Allure Of Prophetstown
Inspection history, citations, penalties and survey trends for this long-term care facility in Prophetstown, Illinois.
- Location
- 310 Mosher Drive, Prophetstown, Illinois 61277
- CMS Provider Number
- 145920
- Inspections on file
- 26
- Latest survey
- December 21, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Allure Of Prophetstown during CMS and state inspections, most recent first.
A resident on hospice care with a physician order for Morphine Sulfate did not receive any doses, and both the medication bottle and count sheet went missing. An LPN noticed the unusual appearance of the Morphine and later found it, along with the count sheet, missing and not signed out on the master count sheet. The DON's investigation, including review of video footage and staff interviews, determined that a nurse had taken the Morphine, resulting in misappropriation of the resident's medication.
A resident on hospice care with a physician order for Morphine Sulfate had a bottle of the medication and its count sheet go missing, with no doses recorded as given. Nursing staff failed to consistently perform and document required shift change counts of controlled substances, resulting in gaps in the medication count process and the loss of the narcotic medication and its documentation.
A resident with significant mobility and medical needs was transferred by two CNAs without the required use of a gait belt or proper assistance, resulting in the resident striking her leg on a wheelchair and sustaining a deep laceration that required stitches. The transfer did not follow the care plan, and the incident was not promptly reported to nursing staff.
A CNA failed to notify a nurse after discovering a deep laceration on a resident's leg during a transfer, instead covering the wound and continuing care without reporting the injury. The resident, who was dependent for transfers and had multiple medical conditions, was later found by another staff member and sent to the ER for sutures. Facility policy requires immediate notification of such changes in condition, but the CNA stated she forgot to inform the nurse after becoming distracted by other duties.
The facility failed to label multidose medication vials with expiration dates after opening, affecting 58 residents. An LPN was observed storing two opened vials of Tuberculin testing solution without written opened or expiration dates. The LPN and DON acknowledged the requirement to mark vials with the opened date to determine expiration, as Tuberculin is viable for about a month after opening. The facility's policy mandates writing open and expire dates on such products.
The facility failed to maintain safe water temperatures in resident bathrooms, with temperatures recorded significantly above the safe range, reaching up to 136 degrees Fahrenheit. Additionally, the facility did not implement adequate fall precautions for residents with a history of falling. One resident with severe cognitive impairment was observed transferring herself without assistance or a gait belt, and another resident, a fall risk, was seen ambulating unassisted without a gait belt, despite needing moderate assistance.
The facility did not follow the prescribed pureed menu for six residents on a pureed diet. The menu required a 5.33-ounce serving of pureed enchiladas using a number 6 scoop, but the cook used a 4-ounce spoodle, resulting in insufficient portion sizes. This was confirmed by the Dietary Manager, and leftover food in the serving container indicated incorrect portioning.
A resident developed a stage three pressure ulcer due to the facility's failure to identify, assess, and treat the wound in a timely manner. Despite existing protocols, staff did not report the wound to the Wound LPN, assuming she was already aware, which delayed treatment and allowed the ulcer to worsen.
A facility failed to apply and document the use of splints for a resident with spastic quadriplegic cerebral palsy, as prescribed. The resident was observed without her wrist-hand orthotics (WHO's) on multiple occasions, and one splint was found on the floor. The care plan lacked specific instructions for splint application, and the Restorative CNA did not document their use or refusal, contrary to the facility's policy.
A resident with significant weight loss was not provided ice cream as ordered for nutritional supplementation. Despite a physician's order and care plan interventions, the resident did not receive ice cream with meals on two observed occasions. Staff interviews confirmed the oversight, and the facility's weight monitoring policy emphasized the need for consistent interventions to maintain nutritional status.
A resident with dementia and a history of dislodging his PEG tube received medications and enteral feeding without prior verification of tube placement. A nurse administered these through the tube without checking its position, contrary to the facility's policy. The Director of Nursing confirmed that placement should be verified by aspirating gastric content.
A resident experienced bilateral underarm pain for about a week without proper assessment or physician notification. Despite complaints, no follow-up occurred after an LPN suggested skin tags, and the RN was unaware of the specific pain. Progress notes lacked documentation of the pain assessment, and while pain medication was given, the location was not recorded. The DON stated that pain complaints should be assessed, documented, and communicated to the physician, as per the facility's Pain Management Policy.
A resident's controlled medication went missing due to the facility's failure to maintain a master count of narcotics. The resident, with chronic pain and fibromyalgia, was sent to the hospital, and upon return, the medication was unaccounted for. Staff interviews and security footage suggested an agency nurse might have taken the medication and count sheet, highlighting a lapse in the facility's policy on reporting misappropriation.
A resident with dementia and a recent hip fracture received Norco for pain, but the LPN failed to document most doses on the MAR. Despite signing out 18 pills over two months, only 2 doses were recorded. The facility's policy requires documentation of medication administration, which was not followed.
A resident with severe cognitive impairment fell and sustained a head injury during a transfer when a CNA attempted to use a mechanical lift alone, contrary to facility policy requiring two staff members. The resident, known to lean forward during transfers, was not adequately supervised, leading to the fall and subsequent hospital transfer.
A resident with severe cognitive impairment fell and sustained a head laceration, but the incident was not documented in the progress notes. The facility's staff acknowledged the omission, which violated the policy requiring documentation of falls, injuries, and notifications.
Misappropriation of Controlled Substance for Hospice Resident
Penalty
Summary
A resident was admitted to the facility and placed on hospice care, with a physician order for Morphine Sulfate to be administered as needed for pain or shortness of breath. The controlled substance record indicated that a 5ml bottle of Morphine Sulfate was received for the resident, but the Medication Administration Record showed that no doses were administered and the resident had no complaints of pain. A nurse noticed that the Morphine bottle appeared unusual, with a thick gel and pink color, and later discovered that both the bottle and the count sheet were missing. The count sheet was later found intact in the shred bin, with no doses signed out, and the master count sheet did not reflect the medication being signed out. The Director of Nursing conducted a review, including video footage of shift change narcotic counts, and determined that the bottle and count sheet were last seen during a morning count between two nurses. The subsequent shift change was not visible on camera, and the nurse who participated in the count did not recall seeing the Morphine bottle. Based on these findings, it was determined that a nurse had taken the bottle of Morphine, resulting in the misappropriation of the resident's medication. The facility's policy defines misappropriation as the deliberate misplacement or wrongful use of a resident's property without consent.
Failure to Properly Count and Document Controlled Narcotic Medication
Penalty
Summary
The facility failed to ensure that controlled narcotic medications were properly counted and documented by nursing staff for one resident who was admitted on hospice care and had a physician order for Morphine Sulfate. The resident's controlled substance record indicated that a 5ml bottle of Morphine Sulfate was received, but no doses were administered according to the medication sheet. Subsequently, the bottle and its count sheet went missing, and there was no record of the medication being signed out on the master count sheet. Interviews with nursing staff revealed that the required shift change counts of controlled substances were not consistently performed or documented, with several shift changes lacking any recorded counts for the medication cart. The Director of Nursing confirmed that the bottle and count sheet were last seen during a morning count and later found the count sheet in the shred bin, still intact and unsigned for any doses. Further review of the facility's procedures and interviews with staff indicated that the process for counting and documenting controlled substances at shift change was not followed as required. The facility's policy mandates that two licensed nurses account for all controlled substances at the end of each shift, but gaps in documentation and missing counts were identified. The failure to perform and document the narcotic counts as required led to the loss of the Morphine Sulfate bottle and its associated count sheet, with no explanation or record of its disposition.
Failure to Provide Safe Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including metabolic encephalopathy, gastrointestinal hemorrhage, and limited mobility, was not safely transferred by staff. The resident's care plan required assistance from two staff members for pivot transfers using a front wheeled walker (FWW) and gait belt, with staff responsible for blocking the resident's feet and providing verbal cues due to visual deficits. Despite these requirements, the resident was transferred without a gait belt, and the transfer was not performed according to the care plan instructions. During the incident, two CNAs were involved in transferring the resident to a recliner. The resident reported that the staff did not use a gait belt and did not provide adequate assistance, resulting in her missing part of the wheelchair seat and striking her leg on the wheelchair, causing a deep laceration that required nine stitches. Blood was later found on the foot pedal pegs of the wheelchair, supporting the conclusion that the injury occurred during the unsafe transfer. The resident expressed that she did not feel safe during the transfer and had not previously met the staff involved. Interviews and record reviews revealed inconsistencies in staff accounts, with one CNA stating she used a sit-to-stand lift by herself and another indicating the resident refused to transfer with a gait belt. The investigation determined that the staff failed to follow the resident's care plan and facility policy for safe transfers, including the use of a gait belt and ensuring proper clearance from wheelchair components. The incident was not immediately reported to nursing staff, and the resident's complaints of pain were not promptly addressed.
Failure to Notify Nurse of Resident Laceration Following Transfer
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to notify a nurse after discovering a laceration on a resident's leg, which constituted a change in the resident's condition. The resident, who had multiple diagnoses including metabolic encephalopathy, gastrointestinal hemorrhage, and bullous pemphigoid, was dependent for transfers and toileting. The incident began when the CNA observed the resident's leg was bleeding, covered the wound with a towel, and proceeded to assist the resident with toileting. The CNA did not immediately inform the nurse about the injury, stating later that she became distracted by answering other call lights and forgot to report the incident. The deficiency was identified when another CNA responded to the resident's call light and noticed the laceration, prompting nurse intervention. Documentation showed that the resident was later sent to the emergency room, where she received nine stitches for the deep laceration. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, confirmed that the CNA had not reported the injury as required by facility policy, which mandates prompt notification of changes in resident condition, including injuries that may require physician intervention. Further investigation, including review of facility camera footage and staff interviews, indicated that the injury likely occurred during a transfer performed by the CNA. The CNA admitted to covering the wound and not reporting it immediately due to fear of getting in trouble and being distracted by other duties. The failure to promptly notify nursing staff delayed appropriate assessment and intervention for the resident's injury.
Failure to Label Multidose Medication Vials with Expiration Dates
Penalty
Summary
The facility failed to ensure that multidose medication vials were marked with expiration dates after opening, affecting 58 residents. During an observation, a Licensed Practical Nurse (LPN) was found to have opened the medication room and storage refrigerator, where two opened vials of Tuberculin testing solution were stored. The first vial was almost empty, and the second vial was approximately half empty, with neither vial having a written opened date or expiration date. The LPN acknowledged that the opened date should be written on the vials to determine the expiration date, noting that Tuberculin is viable for about a month after opening. The Director of Nursing (DON) confirmed that multidose vials need to have the date they were opened written on them. The facility's Medication Expired Dates and Storage Sheet indicated that Tuberculin should be maintained according to manufacturer recommendations in the refrigerator and expires 30 days after opening, with nurses required to write the open and expire dates on the product.
Failure to Maintain Safe Water Temperatures and Implement Fall Precautions
Penalty
Summary
The facility failed to maintain safe water temperatures in resident bathrooms, with temperatures recorded significantly above the safe range of 100-110 degrees Fahrenheit. During the survey, water temperatures in the bathrooms of three residents were found to be excessively high, reaching up to 136 degrees Fahrenheit. A Certified Nursing Assistant (CNA) reported that some bathroom water temperatures were too hot to touch and had informed maintenance, but no action was taken. The Maintenance Director confirmed that water temperatures should not exceed 110 degrees Fahrenheit, acknowledging the risk of scalding. Additionally, the facility did not implement adequate fall precautions for residents with a history of falling. One resident, with severe cognitive impairment and a history of falls, was observed transferring herself without assistance or the use of a gait belt, contrary to her care plan requirements. Another resident, also a fall risk, was seen ambulating unassisted without a gait belt, despite needing moderate assistance according to her care plan. Staff members, including CNAs and nurses, failed to intervene or provide the necessary support, neglecting the facility's policy on the use of gait belts for residents who cannot independently ambulate or transfer.
Failure to Follow Prescribed Pureed Menu
Penalty
Summary
The facility failed to adhere to the prescribed pureed menu for six residents who were on a pureed diet. On the specified date, the menu indicated that pureed enchiladas were to be served using a number 6 scoop, which provides a 5.33-ounce serving size. However, the cook, identified as V7, used a spoodle with a green handle labeled as 4 ounces to plate the pureed enchiladas, resulting in a serving size that was 1.33 ounces less than required. This discrepancy was confirmed by the Dietary Manager, V6, who acknowledged that the menu should have been followed. Observations noted that after serving the meals, there was still pureed enchilada left in the serving container, indicating that the correct portion sizes were not served.
Failure to Identify and Treat Pressure Ulcer
Penalty
Summary
The facility failed to properly identify, assess, and implement treatment for a pressure ulcer, which resulted in the development of a stage three pressure ulcer for one resident. On a specific date, a Wound LPN performed a dressing change on the resident's left buttock, revealing a pressure ulcer measuring 2.6 cm x 1.8 cm x 0.1 cm. Prior assessments indicated discolored excoriation in the same area, and a shower assessment sheet noted redness and ointment application. However, no formal assessment of the pressure wound was documented until two days later, when a stage three pressure ulcer was identified. The Wound LPN reported discovering the open pressure ulcer during toileting and noted that staff failed to notify her of the wound's presence. The facility's policy requires licensed nurses to conduct full body skin assessments weekly and after any newly identified pressure injury, with findings documented in the medical record. Nursing assistants are also required to inspect skin during baths and report concerns immediately. Despite these protocols, the staff did not communicate the presence of the wound, assuming the Wound LPN was already aware, leading to a delay in appropriate treatment and escalation of the wound to a stage three pressure ulcer.
Failure to Apply and Document Use of Splints for Resident
Penalty
Summary
The facility failed to ensure that a resident's splints were applied to her bilateral upper extremity contractures as prescribed. The resident, who has spastic quadriplegic cerebral palsy, osteoarthritis, and mild intellectual disability, was observed multiple times without her prescribed wrist-hand orthotics (WHO's). The physician's order required the resident to wear these splints daily, but observations on consecutive days showed the resident without them, and one splint was found on the floor in her room. The resident's care plan did not specify when the splints should be applied, and the Restorative Certified Nursing Assistant (CNA) responsible for applying the splints stated that they were applied only if the resident wanted them on, with no documentation of their application, removal, or refusal. The facility's policy on the prevention of decline in range of motion required documentation of interventions, including the use of splints, but this was not followed. The lack of documentation and adherence to the care plan contributed to the deficiency.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility failed to ensure that a resident received ice cream as ordered for nutritional supplementation. The resident, identified as R6, was admitted to the facility and had a physician's order dated 7/31/24 for ice cream to be provided at lunch and dinner to address her nutritional needs. R6's weight had decreased from 116.8 pounds on 7/9/24 to 109.8 pounds on 7/30/24, indicating a significant weight loss. Despite the order, observations on 8/5/24 and 8/6/24 revealed that R6 was not served ice cream with her meals, and she did not consume any of her meal on 8/5/24. Interviews with facility staff, including the cook and dietary manager, confirmed that R6 was not provided ice cream as ordered. The dietary manager acknowledged that ice cream should have been served with R6's meals, and the cook admitted to missing the order. The dietitian explained that ice cream is ordered for residents who are eating less than 50% of their meals and not maintaining weight, to help reduce weight loss. R6's care plan included interventions to provide and serve supplements, such as ice cream, as ordered. The facility's weight monitoring policy emphasized the need for interventions consistent with the resident's assessed needs and professional standards to maintain nutritional status.
Failure to Verify Feeding Tube Placement Before Administration
Penalty
Summary
The facility failed to ensure the proper checking of a feeding tube's placement before administering medications and enteral feeding to a resident. The resident, a male with a history of dementia, had a Percutaneous Endoscopic Gastrostomy (PEG) tube placed after a recent hospitalization. The resident had a history of pulling out the tube, leading to dislodgment and requiring replacement. On the morning of August 6, a registered nurse administered water, medications, and enteral feeding through the resident's PEG tube without verifying its placement. The Director of Nursing confirmed that the placement should be checked by aspirating gastric content before any administration, as per the facility's policy revised in November 2023.
Failure to Assess and Manage Resident's Armpit Pain
Penalty
Summary
The facility failed to provide appropriate pain management for a resident experiencing bilateral underarm pain. The resident reported having pain in the armpit area for about a week, but no assessment was conducted, and the physician was not notified. Despite the resident's complaints, the Wound LPN suggested the presence of skin tags and mentioned that a nurse practitioner would see the resident, but no follow-up occurred. The resident continued to experience pain without any intervention or assessment, and the RN was unaware of the resident's specific complaint of armpit pain. The resident's progress notes from the specified period did not document any assessments of the bilateral armpit pain, and while pain medication was administered, the location of the pain was not recorded. The Director of Nursing stated that the protocol for a resident complaining of pain includes assessing the pain, notifying the physician if it is new, and documenting the assessment in the medical record. The facility's Pain Management Policy outlines the need for a thorough assessment and collaboration with healthcare professionals to manage the resident's pain, which was not adhered to in this case.
Controlled Medication Mismanagement
Penalty
Summary
The facility failed to maintain a master count of controlled substances, resulting in the disappearance of a resident's controlled medication. The resident, who was admitted with multiple diagnoses including chronic pain and fibromyalgia, had an order for hydrocodone-acetaminophen to be administered twice daily. On the day the resident was sent to the hospital, the medication was accounted for at the end of the shift. However, upon the resident's return, the medication was missing from the cart. Interviews with staff revealed that there was no master count of narcotics, and the only way to identify missing medication was through the nurses' knowledge of what should be present. Further investigation showed discrepancies in the narcotic count sheets, with one less page turned in the count book during a shift change. Security footage and interviews suggested that an agency nurse, unfamiliar with the facility, may have taken the medication and the count sheet. The facility's policy on reporting misappropriation of resident property was not effectively implemented, leading to the wrongful use of the resident's belongings without consent.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to properly document the administration of controlled medications for a resident, identified as R3, who was admitted with multiple diagnoses including dementia, Alzheimer's disease, and osteoarthritis, and later diagnosed with a fracture of the right femur. The deficiency was identified through observation, interview, and record review, revealing that the Licensed Practical Nurse (LPN), V9, administered Norco, a controlled medication, to R3 but failed to document the administration on the Medication Administration Record (MAR) for several doses. Specifically, between June and July 2024, V9 signed out a total of 18 pills but only documented the administration of 2 doses on the MAR. Interviews with the Director of Nursing (DON) and V9 confirmed that the facility's policy requires each medication to be documented on the MAR after administration, and PRN medications should have their effectiveness documented. V9 admitted to forgetting to document the medication administration despite claiming that all doses signed out were given to R3. Observations of R3 indicated she was alert but unable to communicate her pain levels due to confusion, and her husband noted she likely took pain medication to help with sleep following her hip surgery. The facility's policy mandates that medications be administered by licensed nurses and documented accordingly, which was not adhered to in this case.
Failure to Safely Transfer Resident with Mechanical Lift
Penalty
Summary
The facility failed to transfer a resident safely, resulting in a fall and injury. The resident, who has severe cognitive impairment and is dependent on staff for transfers, was listed as requiring a mechanical lift with two staff assistance. However, on the day of the incident, a CNA attempted to transfer the resident alone using a mechanical lift. During the transfer, the resident began to lean forward, and despite the CNA's attempt to catch her, the resident fell out of the sling and hit her head on the floor, sustaining a laceration. Interviews with staff revealed that the resident is known to lean forward during transfers, necessitating the presence of two staff members for safety. The facility's policy also mandates that two staff members must be present when using a mechanical lift for transfers. However, the CNA did not seek assistance, and the incident occurred without the required second staff member present. The resident was subsequently taken to the hospital for evaluation of the head injury.
Failure to Document Resident Fall and Assessment
Penalty
Summary
The facility failed to document a fall and subsequent assessment for a resident with severe cognitive impairment and multiple diagnoses, including unspecified dementia and expressive language disorder. The resident, who is dependent on staff for all activities of daily living, experienced a fall on 6/15/24, resulting in a head laceration and was sent to the emergency room for observation. However, the progress notes for that day did not document the incident, the assessment, or the time the resident was sent to the hospital. A neurological flow sheet indicated that vital signs and neuro checks were initiated at 2:45 PM, but the progress notes lacked any mention of the fall or the actions taken. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed that the standard procedure for documenting falls was not followed. The staff acknowledged that the incident should have been recorded in the progress notes, including details of the fall, any injuries, and notifications made to relevant parties such as the physician, nurse practitioner, and power of attorney. The facility's policy on incidents and accidents requires documentation of the date, time, nature of the incident, and any immediate interventions, which was not adhered to in this case.
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.
