmed the lack of a consistent schedule for its use. The Director of Nursing acknowledged the deficiency in the restorative programming and the need for clear orders regarding the splint's application. A third resident, who had been discharged from skilled physical therapy, expressed a desire to continue exercises to regain mobility. Despite having a documented plan for restorative exercises, there was no evidence that these exercises were provided after the discharge from therapy. The Chief Nursing Officer was unable to provide documentation confirming the resident's participation in the restorative program, highlighting a gap in the facility's follow-through on care plans.
Failure to Maintain and Store Respiratory Equipment Properly
Penalty
Summary
The facility failed to adhere to its own policies regarding the maintenance and storage of respiratory care equipment for a resident. Specifically, the nebulizer mask and tubing for a resident were not changed every 72 hours as required, nor were they stored in a bag between uses. Additionally, the oxygen tubing was not changed every seven days as stipulated by the facility's Oxygen Administration Policy. These lapses were observed during a survey, where the nebulizer mask was found lying undated and unbagged on the resident's dresser, and the nasal cannula oxygen tubing was also undated. A registered nurse confirmed these observations, acknowledging that the nebulizer masks and medication cups should be changed, dated, and bagged after each use, and that oxygen tubing should be changed weekly and dated. The failure to follow these protocols indicates a lack of compliance with the facility's policies designed to ensure safe and appropriate respiratory care for residents, potentially compromising the quality of care provided to the resident involved.
Failure to Disinfect Shared Glucometer Between Uses
Penalty
Summary
Facility staff failed to disinfect a shared glucometer between resident use, which was observed during a survey. The facility's policy on glucometer disinfection requires that the device be cleaned and disinfected after each use with an EPA-registered healthcare disinfectant effective against HIV, Hepatitis C, and Hepatitis B. However, a Licensed Practical Nurse (LPN) was observed using the glucometer on three residents without disinfecting it between uses. This was noted during blood glucose monitoring for residents diagnosed with diabetes mellitus, who required regular finger stick blood glucose tests. The LPN was seen performing blood glucose tests on three residents consecutively without cleaning the glucometer. The LPN first used the glucometer on a resident with diabetes mellitus and hyperglycemia, then proceeded to use the same device on another resident with diabetic polyneuropathy, and finally on a resident with diabetic retinopathy. Each time, the LPN returned the glucometer to the medication cart without disinfecting it, confirming the failure to adhere to the facility's infection control policy. This oversight was confirmed by the LPN during the survey.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide residents and their representatives with a written notice of transfer, which is a requirement for ensuring proper communication and rights awareness. This deficiency was identified through interviews and record reviews, revealing that two residents, R12 and R219, were transferred to a local hospital without receiving the necessary written notification. R12's medical record showed a transfer on 11/5/24, but there was no evidence of notification to R12 or their representative. Similarly, R219 was sent to the emergency room due to a change in condition, yet their electronic medical record lacked documentation of a written notice of transfer. The facility's administrator confirmed the absence of a process to provide these notifications, acknowledging that residents have not been receiving them.
Failure to Provide Bed Hold Policy Notices
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to residents or their representatives when residents were transferred to the hospital. This deficiency was identified through interviews and record reviews, revealing that the facility did not have a proper process in place to ensure that residents or their representatives received the necessary bed hold notices. The facility's policy requires that written information regarding bed hold practices be provided well in advance and at the time of transfer for hospitalization or therapeutic leave. However, the facility did not adhere to this policy, as evidenced by the lack of documentation in the medical records of residents who were transferred. Specifically, the medical record of one resident, who was hospitalized, did not contain documentation of the bed hold policy being provided to the resident or their representative. Similarly, another resident's electronic medical record lacked documentation of a bed hold notice when the resident was sent to the emergency room due to a change in condition. The facility administrator confirmed that the residents had not been receiving bed hold notices upon discharge to the hospital, acknowledging the absence of an effective process to ensure compliance with the policy.
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.
