Allure Of The Quad Cities
Inspection history, citations, penalties and survey trends for this long-term care facility in Moline, Illinois.
- Location
- 833 Sixteenth Avenue, Moline, Illinois 61265
- CMS Provider Number
- 145027
- Inspections on file
- 42
- Latest survey
- March 28, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Allure Of The Quad Cities during CMS and state inspections, most recent first.
Two residents at high risk for accidents were not adequately protected from hazards or supervised. One resident with severe cognitive impairment, dementia, myasthenia gravis, and a history of falls had a care plan calling for removal of a floor mat in front of the bed and use of a pool noodle, but staff instead used floor mats on both sides of the bed and did not have the pool noodle in place; the resident reported tripping over a floor mat while self-toileting and sustained a forehead laceration requiring sutures. Another resident with dementia, schizophrenia, hallucinations, and an order for a Wanderguard, care planned as an exit-seeking/elopement risk, was observed by staff walking quickly through the unit, banging on exit doors, and then exiting through the front door; staff later found him several blocks away and returned him to the facility, despite a policy requiring adequate supervision for residents at risk of elopement.
The facility failed to prevent physical abuse when two residents with severe cognitive impairment and wheelchair dependence became involved in a physical altercation in the dining room, after one resident’s wheelchair became caught on another’s chair due to limited space. Both residents were observed swinging and throwing punches, with one resident sustaining a swollen, bleeding lower lip and an abrasion that required cleansing and ongoing monitoring, in violation of the facility’s abuse policy that prohibits physical abuse such as punching.
A cognitively impaired, wheelchair-bound resident with known hypersexual behaviors repeatedly engaged in non-consensual sexual contact with three severely cognitively impaired residents in common areas and hallways. Staff observed the resident fondling a female resident’s vaginal area and, on separate occasions, placing a hand inside two male residents’ pants and groin areas while making explicit sexual statements. Although staff separated the residents during each event and recognized the conduct as sexual abuse, the abusing resident’s care plan was not updated to address sexual behaviors, and the victims’ care plans lacked interventions to protect them from sexual abuse despite documented abuse risk. No timely trauma assessments were completed for the abused residents, and the physician was not informed of the pattern of sexual abuse until much later, resulting in an Immediate Jeopardy finding for failure to protect residents from abuse.
A resident with multiple comorbidities and known risk factors for impaired skin integrity developed in-house acquired bilateral heel pressure ulcers after heel offloading orders (floating heels and foam boots) were not incorporated into the care plan and pressure from an ill-fitting bed footboard was allowed to continue. Nursing staff delayed formal wound assessment for several days after the heel wounds were first identified, and the wound care physician’s specific treatment order for the right heel (Leptospermum honey with gauze island border dressing) was never entered into the EMR or reflected on the MAR/TAR, resulting instead in a different dressing regimen being used. The left heel ulcer progressed from a blister to unstageable necrosis and was later revealed as a Stage 4 pressure injury after debridement, while the right heel remained a Stage 4 ulcer; the resident was ultimately hospitalized with sepsis attributed in part to infected bilateral heel wounds and osteomyelitis.
Two cognitively intact residents experienced misappropriation of property when an agency RN was captured on video removing a card of oxycodone from the narcotic drawer, concealing it among papers, and placing it in a personal bag before leaving the building, resulting in ordered pain medication not being available for a resident with chronic pain. In a separate incident, a resident discovered her bank account nearly depleted and reported unauthorized charges for DoorDash, Uber, and Lyft, despite keeping her debit card in a coin purse in a drawer and never authorizing others to use it without her presence; the administrator confirmed the resident did not use these services and that the charges were local to the facility.
A resident with severe cognitive and physical impairments, who required a mechanical lift and assistance from two staff for transfers, was improperly transferred by a CNA acting alone and without the required equipment. This resulted in the resident sustaining a right ankle fracture, as confirmed by x-ray, after being moved in a manner inconsistent with her care plan and facility policy.
A resident with diabetes, a chronic leg ulcer, and cellulitis did not receive the prescribed triamcinolone cream for wound care because it was not available in the facility. Instead, an RN applied an inappropriate antifungal cream and documented the use of the unavailable medication. The DON confirmed the medication should have been reordered and that the substitution was not suitable for the resident's condition.
A resident with a history of stroke and other medical conditions experienced a significant change in condition, including low blood pressure and altered mental status. Although an RN initially assessed the resident and notified the physician, ongoing blood pressure monitoring and documentation were not performed as required. Staff interviews confirmed that vital signs should have been checked and recorded until the resident was stable, but the medical record lacked this documentation.
The facility did not prevent incidents of sexual and physical abuse among residents with severe cognitive impairment. A resident was observed manipulating another resident's genital area, and two residents were involved in a physical altercation resulting in minor injuries, including choking and facial injuries. Staff and LPNs documented and witnessed these events, confirming failures to protect residents from abuse.
Three residents received psychotropic and antipsychotic medications without documented behaviors to justify their use or evidence that nonpharmacological interventions were attempted first. For one resident with severe cognitive impairment, medications were administered without documentation of the behaviors prompting their use or any nonpharmacological strategies. Another resident with dementia and behavioral symptoms had no behavior monitoring as required, and a third resident with multiple psychiatric diagnoses also lacked documented behavior monitoring despite physician orders. Facility leadership confirmed these documentation gaps.
A facility did not conduct a thorough investigation into an allegation of verbal abuse involving a resident and a CNA. Only the reporting LPN and the CNA were interviewed, with no additional staff or resident interviews documented. The DON could not provide evidence of further investigation, and the CNO confirmed that more interviews should have been completed.
A resident with no cognitive impairment and her sister requested a copy of the resident's medical records, but the facility's medical records staff, lacking adequate training, was unsure of the process and did not provide the records or follow up in a timely manner, resulting in a failure to meet policy requirements for access and copies.
A resident with diabetes experienced a high blood sugar episode, and despite a family request, the nurse on duty did not notify the physician, citing that the blood sugar was below a certain threshold and that insulin would be administered during the next scheduled medication pass. The resident's blood sugar was later found to be even higher, requiring extra insulin, and facility policy required physician notification in such situations.
The facility did not ensure accurate shift-to-shift counts of controlled medications on a medication cart, as required by policy. Count sheets were missing signatures or were entirely absent for multiple days, and the DON confirmed the documentation could not be found. This failure potentially affected multiple residents with controlled medications stored on the cart.
A resident's controlled medication was misappropriated after an RN requested specific narcotics from an LPN, who, being new, provided the medication cards. The RN was last seen with the medications and could not account for them, and the DON only received other medications. The missing narcotics were not recovered, and the incident was reported to police.
A resident with a history of chronic urinary incontinence and recurrent UTIs experienced a delay in having a urine specimen collected and sent for urinalysis and culture as ordered by the physician. Only one documented attempt was made within the ordered timeframe, and the sample was contaminated and not sent, resulting in a delay in diagnostic testing.
The facility failed to follow its policy requiring two staff members for mechanical lift transfers, as CNAs admitted to performing transfers alone due to staffing shortages. This affected two residents who required mechanical lift assistance due to their medical conditions.
A resident admitted after knee replacement surgery experienced severe pain due to the facility's failure to provide timely pain medication. Despite being prescribed Acetaminophen/Hydrocodone, the medication was not available due to a missing prescription. Staff were aware of the issue but did not resolve it promptly, leading to the resident's prolonged suffering. The situation improved only after the medication was finally administered.
The facility did not hold quarterly Quality Assessment and Assurance (QAA) meetings as required, and the medical director or their designee did not attend the last meeting. The QAA committee, which should include the director of nursing services, the medical director, and other key staff, failed to meet since June 2024. This deficiency potentially affects all 94 residents in the facility.
The facility failed to align the electronic medical records and care plans of three residents with their POLST preferences for CPR code status. Although the POLST indicated Selective Treatment, the records documented them as DNR. This discrepancy was confirmed by the Corporate Nurse-Nurse Consultant, highlighting a failure to accurately document and communicate residents' treatment preferences.
The facility failed to update care plans for two residents, one receiving Clozapine and another undergoing dialysis. The care plan for the resident on Clozapine lacked details on medication monitoring and guardian involvement, while the dialysis care plan omitted specifics on access device care. Staff acknowledged these omissions.
The facility failed to ensure proper documentation and communication for dialysis care for two residents. One resident's physician orders lacked critical information such as the dialysis facility's details, transportation arrangements, and dialysis schedule. An LPN was unaware of the dialysis facility used and confirmed no communication forms were exchanged. Similarly, another resident's orders were incomplete, missing essential dialysis care details. A nurse confirmed the facility's policy was not followed, indicating a deficiency in providing safe dialysis care.
A facility failed to administer Benztropine with as-needed doses of Clozaril for a resident, as per physician orders. The resident, with a history of complex medical conditions, did not receive Benztropine on multiple occasions when Clozaril was given. The resident's spouse stressed the importance of following the medication regimen, and nursing staff confirmed the oversight, acknowledging the need for Benztropine to prevent EPS.
A facility failed to follow its Enhanced Barrier Precautions policy, which requires gowns and gloves during high-contact care activities for residents with indwelling devices. Staff, including an LPN, DON, and RNs, did not wear gowns while providing care to a resident with a tracheostomy and g-tube, despite physician orders for such precautions. The absence of an EBP sign on the resident's door further contributed to the oversight.
A resident reported mistreatment by a CNA, who was rough and disregarded her pain, leading to fear and discomfort. The facility's investigation found a pattern of discourteous behavior by the CNA towards other residents, resulting in the CNA's termination due to abuse allegations.
The facility failed to implement Enhanced Barrier Precautions (EBP) for 24 residents with conditions like chronic wounds and indwelling urinary catheters. Despite having a policy, no signs or PPE were available, and staff were unaware and untrained about EBP. This lapse was confirmed through observations and staff interviews.
Failure to Implement Fall-Prevention Measures and Prevent Elopement for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow individualized fall-prevention measures for one resident and to prevent an elopement for another resident identified as at risk. One resident (R4) had diagnoses including myasthenia gravis, dementia without behaviors, disorientation, a history of falls, and was assessed as having severe cognitive impairment. R4’s care plan, revised in February, specified fall interventions including a pool noodle to the left side of the bed, removal of the floor mat from in front of the bed, and ensuring the walker was within reach at bedtime. On a February morning, R4 experienced an unwitnessed fall while attempting to self-toilet, reporting that she tripped over a fall mat located next to the bed, resulting in a large forehead laceration and a bruised, painful left knee. Hospital records documented a 3 cm forehead laceration repaired with nine sutures. Subsequent staff interviews and observations showed inconsistency between the care plan and the fall-prevention measures actually in place for R4. A CNA (V12) reported that R4’s fall-prevention measures included having mats on the floor on both sides of the bed, frequent checks at least every 15 minutes, and toileting offers, and stated that R4 sometimes picked up the mats and staff had to put them back down. During room observation, V12 confirmed there was no pool noodle on the left side of the bed, confirmed a fall mat on the right side between the bed and wall, and then placed an additional fall mat on the left side of the bed with the walker on top of it. In contrast, the Assistant DON (V3) stated that R4’s fall-prevention measures were a low bed, non-slip socks while in bed, removal of the fall mat in front of the bed, and keeping the walker within reach at bedtime, and further stated that a fall mat on the left side of the bed would pose more of a fall risk and should never have been used there. The deficiency also includes the facility’s failure to prevent an elopement for a resident (R1) identified as an exit-seeking/elopement risk. R1 had multiple diagnoses including seizures, muscle weakness, gait and mobility abnormalities, dementia without behavioral disturbance, alcohol abuse, schizophrenia, acute kidney failure, visual disturbances, depression, and altered mental status, and was assessed as having moderate cognitive impairment with hallucinations and delusions, ambulating with supervision or touching assistance. R1 had an order for a Wanderguard on the left ankle and a care plan problem for exit seeking/elopement risk related to cognitive impairment, with the goal that he would not leave the center unattended. One evening, nursing documentation and staff interviews described R1 walking quickly through the unit, forcefully banging on an exit door near the nurse’s station, triggering alarms, then moving toward the front door, where he banged on it until it opened and exited the building. Staff reported that he left the building unsupervised, was later located several blocks away walking in the rain, and was brought back by staff in a car. The facility’s policy on elopements and wandering residents states that residents at risk for elopement will receive adequate supervision to prevent accidents and care in accordance with a person-centered plan of care, but R1 was able to leave the premises without necessary supervision.
Resident-to-Resident Physical Altercation Resulting in Facial Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident punched another in the face during breakfast in the dining room. One resident, who was severely cognitively impaired, legally blind, and used a wheelchair, was seated at a table when another resident, also severely cognitively impaired and using a wheelchair, attempted to pass behind him. According to a CNA, the second resident’s wheelchair became caught on the first resident’s chair due to insufficient space, which led to an altercation. The CNA reported seeing both residents swinging and throwing punches, with the second resident throwing multiple punches. As a result of the altercation, the first resident sustained an abrasion and swelling to the lower lip, which was noted to be bleeding and later required cleansing and monitoring. Nursing notes documented the incident as an altercation in the dining room, the presence of an abrasion to the lower lip, and subsequent monitoring, including application of an ice pack and observation of a small amount of red drainage from the mouth area. The facility’s abuse, neglect, and exploitation policy defined physical abuse to include hitting, slapping, punching, biting, and kicking, yet the incident involved punching between residents, resulting in injury to one resident.
Failure to Protect Cognitively Impaired Residents From Repeated Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect cognitively impaired residents from sexual abuse by another resident with a known pattern of sexually inappropriate behaviors. One resident (R4), who had moderately impaired cognition, a history of hypersexual behavior, and was able to self-propel in a wheelchair, repeatedly engaged in sexual contact with other residents who were severely cognitively impaired and dependent on staff for ADLs. On 11/22/25, R4 took a glove from a nurse’s cart while in a hallway on B wing and placed her gloved hand on another resident’s (R7) vaginal area, fondling her labia. Staff separated the residents, but R4’s care plan was not updated to address this sexual behavior, and no interventions were added to prevent further sexual abuse. R7’s care plan, which identified her as low risk for abuse despite dementia with depression and anxiety, was also not updated with interventions to protect her from sexual abuse. On 2/10/26, while in the dementia unit, R4 again engaged in sexual abuse, this time toward a male resident (R5) who had severe cognitive impairment and required assistance with ADLs. During the evening medication pass, staff observed R4 wheeling herself quickly toward R5, then placing her whole hand inside his pants and undergarments, touching his penile area. Staff immediately separated the residents, and R4 became upset and yelled that she wanted to return to R5. The incident was reported to the ADON, and R4 was reportedly placed on 1:1 supervision. However, R4’s care plan was not revised to address this sexual behavior, and R5’s care plan, which later documented him as moderate risk for abuse due to poor cognition, did not include interventions related to the sexual abuse incident or measures to protect him from further sexual abuse. On 3/11/26, R4 again sexually abused another male resident (R6), who had severe cognitive impairment, Alzheimer’s dementia, bipolar disorder, and was identified in his care plan as high risk for abuse due to dementia and mental health diagnoses. During an activity in the common area, R4 and R6 were seated side by side in wheelchairs when staff observed R4’s hand in R6’s groin area, moving toward his private area in an up-and-down tapping motion. R4 loudly expressed sexual intent, stating she wanted to have sex with R6 and would do whatever she wanted. Staff immediately separated them, and R6 appeared wide-eyed and looking around as if for help. Despite this incident and R4’s known pattern of hypersexual behavior, R4’s care plan still did not include interventions addressing her sexual behaviors, and R6’s care plan, although identifying him as high risk for abuse, had no interventions to address the sexual abuse or to protect him from further sexual abuse. Across these incidents, staff interviews confirmed that R4 had been hypersexual, touching other residents in their private areas and making sexually explicit statements to other residents. The DON acknowledged awareness that R4 had inappropriately touched residents in the dementia unit. The Dementia Director/Social Services stated that when abuse occurs, a trauma assessment should be done immediately to assess emotional and psychological impact and provide supportive interventions, but no trauma assessments were completed for R7, R5, or R6 at the time of their respective incidents. The physician reported he was not made aware of the sexual abuse incidents involving R4 and the other residents until 3/13/26. The Regional Director of Operations stated that the care plans for R4, R7, R5, and R6 should have been updated when the incidents occurred to ensure proper interventions were in place. The facility’s own Abuse, Neglect and Exploitation policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required protection of residents’ health, welfare, and rights, but the facility failed to implement timely care plan updates and protective interventions following repeated episodes of resident-to-resident sexual abuse. These failures resulted in an Immediate Jeopardy situation beginning on 11/22/25 when R4 first sexually abused R7 and continuing through subsequent incidents involving R5 and R6. The surveyors determined that the facility did not protect residents from sexual abuse, did not promptly assess for trauma, did not notify the physician in a timely manner, and did not revise care plans or implement effective interventions despite clear evidence of ongoing sexually aggressive behavior by R4 toward severely cognitively impaired residents.
Removal Plan
- R4 was separated from other residents and placed under continuous 1:1 supervision to prevent further inappropriate contact until discharge from facility or her condition warrants immobility.
- R5, R6 and R7 were assessed by nursing staff for physical injury and psychosocial distress.
- SSD/Memory Care Director verified all memory care residents have had a risk for abuse assessment completed per policy.
- The physicians and parties responsible for all residents involved were notified.
- R4, R5, R6 and R7 had an Abuse/Neglect/Trauma assessment.
- R5, R6, and R7 had the Trauma Informed Care Assessment completed.
- Abuse policies were reviewed and no revisions were required.
- DON and ADON educated all staff on facility Abuse, Neglect and Exploitation policy with an emphasis on identifying abuse, reporting abuse, appropriate interventions, following resident care plans, and monitoring of residents with a history of aggressive or sexual behaviors.
- Any staff who did not receive education will be educated prior to next shift.
- The DON or designee reviewed facility abuse policies and procedures with any agency staff prior to their shift.
- Regional Nurse Director in-serviced Administrator and DON on identifying abuse (including sexual abuse) and reporting abuse.
- Regional Nurse Director in-serviced Administrator and DON on the process to relay information to staff regarding the resident's care plans or changes to a resident's care plans pertaining to interventions/strategies to redirect resident when exhibiting either aggressive or sexual behaviors.
- Emergency QAPI was held with Medical Director to discuss citation and develop interventions to ensure safety of other residents.
- Root Cause Analysis was completed.
- R5, R6, and R7 had their care plan updated with safety interventions to protect from abuse.
- R4's care plan was updated to reflect interventions put in place to safeguard other residents on the unit, including but not limited to: one-to-one supervision and providing residents with sensory items to help keep residents occupied and hands busy.
- Administrator will audit weekly for 6 weeks and then monthly for 3 months to monitor residents with history of sexual behaviors/resident abuse and verify appropriate interventions are in place and care plans updated accordingly.
- All abuse findings will be reviewed by the QAPI team to ensure appropriate measures have been put in place.
Failure to Implement and Timely Manage Heel Pressure Ulcer Interventions and Treatments
Penalty
Summary
The deficiency involves the facility’s failure to prevent and properly manage pressure ulcers for a resident with multiple comorbidities, including existing Stage 4 heel ulcers, edema, reduced mobility, and fragile skin. The resident’s care plan identified risk for impaired skin integrity due to fragile skin, bilateral lower extremity edema, reduced mobility, and an indwelling urinary catheter, but physician orders to float the heels and apply foam boots to offload pressure were never incorporated into the care plan. The resident developed in-house acquired blisters on both heels that progressed to pressure ulcers, with the right heel documented as Stage 4 and the left heel as Stage 2 by the nurse practitioner. The wound care nurse later stated that the heel wounds were caused by pressure from the bed’s footboard, which was not long enough, allowing the resident’s heels to press against it. The facility failed to assess and document the new heel wounds in a timely manner and did not promptly implement appropriate wound care interventions. The wound care nurse acknowledged that the heel wounds were first identified by a floor nurse on one date, but her first formal wound assessment was not completed until several days later, instead of the following day as she stated should occur. During this period, interventions such as padded booties and a bed extender were only implemented after the pressure injuries had already developed. Additionally, the wound care physician’s initial evaluation documented a Stage 4 right heel pressure injury and a Stage 2 left heel pressure injury that had been present for more than one day, and debridement of the right heel revealed deep tissue involvement at the muscle/fascia level. The facility also failed to implement the wound care physician’s ordered treatment regimen for the right heel. The physician ordered Leptospermum honey with a gauze island border dressing for the right heel wound, but this order was not entered into the physician orders, MAR, or TAR. Instead, the resident’s orders and MAR reflected a different treatment using normal saline or wound wash followed by xeroform gauze and bordered gauze. The wound care nurse admitted that it was her responsibility to enter new wound treatment orders into the electronic medical record the same day they were ordered and acknowledged that the physician’s treatment recommendation for the right heel was not implemented. Subsequent wound evaluations showed the left heel wound progressed to unstageable necrosis and, after debridement, was revealed to be a Stage 4 pressure injury, while the right heel remained a Stage 4 pressure wound. The resident was later hospitalized with sepsis secondary to UTI and wound infection, with imaging and operative findings indicating severe bilateral heel ulcerations and osteomyelitis, and cultures growing multiple resistant organisms from the heel wounds.
Misappropriation of Controlled Drugs and Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of property, including controlled medications and personal funds. One cognitively intact resident, R9, had active orders for oxycodone 5 mg in multiple dosing schedules for chronic pain related to encephalopathy, cellulitis of both lower limbs, CHF, bilateral lower extremity contractures, chronic pain, low back pain, depression, and localized edema. R9 reported ongoing pain in his feet and buttocks and stated that his pain medication had been misplaced in the past. On March 6, 2026, staff noted that a card containing 43 tablets of oxycodone 5 mg and the associated narcotic count sheet were missing from the medication cart, and when a nurse attempted to administer oxycodone to R9 that morning, there was no oxycodone available despite an expectation that another card with 48 tablets should have been present. The facility’s internal review and video surveillance showed that an agency RN, identified as V19, removed the narcotic card from the narcotic drawer, placed it on top of the medication cart, turned her back to the camera, then placed the card between papers and put these items into her personal bag. She was then seen exiting the building with the bag, placing it in her vehicle, and returning to the facility without the bag. Multiple attempts by facility leadership to contact this RN for verbal and written statements were unsuccessful. The missing oxycodone card and narcotic count sheet were not located despite searches of the building, medication carts, and narcotic drawers, and no other missing items were identified at that time. A second cognitively intact resident, R3, experienced misappropriation of personal funds. R3 discovered she had virtually no money remaining in her bank account after reviewing a bank statement and reported this to the business office manager. Bank records showed multiple debit transactions for services such as DoorDash, Uber, and Lyft that R3 stated she did not make. R3 reported that her debit card had been kept in a coin purse in a drawer, that she had never given anyone permission to use her card without her being present, and that she believed someone from the facility took her card. The administrator confirmed that R3 did not use these services and that the charges, totaling $186.35, were associated with local vendors near the facility. The facility’s abuse, neglect, and exploitation policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent and states that the facility will provide oversight and supervision of staff to ensure implementation of these policies.
Improper Transfer by CNA Results in Resident Ankle Fracture
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, muscle weakness, and impaired functional abilities in both lower extremities, who was dependent on two or more staff for transfers and required a mechanical lift, was transferred unsafely. Despite the resident's care plan and facility policy requiring the use of a mechanical lift with two staff members, a CNA independently attempted to transfer the resident by standing and pivoting her into bed without assistance or the proper equipment. This action was not in accordance with the resident's assessed needs or the facility's safe transfer protocols. As a result of this improper transfer, the resident sustained a fracture involving the lateral and medial malleoli of the right ankle, as confirmed by an x-ray. The incident was discovered after the resident was observed with swelling and bruising to the right ankle, and subsequent investigation revealed that no other staff assisted or were asked for help during the transfer. The CNA responsible for the transfer did not follow established procedures and did not seek assistance, directly leading to the resident's injury.
Failure to Provide and Administer Prescribed Medication for Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's prescribed medication, triamcinolone acetonide cream, was available and administered as ordered. The resident, who had multiple diagnoses including type 2 diabetes mellitus, a non-pressure chronic ulcer of the right lower leg, and cellulitis, had a physician's order for daily application of triamcinolone cream to the right lower extremity for wound care. On review, it was found that the cream was not in stock, and a registered nurse substituted an antifungal cream (miconazole nitrate) instead, which was not appropriate for the resident's condition. The nurse could not recall the last time the prescribed cream was used and confirmed that the antifungal cream was not the same as the ordered medication. Further investigation revealed that the last order for the triamcinolone cream was placed several months prior, and the medication had not been reordered since. The Director of Nursing confirmed that the triamcinolone cream should have been reordered through the pharmacy and that the antifungal cream was not an appropriate substitute. Documentation indicated that the cream was being applied daily, despite its unavailability. Facility policy requires that medications be administered as ordered by the physician and in accordance with professional standards, including verifying the right drug before administration.
Failure to Monitor and Document Blood Pressure After Change in Condition
Penalty
Summary
The facility failed to ensure proper blood pressure monitoring following a change in condition for a resident with a history of left-sided hemiplegia, hemiparesis, psychophysiologic insomnia, epileptic syndrome, and cognitive and emotional deficits after cerebrovascular disease. On the day of the incident, the resident was noted to have altered mental status and slurred speech, and a CNA reported these changes to an RN. The RN found the resident's blood pressure to be significantly low (66/40), and after interventions such as laying the resident down and providing fluids, the blood pressure improved slightly. The physician and the resident's son were notified, and the physician instructed continued monitoring, with the RN relaying the situation to the oncoming nurse at shift change. Despite these instructions and the facility's policy requiring documentation of changes in condition and ongoing monitoring, there was a lack of documented blood pressure readings and vital signs after the initial incident. The only documented blood pressure readings were at the time of the incident and one subsequent reading, with no times recorded for the latter. Progress notes indicated that monitoring was to continue, but there were no further documented vital signs or blood pressure checks in the medical record, and the electronic charting tab showed no recent entries. Interviews with staff confirmed that vital signs should have been monitored and documented until the resident was stable, but this was not done.
Failure to Prevent Sexual and Physical Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, including sexual and physical abuse, as evidenced by multiple incidents involving residents with severe cognitive impairment. One resident with dementia and a BIMS score indicating severe cognitive impairment was observed manipulating another resident's genital area over her clothing while both were in the closed Alzheimer's Unit. Both residents were unable to answer questions appropriately, and the facility recognized this as an instance of sexual abuse. Additionally, two other residents, both with dementia and other significant medical conditions, were involved in a physical altercation in the secure Memory Care Unit. One resident entered another's room, resulting in a struggle where one attempted to choke the other, who responded by striking back. Both sustained minor injuries, including red marks around the neck, a cut lip, and facial scratches. Staff and CNAs witnessed the incident, and documentation confirmed the altercation as resident-to-resident abuse.
Failure to Document Indications and Nonpharmacological Interventions Prior to Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic and antipsychotic medications were only used when clinically indicated and after nonpharmacological interventions had been attempted or deemed clinically contraindicated. For three residents reviewed, there was a lack of documented behaviors to warrant the use of these medications, and no evidence that nonpharmacological interventions were tried prior to administration. Facility policy requires that psychotropic medications be used only for documented medical symptoms and not for staff convenience or discipline, and that behavioral interventions should be exhausted before resorting to such medications. One resident with severe cognitive impairment and a history of dementia, anxiety, insomnia, and repeated falls received multiple psychotropic medications, including Hydroxyzine and Haloperidol, without documentation of the specific behaviors leading to administration or any nonpharmacological interventions attempted beforehand. The care plan for this resident did not include nonpharmacological strategies, and staff confirmed that education interventions would not be effective due to the resident's cognitive status. Another resident with Alzheimer's disease and depression was receiving Donepezil for dementia, with care plans noting behavioral symptoms such as wandering and involvement in altercations, but there was no behavior monitoring documented as required. A third resident with bipolar disorder, anxiety disorder, and paranoid schizophrenia was prescribed multiple antipsychotic and psychotropic medications, with physician orders specifying that staff should monitor and document specific target behaviors. However, the medical record lacked any behavior monitoring documentation as ordered. Facility leadership confirmed the absence of required behavior monitoring for these residents, indicating a systemic failure to document both the need for psychotropic medication use and the exhaustion of nonpharmacological interventions prior to administration.
Failure to Thoroughly Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving one resident. According to the facility's policy, an immediate and comprehensive investigation is required when abuse is suspected or reported, including identifying responsible staff, preserving evidence, interviewing all involved parties and witnesses, and documenting the investigation in detail. In this case, a nurse reported witnessing a certified nurse aide (CNA) and a resident pulling a tray back and forth, with the CNA allegedly yelling at the resident to leave the dining room. The CNA acknowledged the interaction but denied any inappropriate behavior or yelling. The investigation documentation only included statements from the reporting nurse and the CNA involved. There were no interviews conducted with other staff members or residents who may have had relevant information or prior experience with the CNA. The Director of Nursing, who conducted the investigation, could not provide documentation of any additional interviews. The Chief Nursing Officer confirmed that no further interviews were available and acknowledged that additional interviews should have been conducted and documented as part of the investigation.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide a resident with access to her medical records upon request, as required by policy and regulation. A resident, who had no cognitive impairment, and her sister contacted the facility's medical records staff to request a copy of the resident's medical records. The staff member, who was newly assigned to the medical records role and had limited training, was unsure if residents or their families were permitted to obtain copies of records and believed only insurance companies could do so. The staff member sought clarification from corporate leadership and the DON, who confirmed that residents and their families have the right to access records, but did not follow up with the resident or her sister in a timely manner. The facility's policy states that residents or their legal representatives are entitled to access their records within 24 hours of a request and to receive copies within two working days. Despite this, the resident and her sister did not receive the requested records or a return call from the medical records staff, resulting in a failure to meet the required timeframe and to honor the resident's rights.
Failure to Notify Physician of High Blood Sugar
Penalty
Summary
A deficiency occurred when facility staff failed to notify a physician of a resident's high blood sugar, despite a specific request from the resident's family. The resident, who had a history of diabetes mellitus and diabetic neuropathy, was monitored by his family through a Dexcom system that alerted them to abnormal blood sugar levels. On the night in question, the family received an alert that the resident's blood sugar was 400 and called the facility to request that the nurse notify the physician. The nurse checked the resident, found his blood sugar to be 323, and informed the family but refused to contact the physician, stating that the level was below 350 and that the resident would receive insulin during the morning medication pass. The nurse practitioner's interview confirmed that a blood sugar above 300 is considered high and that the physician should have been notified as per the family's request. The resident's blood sugar was later recorded as 426 during the morning shift, requiring additional insulin coverage. The Director of Nursing acknowledged that the nurse should have called the physician, as the facility's policy requires prompt notification of the physician when there is a significant change in the resident's condition.
Failure to Maintain Accurate Shift-to-Shift Controlled Medication Counts
Penalty
Summary
The facility failed to ensure accurate shift-to-shift controlled medication counts for all residents with controlled medications stored on the Station C/Front Hall medication cart during April 2025. Facility policy requires two licensed nurses to account for all controlled substances and access keys at the end of each shift, and the Narcotic and Controlled Substance Shift-To-Shift Count Sheet mandates that all resident and emergency supply controlled substances be counted at every shift change. However, review of the count sheets revealed missing or incomplete signatures for several dates in April, and the count sheet for April 19th through 30th was entirely missing. The Director of Nursing confirmed that the required documentation for these dates could not be located and that the Assistant Directors of Nursing were responsible for monitoring compliance with these counts. This deficiency potentially affected 27 residents who had controlled medications stored in the affected medication cart during the month in question.
Failure to Prevent Theft of Controlled Medications
Penalty
Summary
The facility failed to prevent the theft of controlled medications belonging to one resident. According to the report, a registered nurse (RN) requested an LPN to provide excess medications from the narcotic box, specifically naming the medications she wanted, including Hydrocodone prescribed to the resident. The LPN, being new and unfamiliar with procedures, handed over the medication cards to the RN, who then proceeded toward the Director of Nursing's (DON) office. Video footage later confirmed the RN entered the DON's office with several medication bottles and pill cards but left still carrying the pill cards. The DON only received two bottles of liquid medication, not the Hydrocodone cards. The RN was unable to account for the missing medications when questioned and was the last person seen with them. The investigation substantiated the allegation of missing narcotics, with a total of 64 Hydrocodone tablets unaccounted for. The incident was reported to local police, and a thorough search of medication carts did not recover the missing narcotics. The resident had an as-needed order for Hydrocodone and did not go without medication, as they had not requested it during the period in question. The facility's policies required safeguards to prevent misappropriation of resident property and controlled substances, but these were not effectively implemented in this instance, resulting in the misappropriation of the resident's medication.
Delay in Obtaining Ordered Urine Specimen for UA and C&S
Penalty
Summary
The facility failed to obtain a urine specimen for urinalysis and culture and sensitivity as ordered by the physician for one resident. The resident, who had a history of chronic urinary incontinence, overactive bladder, and recurrent urinary tract infections, was experiencing burning pain with urination. The physician's order specified that a urine sample should be obtained and allowed for straight catheterization every shift for two days. Documentation showed only one attempt to obtain the specimen within the ordered timeframe, and that sample was contaminated and not sent to the lab. The urine specimen was not successfully collected and sent until several days later, resulting in a delay in following the physician's order for timely diagnostic testing.
Failure to Follow Mechanical Lift Transfer Protocols
Penalty
Summary
The facility failed to adhere to its policy requiring two staff members to assist with mechanical lift transfers for residents, leading to a deficiency in safe resident handling. The policy, which is designed to prevent injury to both residents and staff, mandates that two staff members must be present during mechanical lift transfers. However, interviews and record reviews revealed that this policy was not followed for two residents, R1 and R2, who were dependent on mechanical lifts for transfers. Both residents reported that typically only one staff member assisted them during transfers, contrary to the facility's guidelines. R1, who has multiple medical conditions including arthritis, chronic kidney disease, and diabetes, is documented as requiring a two-person assist with a mechanical lift due to non-weight bearing status on both lower extremities. Similarly, R2, who suffers from conditions such as radiculopathy and chronic pain syndrome, also requires mechanical lift assistance. Despite these requirements, CNAs admitted to performing mechanical lift transfers alone due to staffing shortages and high workload, particularly in the Memory Care/Dementia Unit. This practice was confirmed by multiple CNAs who stated that they often conducted transfers solo because it was too busy to wait for assistance, leading to a breach in the facility's safety protocols.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident, R2, who was admitted after a total right knee replacement. Upon admission, R2 was prescribed Acetaminophen/Hydrocodone for pain management, but the facility did not have the medication available. R2 experienced severe pain, rated as 9 out of 10, and later 10 out of 10, from the time of admission until several days later. The facility's staff only administered Tylenol once, which was ineffective, and failed to document further pain assessments until days later. The delay in obtaining the prescribed pain medication was due to the absence of a hard prescription, which prevented the pharmacy from filling the order. Despite multiple calls and notifications to the Director of Nurses and attempts to contact the prescribing physician, the medication was not secured until several days after R2's admission. During this time, R2 was in excruciating pain, unable to sleep or eat, and the ice machine intended to help manage her pain was not properly maintained. The facility's staff, including the Registered Nurse and Licensed Practical Nurse, were aware of R2's pain and the absence of her prescribed medication. However, there was a lack of effective communication and follow-through with the physician and pharmacy to resolve the issue promptly. The pharmacist confirmed that the prescription was not received until days later, which delayed the administration of the necessary pain medication. Once the medication was finally administered, R2's condition improved significantly.
Failure to Conduct Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee met the required quarterly schedule and included the necessary members, specifically the medical director or their designee. According to the facility's policy on Quality Assurance and Performance Improvement (QAPI), the QAA committee must be interdisciplinary and include the director of nursing services, the medical director or their designee, at least three other staff members, including the administrator or another individual in a leadership role, and the infection preventionist. The committee is required to meet at least quarterly to coordinate and evaluate activities under the QAPI program. Upon review of the facility's QAPI meeting notes, it was found that the most recent meeting occurred on June 26, 2024, and the medical director or their designee did not attend. Furthermore, the facility had not conducted a quarterly meeting since June 2024, as confirmed by the Regional Director of Operations. This oversight has the potential to impact all 94 residents residing in the facility, as documented in the facility's Long-Term Care Application for Medicare and Medicaid dated November 12, 2024.
Discrepancy in POLST and Care Plans for CPR Code Status
Penalty
Summary
The facility failed to ensure that the electronic medical records and care plans of three residents matched their Physician's Order for Life-Sustaining Treatment (POLST) regarding their cardio-pulmonary resuscitation (CPR) code status. Specifically, for three residents, the POLST indicated a preference for Selective Treatment, but their physician orders and care plans documented them as Do Not Resuscitate (DNR). This discrepancy was identified during a review of the residents' records and confirmed by the Corporate Nurse-Nurse Consultant. The facility's policy on Residents' Rights Regarding Treatment and Advance Directives requires that any decision-making regarding a resident's choices be documented in the medical record and communicated to the interdisciplinary team. However, in these cases, the residents' preferences for Selective Treatment, as indicated on their POLST forms, were not accurately reflected in their electronic medical records or care plans. This oversight was confirmed by the Corporate Nurse-Nurse Consultant, who acknowledged that the Selective Treatment option should have been entered into the electronic medical record as a physician's order and on the care plan.
Care Plan Deficiencies for Antipsychotic Medication and Dialysis
Penalty
Summary
The facility failed to revise the care plans for two residents, R12 and R23, as required. For R12, the care plan did not specify which target behaviors were associated with specific medications, particularly Clozapine, an atypical antipsychotic that requires monthly blood tests and close physician monitoring. The care plan also omitted the 14-day required direct physician examination and assessment to reorder as needed Clozapine. Additionally, the care plan did not address the involvement of R12's legal guardian, who must be present for the medication's reordering process. Interviews with a registered nurse and R12's spouse confirmed these omissions and the need for special monitoring and guardian involvement. For R23, the care plan failed to include details about the type of dialysis access device, specific monitoring, or care of the fistula, despite the physician's order to monitor the bruit/thrill of the right arm fistula every shift. A registered nurse acknowledged that the dialysis access site and monitoring should be included in the resident's care plan. These deficiencies indicate a lack of comprehensive and updated care planning for residents receiving specific medical treatments.
Deficient Dialysis Care Documentation and Communication
Penalty
Summary
The facility failed to ensure proper documentation and communication regarding dialysis care for two residents, R23 and R87, who require dialysis services. For R87, the physician orders only included the nephrologist's name and phone number and the type of port access, but lacked critical information such as the dialysis facility's name and phone number, transportation arrangements, dialysis schedule, and any medication or fluid restrictions. A Licensed Practical Nurse (LPN) assigned to R87 was unaware of the dialysis facility used and confirmed that no communication forms had been sent or received regarding R87's dialysis. The Director of Nursing acknowledged the absence of completed dialysis communication forms and the incomplete physician orders for R87. Similarly, R23's physician orders were incomplete, missing the dialysis schedule, nephrologist's contact information, dialysis facility details, transportation arrangements, and dialysis site information. The current orders only included monitoring instructions for the right arm fistula and a fluid restriction. A Registered Nurse confirmed that the facility's policy, which requires comprehensive documentation and communication for dialysis care, was not followed. These deficiencies highlight a lack of adherence to the facility's policy on providing safe and appropriate dialysis care.
Failure to Administer Benztropine with As-Needed Clozaril
Penalty
Summary
The facility failed to administer Benztropine, a medication intended to prevent Extrapyramidal Symptoms (EPS), in conjunction with as-needed doses of Clozaril, an antipsychotic medication, as per physician orders for a resident. This deficiency was identified through interviews and record reviews, revealing that the resident, who has a complex medical history including Anxiety Disorder, Neurocognitive Disorder with Lewy Bodies, Bipolar Disorder, and a history of Malignant Neuroleptic Syndrome, did not receive Benztropine on multiple occasions when as-needed Clozaril was administered. The facility's policy mandates that medications be administered according to physician orders and that any medication errors be evaluated for significance, yet the omission of Benztropine was not addressed. The resident's spouse, who is also the legal guardian, emphasized the importance of adhering to the prescribed medication regimen, as it took years to stabilize the resident's condition. Interviews with nursing staff confirmed that Benztropine should be administered once per day if the resident receives an as-needed dose of Clozaril, but this was not consistently done. The Psychotropic RN acknowledged the oversight and noted that the continuation of the as-needed Clozaril with Benztropine was recently recommended by the psychiatry service following the resident.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) policy, which is designed to prevent the transmission of multidrug-resistant organisms. The policy mandates the use of gowns and gloves during high-contact resident care activities, such as those involving indwelling devices like tracheostomy and gastrostomy tubes. However, during observations, staff members, including a Licensed Practical Nurse (LPN), a Director of Nurses (DON), and Registered Nurses (RNs), did not wear protective gowns while administering medications through a gastrostomy tube, providing g-tube site care, and performing tracheostomy suctioning and care for a resident with a tracheostomy and g-tube. Additionally, there was no EBP sign on the resident's door to indicate the need for such precautions. The resident involved had specific physician orders for enhanced barrier precautions due to the presence of indwelling devices, which were not followed by the staff. The Assistant Director of Nurses/Infection Preventionist confirmed that the facility's expectation was for gowns to be worn during the resident's care. The lack of adherence to the EBP policy was observed multiple times, indicating a systemic issue in the implementation of infection control measures for residents with indwelling devices.
Resident Mistreatment by CNA
Penalty
Summary
The facility failed to ensure that a resident was free from mistreatment, as evidenced by the actions of a Certified Nurse Assistant (CNA), identified as V5. The resident, referred to as R1, reported that V5 was rough and fast when handling her, disregarding the pain she was experiencing. R1 expressed her concerns to her daughter and the facility's Administrator, V1, leading to V5 being removed from her duties the following day. R1 further reported feeling scared and uncomfortable with V5's care, noting that V5 did not allow her to move at her own pace and made her feel like a bother when she needed assistance. The facility's investigation revealed that V5's behavior was not isolated to R1, as other residents assigned to V5 also reported discourteous behavior and a reluctance to provide care. The investigation concluded with the termination of V5 due to allegations of abuse. The facility's policy on abuse, neglect, and exploitation emphasizes the prohibition and prevention of such actions, yet the findings indicate a failure to uphold these standards, resulting in the mistreatment of R1 and potentially other residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to initiate and implement Enhanced Barrier Precautions (EBP) for 24 residents who required such measures due to conditions like chronic wounds, indwelling urinary catheters, tracheostomies, and gastric feeding tubes. Despite having a policy in place that mandates the use of EBP for residents with these conditions, the facility did not have any posted signs indicating EBP or Personal Protective Equipment (PPE) available near or outside the rooms of the affected residents. This lapse was observed during a tour of the facility, where only one resident was noted to have a Contact Precaution sign and PPE setup outside their room. Interviews with staff revealed a lack of awareness and training regarding EBP. An agency RN stated she had no idea which residents were on EBP and had not received any training from the facility. The Regional Nurse initially believed that EBP was already in place but later confirmed with the Director of Nursing that it had not been implemented. A list of 24 residents requiring EBP was presented, indicating various conditions such as indwelling urinary catheters, chronic wounds, tracheostomies, and gastric feeding tubes, but no actions had been taken to implement the necessary precautions for these residents.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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