Allure Of Knox County
Inspection history, citations, penalties and survey trends for this long-term care facility in Galesburg, Illinois.
- Location
- 280 East Losey Street, Galesburg, Illinois 61401
- CMS Provider Number
- 145012
- Inspections on file
- 33
- Latest survey
- September 13, 2025
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Allure Of Knox County during CMS and state inspections, most recent first.
A cognitively impaired male resident with a history of elopement risk was able to exit the facility through his window after staff failed to perform required 15-minute checks and did not assess his window or increase supervision, despite being warned by the resident's family member of his intent to escape. The resident was later found unsupervised near railroad tracks, and staff interviews and video evidence confirmed that care plan interventions were not followed.
A resident was not protected from a significant medication error, as required, due to a failure in medication administration or management.
A resident with a history of amputation, spinal stenosis, anxiety, and depression did not have pain assessments documented before or after receiving scheduled pain medications, contrary to facility policy. The DON confirmed that pain assessments were not performed or recorded, and the resident reported experiencing pain and delays in medication administration.
A resident with multiple medical conditions experienced significant medication errors, including late and missed doses of pain and other critical medications. The errors were not properly documented, and required notifications and assessments were not completed, resulting in the resident being visibly uncomfortable and anxious.
A resident with a history of amputation, spinal stenosis, anxiety, and depression, who was prescribed scheduled pain medications, did not have pain assessments documented before or after medication administration. The DON confirmed that pain assessments were not completed as required by facility policy.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
A resident with severe cognitive impairment and a history of agitation was not provided with appropriate interventions or increased supervision, leading to two incidents of physical aggression against other residents, including one resulting in a bleeding laceration. Staff were not educated on increased supervision, communication, or redirection strategies, and individualized care plans were not implemented in a timely manner, resulting in physical harm and risk to others in the dementia unit.
The facility failed to obtain informed consent for psychotropic medications for two residents. One resident's antidepressant was changed without consent from their Health Care Power of Attorney, and another resident was administered Duloxetine without a signed consent form since admission. The facility's policy requires informed consent for such medications.
The facility did not ensure that an RN was scheduled to work for eight consecutive hours on certain days, as required. This deficiency was confirmed through staffing records and interviews, affecting all 44 residents in the facility.
The facility failed to maintain cleanliness in the kitchen, affecting all 44 residents. A large amount of white, crusty build-up was found on the coffee maker's hot water dispenser, and the walk-in cooler had dust and debris on the fan covers, walls, and ceiling. The Dietary Manager confirmed these issues and acknowledged the need for cleaning.
The facility failed to implement all components of their Infection Prevention and Control Program, affecting 44 residents. The policy requires surveillance for infections among all individuals associated with the facility. However, no documentation of employee illness tracking was found, and the DON confirmed that only resident infections were logged.
The facility failed to implement its Antibiotic Stewardship Program, affecting all 44 residents. The Director of Nursing/Infection Preventionist admitted to not using protocols to review clinical signs or lab reports before administering antibiotics, relying instead on physician orders based on staff belief. This lack of adherence to established protocols indicates a significant gap in the facility's infection prevention and control program.
The facility failed to respond to call lights in a timely manner for several residents, as discussed in a Resident Council meeting. One resident reported waiting 20 minutes for assistance after a bowel movement, while another noted that staff behavior changes when the State Agency is present. The Administrator confirmed ongoing concerns about call light response times over several months.
The facility failed to provide the required bed hold policy to residents or their representatives upon hospital transfer, as documented in the cases of four residents. The facility's policy mandates written notice at the time of transfer, but the medical records lacked this documentation, confirmed by the Regional Nurse.
A facility failed to include a plan for oxygen use in a resident's care plan, despite the resident having a physician's order for oxygen administration. The facility's policy requires comprehensive care plans to address all identified needs, but the resident's care plan lacked documentation for oxygen management. This deficiency was confirmed by the DON.
A facility failed to assess and manage a resident's range of motion (ROM) needs, resulting in a deficiency. The resident, with a history of contractures following a stroke, was not provided with necessary equipment or interventions. Staff interviews revealed a lack of awareness and action regarding the resident's ROM needs, with no contracture assessments being completed and the care plan not addressing the contractures.
A facility failed to follow its policy for IV administration through a PICC line by not checking for blood return before administering medication to a resident. An RN administered normal saline and started an IV infusion without aspirating for blood return, contrary to the facility's policy. The DON confirmed that the RN should have checked for blood return.
A resident's symptoms of depression were not addressed by the facility, despite mood assessments indicating moderate to mild depression. The facility's policy requires behavioral health services to maintain residents' mental well-being, but the resident's depressive symptoms were neither documented nor communicated to the DON or physician. Observations showed the resident was withdrawn and dissatisfied, yet no care plan was developed to address these issues.
The facility failed to employ a licensed Administrator, affecting all 52 residents. An AIT was acting as the Administrator without a current or temporary license, as required. The AIT had an expired license from 2007 and was preparing for the Nursing Home Administration exam. An Administrator from a sister facility occasionally assisted but was not full-time. The facility could not provide the AIT's Administrator's license, only a Registered Nurse license.
The facility failed to conduct pressure ulcer risk assessments and implement necessary interventions for three residents, leading to severe deterioration in their conditions. One resident's stage one ulcer worsened to stage four, requiring surgery, while another developed an unstageable heel ulcer due to lack of offloading. A third resident, at high risk, did not have a care plan with pressure-relieving interventions, and staff failed to properly offload heels.
A resident reported $50 missing from their wallet to a CNA, who failed to notify the administrator as required by the facility's policy. Consequently, no investigation was conducted, and the incident was not reported to the state agency or police. The CNA was suspended pending further investigation for not following the reporting procedures.
Failure to Provide Adequate Supervision and Implement Elopement Precautions
Penalty
Summary
A cognitively impaired male resident with a history of Alzheimer's Disease, restlessness, agitation, and a previous elopement attempt was identified as being at high risk for elopement. The resident's care plan included interventions such as a wander guard and 15-minute visual checks, which were to be implemented due to his severe cognitive impairment and prior behaviors. On the evening in question, the resident's family member notified facility staff that the resident had expressed intent to escape through his window. Despite this warning, staff did not immediately assess the resident or his window, nor did they increase supervision beyond the prescribed 15-minute checks. Video surveillance and staff interviews revealed that staff failed to perform the required 15-minute checks as directed by the care plan. No staff were observed entering the resident's room to check on him during the critical period before his elopement. Staff members admitted to not physically checking on the resident every 15 minutes and were unaware of the specific reasons for the increased monitoring. Additionally, staff did not assess the window for potential hazards after being informed of the resident's intentions, and some staff were not trained on how to access or interpret care plans for residents at risk of elopement. As a result of these failures, the resident was able to manipulate the window lock over time and exit the facility through his room window without staff knowledge or supervision. He was later found by staff and police a block away from the facility, near active railroad tracks. The lack of immediate and adequate supervision, failure to follow the care plan, and insufficient staff training directly led to the resident's unsupervised exit and the resulting Immediate Jeopardy finding.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the administration or management of medications as required by regulations. No further details about the specific actions, inactions, or the condition of the resident(s) at the time of the deficiency are provided in the report.
Failure to Assess and Document Pain Management for Resident Receiving Scheduled Pain Medications
Penalty
Summary
Facility staff failed to assess the pain of a resident who was receiving scheduled pain medications, as required by the facility's pain management policy. The policy mandates that pain management must be provided in accordance with professional standards, the resident's care plan, and their goals and preferences, including regular reassessment for effectiveness and adverse effects. However, review of the medical record for a resident with a history of left below the knee amputation, spinal stenosis, anxiety, and depression revealed no documentation of pain assessment before or after administration of scheduled pain medications, which included hydrocodone, pregabalin, and tizanidine. During an interview, the resident reported being in pain and noted delays in receiving morning medication, particularly when agency nurses were on duty. The Director of Nursing confirmed that pain assessments were not performed or documented prior to or after medication administration, acknowledging that the pain scale was missing from the record. This lack of assessment and documentation represents a failure to follow the facility's own pain management policy and to ensure appropriate pain management for the resident.
Failure to Prevent Significant Medication Errors and Ensure Timely Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by multiple instances where scheduled medications were not administered at the prescribed times or were omitted entirely. The resident, who had a history of left below the knee amputation, spinal stenosis, anxiety, and depression, was observed to be visibly uncomfortable, pale, and anxious while waiting for her morning medications, which were administered over three hours late. On several occasions, documentation was missing regarding the reasons for late or omitted medication administration, and there was no record of the resident's condition at those times. Staff interviews revealed uncertainty about whether medications were given late or simply not documented, and there was no evidence that the physician or other staff were notified of these errors. The resident's Medication Administration Record showed repeated late administration of critical medications, including pain management drugs and antihypertensives, as well as missed doses of Pregabalin. The facility's policy required assessment, documentation, and notification in the event of medication errors, but these procedures were not followed. Staff could not provide clear explanations for the discrepancies, and there was no documentation of monitoring or interventions in response to the errors. The lack of adherence to medication administration protocols resulted in the resident experiencing discomfort and anxiety.
Failure to Assess Pain for Resident Receiving Scheduled Pain Medications
Penalty
Summary
Facility staff failed to assess the pain of a resident who was receiving scheduled pain medications, as required by the facility's pain management policy. The policy mandates that pain management must be provided in accordance with professional standards, the resident's care plan, and their goals and preferences, including regular reassessment for effectiveness and adverse effects. Despite this, there was no documentation of pain assessment before or after the administration of scheduled pain medications for the resident. The resident in question had a medical history including a left below-the-knee amputation, spinal stenosis, anxiety, and depression. On the day of observation, the resident was alert, appeared pale, had a damp hairline, and was breathing rapidly, and reported being in pain while waiting for her morning medication. The resident's medical record showed scheduled orders for hydrocodone, pregabalin, and tizanidine, but lacked any pain assessment documentation related to these medications. The DON confirmed that pain assessments were not performed as required.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Interventions and Staff Education
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse after a resident with severe cognitive impairment and a history of agitation and aggression was not provided with appropriate interventions or increased supervision. Despite documented behaviors such as wandering, suspicion, agitation, and combativeness, there was no behavior care plan for aggression in place for this resident until after multiple incidents occurred. Staff were not educated on increasing supervision or on specific interventions following an initial altercation where the resident threw a handheld radio, striking another resident. Subsequently, the same resident was involved in a second incident where he physically shoved a trash can into another resident's face, resulting in a bleeding laceration to the upper and lower lips. Staff interviews revealed that there were no individualized interventions for residents on the dementia unit, and that staff had not been educated on communication, redirection strategies, or monitoring for signs of agitation after the altercation. Additionally, the two residents involved in the altercation continued to have rooms next to each other, despite ongoing conflict and aggressive behaviors. The facility's own policies required the identification, assessment, care planning, and monitoring of residents with behaviors that could lead to conflict or abuse, as well as staff training and ongoing supervision. However, these policies were not implemented as written, and there were system failures regarding care plans, documentation, and communication of interventions to floor staff. The lack of timely and effective interventions resulted in physical harm to a resident and placed all residents in the dementia unit at risk.
Removal Plan
- The DON/Director of Nursing, Social Services Director and designee assessed all residents in memory care to determine their level of risk with the Abuse assessments and Aggressive behavior assessment.
- 15-minute checks for R1 changed to 1:1 supervision.
- R1 was evaluated by V13's team with inpatient hospital evaluation/treatment and review of medications.
- R1's care plan updated with individualized interventions for aggressive behaviors.
- R1 is not to be seated by other residents with activities, dining etc. when agitated.
- Social Services Director, DON and Administrator re-educated staff on Abuse/Neglect & Exploitation policy and Abuse Prevention.
- All Agency staff being in-serviced on Abuse/Neglect & Exploitation policy and Abuse Prevention prior to start of next shift.
- R1's abuse and aggression assessments completed/updated.
- R1's care plan reviewed and revised by facility interdisciplinary team and revisions and interventions communicated to front line staff caring for R1.
- Abuse policies reviewed/revised to include resident to resident altercations.
- Abuse investigation procedures and documentation process reviewed/revised, and Education provided to all staff.
- DON and designee educated Nurse Aids and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director/MDS/Minimum Data Set Coordinator or designee and care plans to be updated as indicated. Staff will be educated on new interventions either verbally or in writing by Care Plan Coordinator or designee.
- An emergency QAPI (Quality Assessment Performance Improvement) meeting was held to develop and implement plans to prevent further resident abuse.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to two residents. For the first resident, diagnosed with Major Depressive Disorder, Bipolar Disorder Depressive State, and Anxiety Disorder, the facility's Medical Director ordered a change in antidepressant medication from Venlafaxine to Sertraline. However, the facility did not document obtaining consent from the resident's Health Care Power of Attorney before initiating the new medication. The Director of Nursing confirmed that consent should have been obtained prior to the medication change. For the second resident, diagnosed with Major Depressive Disorder, Recurrent, Unspecified, the facility administered Duloxetine for depression without a signed consent form. The Regional Nurse Consultant confirmed that the resident had been taking the medication without consent since admission, and the consent form was only signed on the day of the survey. Both cases highlight the facility's failure to adhere to its policy of obtaining informed consent for psychotropic medications.
Failure to Ensure RN Coverage for Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled to work for eight consecutive hours, seven days a week, as required. This deficiency was identified through interviews and record reviews, which revealed that on specific dates, namely 11/26/24, 12/02/24, and 12/07/24, the facility did not have an RN scheduled for the required duration. The facility's Daily Staffing Assignment Sheets, provided by the Administrator, documented the staffing schedules and confirmed the absence of eight consecutive hours of RN coverage on these days. This oversight has the potential to affect all 44 residents residing in the facility, as indicated by the facility's Long-Term Care Facility Application for Medicare and Medicaid, which was signed by the Administrator.
Kitchen Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen, which has the potential to affect all 44 residents residing in the facility. During an observation, a large amount of white, crusty build-up was found around the dispensing spout of the hot water dispenser on the coffee maker. The Dietary Manager confirmed the presence of the build-up and acknowledged the need for cleaning with lime scale. Additionally, the walk-in cooler was observed to have a large amount of dust and debris adhered to the fan covers, as well as the surrounding wall and ceiling. The Dietary Manager also confirmed the presence of dust and debris in the walk-in cooler and stated that it needed to be cleaned.
Failure to Implement Comprehensive Infection Control Program
Penalty
Summary
The facility failed to implement all components of their Infection Prevention and Control Program, which has the potential to affect all 44 residents currently residing in the facility. The facility's policy requires a system of surveillance for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all individuals associated with the facility. However, upon review of the facility's Infection Control Log, no documentation of employee illness tracking and trending was found. The Director of Nursing/Infection Preventionist confirmed that employee illness tracking was not being conducted, and the only infection log maintained was for the residents.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program, which is designed to optimize infection treatment and reduce adverse events associated with antibiotic use. The policy outlines responsibilities for the Director of Nursing and the Infection Preventionist, including establishing standards for assessing, monitoring, and communicating changes in residents' conditions, ensuring antibiotics are prescribed appropriately, and educating nursing staff. The policy also requires tracking antibiotic use, monitoring adherence to evidence-based criteria, and reviewing antibiotic resistance patterns. However, the Director of Nursing/Infection Preventionist admitted that the facility does not implement protocols to review clinical signs, symptoms, or laboratory reports before administering antibiotics. They also do not use assessment tools or management algorithms to determine the necessity of antibiotics, instead relying on physician orders based on staff belief of need. This deficiency has the potential to affect all 44 residents residing in the facility, as documented in the facility's Long-Term Care Facility Application for Medicare and Medicaid. The lack of adherence to the established antibiotic stewardship protocols indicates a significant gap in the facility's infection prevention and control program. The Director of Nursing/Infection Preventionist's statement highlights the absence of a systematic approach to antibiotic use, which is contrary to the facility's policy that emphasizes the importance of using narrow-spectrum antibiotics and specifying the dose, duration, and indication for use in prescriptions.
Deficiency in Timely Call Light Response
Penalty
Summary
The facility failed to ensure timely responses to call lights for eight residents who attended a Resident Council meeting. During the meeting, residents expressed concerns about staff response times, with one resident recounting an incident where they had to call the receptionist after waiting 20 minutes for assistance following a bowel movement. The staff member who eventually responded did not seem to care, and when the issue was reported, the resident was informed that an audit showed the call light was on for 15 minutes, which the resident still considered too long. Another resident noted that staff behavior changes when the State Agency is present. The Administrator confirmed that concerns about call light response times had been raised by residents for seven consecutive months in the past year. The report highlights a deficiency in the facility's ability to honor residents' rights to a dignified existence and timely assistance, as evidenced by the repeated complaints and the Administrator's acknowledgment of ongoing issues.
Failure to Provide Bed Hold Policy Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to residents or their representatives upon transfer to a hospital, as required by their own policy. This deficiency was identified for four residents (R6, R9, R29, and R52) out of a sample of 28. The facility's Bed Hold Notice Upon Transfer Policy mandates that at the time of transfer for hospitalization or therapeutic leave, the facility must provide written notice to the resident or their representative, specifying the duration of the bed-hold policy and information about the resident's return to the next available bed. The medical records of the residents in question did not contain documentation of the required written notice. Specifically, R9 was hospitalized multiple times, and R29, R6, and R52 were each transferred to the hospital, yet none of their records included documentation of the bed hold policy being provided. The Regional Nurse confirmed that if the bed hold policy is not documented in the nursing progress notes, it was not given, indicating a lapse in following the facility's policy.
Failure to Develop Comprehensive Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident's use of oxygen. The facility's policy mandates the creation of a person-centered care plan that includes measurable objectives and timeframes to address a resident's medical, nursing, and psychosocial needs as identified in their comprehensive assessment. However, the care plan for a resident who was observed using oxygen at two liters per nasal cannula did not include any documentation regarding the management of their oxygen use. This oversight was confirmed by the Director of Nursing, who acknowledged that the resident's care plan should have included a plan for oxygen administration.
Failure to Assess and Manage Resident's Range of Motion Needs
Penalty
Summary
The facility failed to adequately assess and manage a resident's range of motion (ROM) needs, leading to a deficiency in care. The facility's policy required quarterly assessments and the development of a care plan to prevent decline in ROM, but these were not conducted for a resident with a history of contractures. The resident, who had a fall resulting in a stroke and subsequent contractures, was not provided with necessary equipment or interventions to maintain or improve her ROM. The resident reported that a splint, previously used to manage her contractures, was broken and never replaced, and no exercises were performed by staff. Interviews with staff revealed a lack of awareness and action regarding the resident's ROM needs. The restorative aid was unaware of the resident's need for a splint, and the registered nurse confirmed that the splint had not been applied for months. The Director of Nurses admitted to not having a restorative nurse in-house and was unfamiliar with contracture assessments. The Director of Rehab confirmed that no staff were completing contracture assessments, and the resident's care plan did not address her contractures, indicating a systemic failure to provide necessary care and equipment.
Failure to Check Blood Return Before IV Administration
Penalty
Summary
The facility failed to adhere to its policy regarding the administration of intravenous (IV) fluids through a peripherally inserted central catheter (PICC) line for a resident. The policy required staff to check for venous blood return before administering IV medication to ensure proper catheter placement. On December 10, 2024, a registered nurse (RN) attached a 10mL normal saline syringe to the resident's PICC line and administered the saline without aspirating for blood return. The RN then connected the IV medication and started the infusion. The RN later stated that they only check for blood return on double lumen PICC lines, not single lumen ones. The Director of Nursing confirmed that the RN should have checked for blood return prior to starting the IV infusion.
Failure to Address Resident's Depression
Penalty
Summary
The facility failed to address a resident's symptoms of depression and develop a care plan with interventions to recognize and treat these symptoms. The facility's Behavioral Health Services Policy mandates that all residents receive necessary behavioral health services to maintain their highest level of mental and psychosocial functioning. However, for one resident, identified as R47, the facility did not adhere to this policy. R47's mood assessments indicated moderate to mild depression, but these findings were not documented in the social service progress notes, nor were they communicated to the Director of Nursing or the resident's physician. This lack of communication and documentation resulted in the absence of a care plan to address R47's depressive symptoms. Observations and interviews revealed that R47 was often withdrawn, expressed dissatisfaction with the facility, and showed no interest in participating in activities. Despite these clear signs of depression, the facility did not take appropriate steps to assess and address the resident's mental health needs. The social services staff member, V8, admitted to not notifying the necessary parties about R47's mood assessment results, and the Director of Nursing confirmed that there was no communication with the physician regarding R47's mood and behavior. This oversight highlights a significant deficiency in the facility's behavioral health care services.
Facility Lacks Licensed Administrator
Penalty
Summary
The facility failed to employ a licensed Administrator, which has the potential to affect all 52 residents residing in the facility. The facility's Department Head List indicated that an Administrator in Training (AIT) was acting as the Facility Administrator. However, the AIT did not possess a current or temporary Administrator's license, as required by the facility's job description and state regulations. The AIT had an expired Administrator's license from 2007 and was in the process of preparing for the Nursing Home Administration exam but had not yet completed the necessary paperwork to obtain a new license. The AIT had also been performing dual roles, acting as both the Administrator and the Director of Nursing until a new Director of Nursing was hired. An Administrator from a local sister facility, who held a valid Administrator's license, occasionally assisted but was not present full-time. The facility was unable to provide documentation of the AIT's Administrator's license or Administrator in Training License, only providing an active Registered Nurse license. This lack of a licensed Administrator was identified through observations, interviews, and record reviews conducted by surveyors.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to perform pressure ulcer risk assessments and implement appropriate interventions for three residents, leading to significant deterioration in their conditions. Resident 1, who was admitted with a stage one pressure ulcer on the left hip, did not receive a pressure ulcer risk assessment or a care plan with pressure-relieving interventions. The ulcer worsened to a stage four, requiring surgical debridement. The facility staff did not document weekly assessments or treatments for the ulcer, and the resident's preference to lie on the left hip was not addressed in the care plan. Resident 2, who was at risk for pressure ulcers, did not have a quarterly Braden Scale assessment completed, and the facility failed to implement a turning and repositioning program. The resident developed an unstageable pressure ulcer on the right heel, which was not offloaded or treated with pressure-relieving boots as required. The ulcer was discovered to be necrotic and required surgical debridement. Despite the resident's deteriorating condition, the facility did not ensure the use of pressure-relieving interventions, and staff failed to apply the necessary protective measures. Resident 3 was identified as high risk for pressure ulcer development but did not have a care plan with pressure-relieving interventions. Observations revealed that the resident's heels were not properly offloaded, as pillows were placed directly under the heels instead of under the ankles and calves. The facility staff, including CNAs, did not elevate the resident's heels off the bed, which is necessary to prevent pressure ulcer development. The lack of appropriate care plans and interventions contributed to the risk of pressure ulcer development for this resident.
Failure to Report Misappropriation of Funds
Penalty
Summary
The facility failed to report an allegation of misappropriation of funds involving a resident, identified as R1, to the administrator, state agency, and local police department. According to the facility's policy on Abuse, Neglect, and Exploitation, any alleged violations must be reported to the appropriate authorities within specified timeframes. In this case, R1 reported to a Certified Nursing Assistant (CNA) that $50 was missing from his wallet. The CNA, identified as V4, acknowledged receiving this report but failed to notify the administrator, V1, as required by the facility's policy. The administrator, V1, confirmed that they were unaware of the missing money report and, as a result, no abuse investigation was conducted, nor was the incident reported to the state agency or police. The failure to report the incident was a direct violation of the facility's policy, which mandates immediate reporting of such allegations. Consequently, V4 was suspended pending further investigation for not adhering to the policy and procedure regarding the reporting of abuse and neglect allegations.
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.
