Batavia Rehabilitation And Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Batavia, Illinois.
- Location
- 520 Fabyan Parkway, Batavia, Illinois 60510
- CMS Provider Number
- 14E095
- Inspections on file
- 17
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Batavia Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dementia-related behavioral issues was physically abused by a CNA, who was witnessed pulling the resident's hair and pushing her into a chair. The incident was substantiated based on an RN's eyewitness account, and the resident, due to her cognitive status, could not be interviewed. The facility's abuse policy prohibits such actions and requires reporting and investigation.
The facility did not provide the required 8 hours of RN coverage on multiple days over a six-month period, with only LPNs available on some days due to staffing shortages and last-minute call-offs. The DON, who is an RN, was not present on all required days, resulting in gaps in RN coverage for all residents.
The facility did not have a comprehensive QAPI plan in place. The administrator provided a policy document as the QAPI plan, but it lacked details on identifying and correcting quality deficiencies, tracking performance, setting goals, analyzing root causes, and monitoring corrective actions. This deficiency affected all residents in the facility.
The facility did not follow its Legionella water management plan, failing to document control measures or include interventions when limits were not met, and did not regularly clean or disinfect shower heads as required. Additionally, the DON, acting as Infection Preventionist, stopped using standardized infection surveillance tools and did not document a recent COVID-19 outbreak in the infection log, contrary to facility policy.
The facility did not have an active Antibiotic Stewardship Program or a standardized tool to assess infections among all residents. The DON/Infection Preventionist stopped using McGeer's Criteria and did not track antibiotic use, citing workload issues. The facility's policy referenced antibiotic stewardship, but no current program or monitoring system was in place.
Three residents received psychotropic medications without proper documentation or evaluation, including extended use of as needed antipsychotics and antianxiety drugs without timely practitioner assessments, and continued daily antipsychotic use despite pharmacist recommendations for dose reduction and no documented behaviors.
Two residents did not have comprehensive care plans addressing their specific needs: one resident's care plan lacked details on oxygen therapy despite physician orders and documented use, while another resident with PTSD had no assessment or interventions for trauma-informed care, contrary to facility policy.
A resident with an active order for oxygen therapy was found with undated and improperly stored oxygen tubing and nasal cannula, which were draped over the concentrator and touching the floor. Additionally, there was no 'oxygen in use' sign posted on the door, contrary to facility policy. The DON confirmed these requirements were not met.
A resident with a documented history of PTSD, dementia, anxiety, and depression was not properly assessed for trauma triggers, and her PTSD was not documented in social service assessments or addressed in physician orders. Staff interviews revealed a lack of awareness regarding the resident's trauma history and ongoing symptoms, resulting in a failure to provide trauma-informed care as required by facility policy.
A resident with a history of UTIs received both Bactrim for prophylaxis and Keflex for treatment at the same time, without clinical documentation supporting concurrent use or the extended duration of Keflex. The DON confirmed that the Bactrim should have been held during Keflex therapy and that the prolonged antibiotic administration resulted from an order entry error and lack of timely antibiotic tracking.
Three residents on pureed diets were served food that was not processed to a smooth, pudding-like consistency as required by facility policy. The cook prepared pureed spaghetti with meat sauce and green beans, but both items contained unblended pieces that required chewing, and the green beans had pieces of skin. The Food Service Manager confirmed the food did not meet the required texture and instructed the cook to reprocess the items, but the green beans could not be made suitable for serving.
The facility's kitchen failed to comply with food safety and sanitation protocols, as observed during a survey. The Dietary Manager did not wear hair or beard restraints, and several food items were improperly labeled, stored, or expired. Additionally, expired test strips were used for sanitation checks, leading to inaccurate results. These actions violated the facility's policies on personal hygiene, storage, and equipment sanitation.
The facility failed to document and implement the correct code status for two residents. One resident was marked as DNR but lacked proper documentation, leading to confusion among staff. Another resident's advance directives conflicted with their expressed wishes, showing full code with comfort-focused treatment, which was inconsistent with facility policy.
A CNA failed to maintain a resident's privacy during incontinence care by leaving the window curtains open, exposing the resident to view from outside. The resident, with multiple health conditions, was left exposed from the waist down while the CNA retrieved supplies. The facility's policy requires curtains to be closed and residents to be draped for privacy.
A resident with severe cognitive impairment was inaccurately assessed for fall risk after a fall, as the facility failed to account for antihypertensive medication in the assessment. The absence of a visual alert and incorrect risk classification by the DON contributed to the deficiency.
The facility failed to provide adequate ADL care for two residents. One resident had excessively long nails due to inconsistent staff responsibilities and lack of care planning for refusal. Another resident, dependent on staff for hygiene, was found with a saturated incontinence brief and improper care techniques, leading to potential skin irritation. The facility's policies on nail and incontinence care were not followed.
A resident with type 2 diabetes was served meals high in carbohydrates and sugar, contrary to her dietary needs. The facility's dietary staff failed to differentiate between regular and diabetic diets, resulting in the resident receiving inappropriate meals. The resident's care plan and physician orders specified a low concentrated sweets, carbohydrate-controlled diet, but this was not followed.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A resident with severe cognitive impairment and a history of dementia-related behavioral disturbances was subjected to physical abuse by a Certified Nurse Assistant (CNA). The resident's care plan indicated a need for staff redirection and time to manage her behaviors, and her abuse risk assessment identified her as at risk due to her mental and behavioral changes. On the date of the incident, a Registered Nurse (RN) witnessed the CNA pulling the resident's hair and pushing her back into a chair. The CNA denied the incident, but the RN reported it to the appropriate parties and conducted a skin check, which revealed no injuries or signs of distress in the resident. The facility's investigation, based on the RN's eyewitness account, substantiated the abuse allegation. The resident was unable to be interviewed due to her cognitive impairment, but documentation confirmed her vulnerability and the need for specialized care. The facility's abuse policy prohibits all forms of abuse and outlines procedures for screening, training, prevention, identification, investigation, protection, and reporting. The incident was reported and documented as required, and the abuse was confirmed through the facility's internal processes.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required 8 hours of Registered Nurse (RN) coverage on 20 days over a six-month period, affecting all 37 residents. Payroll Based Journal (PBJ) records and staffing schedules revealed specific dates in December, January, February, March, April, and May when no RN was present in the facility. The Director of Nursing (DON), who is an RN, typically worked Monday through Friday and provided RN coverage on those days, but was absent on several occasions, resulting in no RN coverage. On days when the DON was not present, only Licensed Practical Nurses (LPNs) were available, as the facility was unable to secure RN coverage due to staffing shortages and last-minute call-offs. The administrator acknowledged that reductions in nurse staffing contributed to these RN shortages.
Failure to Develop and Present Comprehensive QAPI Plan
Penalty
Summary
The facility failed to develop and present a comprehensive QAPI (Quality Assurance Performance Improvement) plan as required. During the survey, the administrator provided a QAPI Policy document dated January 2024, stating it was the facility's QAPI plan. However, upon review, the document did not detail how the QAPI committee would identify and correct quality deficiencies, nor did it reflect specific aspects unique to the facility's population and programs. The policy also lacked information on tracking and measuring performance, establishing goals and thresholds, analyzing root causes of quality concerns, and monitoring or evaluating the effectiveness of corrective actions. This deficiency applied to all 37 residents in the facility at the time of the survey.
Failure to Implement Legionella Water Management and Infection Surveillance
Penalty
Summary
The facility failed to maintain and implement an effective water management plan for Legionella prevention and did not follow its own infection prevention and control program for infection surveillance. The Maintenance Director reported that while hot water heaters are emptied monthly, the kitchen's hot water heater is not emptied due to the presence of a water softener, and shower heads are only replaced when broken rather than being regularly cleaned or disinfected. The facility's water management plan outlined specific control measures such as maintaining water heater temperatures, annual cleaning, quarterly disassembly and cleaning of shower heads, and regular temperature checks and flushing of unused water outlets. However, there was no documentation to show that these control measures were being monitored, and the plan did not include interventions for when control limits were not met. The Administrator acknowledged that although a Legionella environmental assessment was completed, no further action was taken based on its findings. Additionally, the facility's Infection Preventionist, who is also the DON, stated that she had stopped using McGeer's Criteria for infection surveillance and did not utilize a standardized tool for collecting infection data. During a recent COVID-19 outbreak, the infection log did not include residents who tested positive, despite the facility's policy requiring ongoing surveillance and systematic data collection to identify and control infections. The policy emphasized the importance of surveillance in identifying communicable diseases and outbreaks, but the facility failed to follow these procedures, resulting in incomplete infection tracking and reporting.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an Antibiotic Stewardship Program with a standardized tool and criteria to assess residents for infections, affecting all 37 residents. The Director of Nursing, who also serves as the Infection Preventionist, reported discontinuing the use of McGeer's Criteria for infection assessment and not utilizing any standardized tool for data collection regarding resident infections. Additionally, the facility did not have a current Antibiotic Stewardship Program policy in place, and tracking of resident antibiotic use was not maintained due to competing work demands. The facility's existing Infection Prevention and Control Program policy referenced the need for an antibiotic stewardship program and monitoring system, but these elements were not operational at the time of the survey.
Failure to Prevent Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, as evidenced by the care of three residents. One resident with multiple neurocognitive and psychiatric diagnoses was prescribed as needed Haloperidol for agitation and restlessness, but there was no documentation that the prescribing practitioner directly examined the resident every 14 days to assess the continued need for the medication, as required. The resident received the medication on multiple occasions, and the as needed order remained active for an extended period without the necessary evaluations or new orders. Another resident with severe cognitive impairment and psychiatric diagnoses received frequent doses of as needed Lorazepam for anxiousness, but the facility lacked documentation from the prescribing practitioner justifying the extended use or specifying the duration for the medication. Additionally, a third resident with dementia and psychiatric conditions was maintained on a daily antipsychotic medication despite a consultant pharmacist's recommendation for gradual dose reduction due to the absence of documented behaviors. The recommendation was not communicated to the prescriber, and the resident continued to receive the medication without documented indication for its ongoing use.
Failure to Develop Comprehensive Care Plans for Oxygen Use and Trauma-Informed Care
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents regarding their oxygen use and trauma-informed care needs. For one resident with chronic obstructive pulmonary disease, diabetes, and a history of pneumonia, the care plan did not address the use of oxygen, monitoring parameters for when to use oxygen, or safety precautions, despite physician orders for oxygen therapy and documented episodes of shortness of breath requiring oxygen. The care plan only referenced asthma and shortness of breath while lying flat, omitting critical details related to oxygen management. Another resident with diagnoses including dementia, anxiety, depression, and PTSD did not have an assessment or care plan interventions addressing PTSD, its triggers, or support strategies. The resident reported a history of significant trauma and ongoing symptoms such as nightmares and anger issues, but these were not reflected in the care plan or social service assessments. The facility's own policies require trauma-informed care planning and regular reassessment, but these were not followed for this resident.
Failure to Properly Label and Store Oxygen Equipment and Post Required Signage
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including chronic obstructive pulmonary disease, type 2 diabetes, a history of pneumonia, and bipolar disorder, was observed to have an oxygen concentrator in their room with tubing and a nasal cannula that were undated and stored improperly, draped over the concentrator and touching the floor. The resident had an active physician order for oxygen administration as needed for shortness of breath, and had recently experienced an episode of low oxygen saturation requiring oxygen use and hospitalization for pneumonia before returning to the facility. On two separate occasions, surveyors observed that there was no 'oxygen in use' sign on the door to the resident's room, despite the presence of the oxygen concentrator and an active order for oxygen therapy. The Director of Nursing confirmed that facility policy requires an 'oxygen in use' sign to be posted whenever oxygen is present in the room, and that oxygen tubing should be labeled with the date of the last change and replaced weekly. The facility's policy also specifies these requirements, but they were not followed in this instance.
Failure to Assess and Identify PTSD Triggers for Resident
Penalty
Summary
The facility failed to assess and identify trauma triggers for a resident diagnosed with PTSD, as required for trauma-informed care. The resident's electronic medical record documented a history of PTSD, dementia with psychotic disturbances, anxiety, and depression. However, quarterly social service assessments did not mention PTSD, and there were no physician orders to monitor for PTSD-related triggers or behaviors. Interviews revealed that the resident had experienced significant trauma, including childhood abuse, sexual assault, and domestic abuse, and continued to experience symptoms such as nightmares and anger issues. Despite this, staff were either unaware of the resident's trauma history or did not recognize or document her triggers. The facility's policy required identification of trauma survivors and assessment of trauma and triggers during admission and at least annually, but this was not followed for the resident in question. The social worker acknowledged the resident's PTSD diagnosis and history of trauma but stated she was unaware of any triggers, despite evidence of ongoing symptoms. The MDS nurse also confirmed the PTSD diagnosis from hospital records but did not know the specifics of the trauma or triggers. This lack of assessment and documentation resulted in a failure to provide trauma-informed care as outlined in the facility's policy.
Failure to Prevent Unnecessary Concurrent Antibiotic Use
Penalty
Summary
A resident with a history of urinary tract infections (UTIs) was prescribed Bactrim for UTI prophylaxis to be administered on Mondays, Wednesdays, and Fridays, starting April 1, 2025, with no specified end date. Following a hospital admission for weakness and lack of responsiveness, the resident returned to the facility with a new order for Keflex, intended for a 7-day course, but the order was entered into the system without a stop date and was continued for 30 days. During this period, the resident continued to receive Bactrim concurrently with Keflex, despite no clinical documentation supporting the simultaneous use of both antibiotics or the extended duration of Keflex therapy. The facility's records and infection control log confirmed that both antibiotics were administered together, and there was a lack of documentation justifying this practice. The DON acknowledged that the Bactrim order should have been placed on hold while the resident was receiving Keflex and that the extended duration of Keflex was due to an error in order entry. Additionally, the DON reported being behind on tracking antibiotic use during this period, which contributed to the oversight.
Failure to Prepare Pureed Foods to Required Consistency
Penalty
Summary
The facility failed to properly prepare pureed food items to a smooth consistency as required by their own policy. During observation, the cook prepared pureed spaghetti with meat sauce and pureed green beans for three residents on pureed diets. The food was processed according to the recipe, but both the spaghetti and green beans contained small, unblended pieces that required chewing, and the green beans had pieces of skin remaining. The Food Service Manager confirmed that the foods did not meet the required smooth, pudding-like consistency and instructed the cook to reprocess the items. Despite additional attempts, the green beans could not be pureed to the correct consistency and were deemed unsuitable for serving. The facility's policy on pureed foods specifies that items should be processed until very smooth, like pudding, with commercial thickener or stabilizer added as directed. The deficiency was identified for three residents who required pureed diets, as the food provided did not meet the necessary texture requirements. The issue was observed directly by surveyors and confirmed by staff during the meal preparation process.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation protocols, as observed during a kitchen tour. The Dietary Manager, identified as V11, did not wear a hair or beard restraint while in the kitchen, which is against the facility's policy. During the tour, several issues were identified, including an opened package of turkey breast deli meat that was not sealed, labeled, or dated, and expired vanilla wafers in the dry storage. Additionally, the quaternary sanitizer bucket and the low-temperature dishwasher were tested with expired strips, leading to inaccurate results. V11 admitted to not ordering new testing strips since assuming the role of Dietary Manager. The facility's policies on personal hygiene, storage, and equipment sanitation were not followed. The Personal Hygiene and Dress Code policy requires food service employees to wear hair and facial hair coverings, which V11 did not comply with. The Storage policy mandates that opened food products be sealed, labeled, and dated, which was not done for the turkey breast deli meat. The In-place Equipment policy requires the use of appropriate test strips to check sanitizer levels, which were expired in this case. V11 acknowledged the importance of these practices to prevent contamination and potential illness among residents.
Failure to Document and Implement Residents' Code Status
Penalty
Summary
The facility failed to accurately document and implement the physician's orders reflecting the residents' chosen code status for two residents. Resident R7 was identified as a Do Not Resuscitate (DNR) by a red sticker on their chart, but there was no advanced directive, POLST form, or current DNR physician's order in the chart. Despite the POLST form being signed by the resident's health care power of attorney, it was not placed in the physician's folder, and the physician signed it approximately two months later. This discrepancy led to confusion among the nursing staff, with some considering R7 a full code due to the lack of documentation. Resident R21's advance directives form indicated a full code status but also mentioned comfort-focused treatment, which led to conflicting interpretations among the staff. The resident expressed a desire for full resuscitation efforts, but the POLST form showed a full code with comfort-focused treatment, which was not consistent with the resident's wishes. The Director of Nursing and Medical Director clarified that a resident could not be full code with comfort-focused treatment, highlighting a misalignment between the documented preferences and the resident's actual wishes. The facility's policy required that advance directives be prominently displayed in the medical record and that the plan of care aligns with the resident's documented treatment preferences.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to preserve a resident's privacy and dignity during incontinence care. A Certified Nursing Assistant (CNA) provided care to a resident with multiple diagnoses, including transient ischemic attack and heart failure, without closing the bedroom window curtains. The resident's room was on the first floor, and the window was visible to parked cars outside. During the care, the CNA left the resident exposed from the waist down while retrieving supplies, leading the resident to express concern about being on display. The Director of Nursing confirmed that the standard practice is to close curtains to ensure privacy, and the facility's policy on incontinence care requires draping residents for privacy.
Inaccurate Fall Risk Assessment After Resident Fall
Penalty
Summary
The facility failed to conduct an accurate fall risk assessment for a resident after a fall incident. The resident, a female with severe cognitive impairment, was admitted with a documented high risk for falls. However, the facility did not place a visual alert (red star) on the resident's name plaque, which is part of their fall prevention policy. The Director of Nursing incorrectly stated that the resident was not at high risk for falls, which led to the absence of the visual alert. Further review revealed that the fall risk assessment conducted after the resident's fall did not account for the antihypertensive medication the resident was receiving, resulting in an inaccurate low-risk score. This oversight was acknowledged by the MDS Coordinator, who confirmed that an accurate assessment would have identified the resident as high risk, allowing for appropriate interventions. The corrected assessment later confirmed the resident's high fall risk status.
Deficiencies in ADL and Incontinence Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for two residents who required assistance. One resident, identified as R15, had excessively long fingernails and toenails, which were not trimmed despite his requests. The staff, including a CNA and an RN, provided conflicting information about who was responsible for nail care, especially for residents with diabetes. The resident's care plan did not address his refusal of nail care, and the facility's nail care policy was not followed, as it required nails to be trimmed and clean. Another resident, R8, who was completely dependent on staff for personal hygiene, was found with an overly saturated incontinence brief and reddened skin, indicating inadequate incontinence care. The CNA responsible for R8's care used improper techniques during incontinence care, which could contribute to skin irritation. The Director of Nursing acknowledged that the resident should have received care every two hours, but this was not done, leading to prolonged exposure to urine and potential skin breakdown. The facility's incontinence care policy was not adhered to, as it required regular and as-needed care to prevent skin irritation and odor.
Failure to Provide Appropriate Diabetic Diet
Penalty
Summary
The facility failed to provide meals that meet a resident's health care needs as ordered by the physician. This deficiency was identified for a resident with a diagnosis of type 2 diabetes, among other conditions, who reported being served meals high in carbohydrates and sugar, contrary to her dietary needs. The resident's meal card indicated a regular diet, and she received the same food items as other residents, despite her diabetic condition. The meals included items such as potatoes, pastries, and regular pudding, which are not suitable for a diabetic diet. The dietary manager and staff were unaware of the specific dietary requirements for diabetic residents, as evidenced by the lack of differentiation between regular and diabetic diets, except for the omission of regular sugar packets. The facility's policies on diet orders and dietary services communication were not effectively implemented, leading to the resident receiving inappropriate meals. The resident's care plan and physician orders specified a low concentrated sweets, carbohydrate-controlled diet, but this was not reflected in the meals provided, indicating a breakdown in communication and adherence to dietary protocols.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
