Park View Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 5888 North Ridge, Chicago, Illinois 60660
- CMS Provider Number
- 145765
- Inspections on file
- 41
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Park View Rehab Center during CMS and state inspections, most recent first.
A resident with multiple medical and psychiatric conditions, documented wandering, and a completed elopement risk assessment indicating they were an elopement risk and not safe for unsupervised community access repeatedly attempted to exit through a stairwell door and was redirected earlier in the day. Later that evening, the resident was observed pacing and exit-seeking, but at the time of elopement there was no CNA actively monitoring the hallway because an LPN was passing meds there, despite a facility practice of continuous hallway/dining room observation. The resident then pushed through the alarmed stairwell door, ran down the stairs and out the back door in cold, snowy weather wearing only a sweater, pants, and shoes without socks, and eloped from the building. Staff pursued briefly but were unable to stop the resident, who remained outside until located by police and transported to a hospital, where foot pain and redness were documented before the resident was returned.
The facility failed to prevent resident-to-resident abuse when two cognitively intact, ambulatory roommates with psychiatric diagnoses engaged in escalating verbal conflict that led to one resident pushing the other in the face after threats and verbal abuse over music from a phone. Staff heard the argument and later documented that both residents cursed at each other and that the push occurred, and facility leadership acknowledged this behavior met their own definitions of physical and verbal abuse. In a separate incident, a deaf, nonspeaking resident with schizophrenia communicated through written questions and head nods that another resident had hit him and that he felt afraid and hurt, while documentation also showed a report that this deaf resident had kicked the other resident. These events show that residents were not adequately protected from physical and mental abuse by other residents.
Multiple residents were physically assaulted by other residents despite facility policies guaranteeing freedom from abuse. In one case, a cognitively intact resident with psychiatric diagnoses was punched repeatedly in his room by another cognitively intact resident with schizophrenia after a brief interaction about cigarettes, resulting in a subdural hematoma and nasal bone fracture. Staff reported that the aggressor had prior behavioral incidents with peers and property damage, yet he was not on 1:1 monitoring at the time, and the assault occurred during hours when staff were expected to monitor hallways to prevent residents from entering others’ rooms. In separate incidents, a cognitively intact resident sitting in a hallway and another cognitively intact resident exiting a public restroom were each struck in the face by a cognitively impaired resident with schizophrenia, with staff hearing the victims yell to stop and observing the aggressor near them making a fist or swinging her arms. Facility investigations substantiated these events as abuse, confirming that residents were struck in the face by other residents.
The facility failed to notify physicians after an allegation of resident-to-resident physical abuse. A cognitively intact resident with osteoarthritis, HTN, and psychosis reported being struck in the face by another resident near a bathroom. An RN heard the allegation and informed the administrator but did not complete the abuse protocol, which required notifying the MD and family for both the alleged victim and perpetrator. An LPN reported not receiving direction to complete the protocol and did not contact either resident’s MD or family. The psychiatric services director confirmed that no psychiatrist notification occurred, despite facility policy requiring MD notification for such incidents. Record review showed no documentation of physician contact or related orders, and census data contradicted the incident report’s statement that the alleged perpetrator was sent to the hospital, demonstrating that required notifications and actions were not carried out.
A resident who is bedbound and cognitively intact was denied visitation from her best friend after a roommate objected to the visitor's presence. Staff escorted the visitor out, and no alternative arrangements were made to support the resident's right to receive visitors, despite facility policy and staff acknowledgment of this right.
A medication error rate of 24% was identified after several instances where nurses administered incorrect dosages, failed to notify physicians when medications were withheld or unavailable, and did not follow proper medication administration protocols. Errors included giving the wrong dose of Risperidone, withholding Metoprolol without physician notification, improper measurement of Sucralfate, and administering the wrong strength of Simethicone.
A resident with rheumatoid arthritis did not receive required hand splints for over a year after they went missing, despite physician orders and care plan interventions. Staff interviews confirmed the absence of splints, and facility records lacked documentation of their use or monitoring, contrary to facility policy.
Two residents experienced repeated delays in receiving scheduled medications, with audit records confirming that morning and evening doses were often administered hours late. An LPN withheld a blood pressure medication due to low readings but still gave other medications late, while another resident reported frequent late evening medication administration. The DON acknowledged that new nursing staff may have contributed to these delays, which were not in accordance with the facility's medication administration policy.
A resident, who was cognitively intact, reported a missing clock radio and stated it was stolen, involving police intervention. Despite informing staff and the police visiting the facility, the incident was not documented or reported to the Abuse Coordinator as required by facility policy. An LPN acknowledged awareness of the allegation but did not report it, and the Administrator was not informed, resulting in a failure to follow mandated reporting and investigation procedures.
Multiple residents were subjected to physical abuse by peers, including hitting, pushing, and punching, resulting in injuries such as a laceration requiring stitches. In several cases, staff were not present or failed to provide adequate supervision, leaving residents vulnerable to harm. Facility protocols for monitoring and separating residents with behavioral issues were not effectively implemented, contributing to repeated incidents of abuse.
Multiple residents with mental health diagnoses were involved in physical altercations, resulting in minor injuries. In one case, two residents engaged in a fight in an elevator, both sustaining scratches before staff could intervene. In another case, a resident was struck in the head by a peer in the dining room. Staff responded after the incidents began, and both events were substantiated as abuse.
A resident with insomnia and anxiety disorder did not receive medications as scheduled, with instances of late administration and lack of physician notification. The resident reported not receiving Ambien one evening, despite its availability. Staff interviews confirmed that medications should be administered within one hour of the scheduled time, but this protocol was not followed.
A facility failed to ensure the availability and proper administration of anti-anxiety medication for a resident with schizophrenia and paranoia, leading to hospitalization. The resident's medication administration record showed inconsistencies, and the anti-anxiety medication was unavailable. The resident expressed concerns about inconsistent medication administration, and the DON acknowledged the importance of proper documentation and administration.
A resident with a history of traumatic brain injury and falls was injured during a bed-to-wheelchair transfer due to inadequate assistance. Despite requiring two-person assistance, only one CNA was present, leading to the resident falling and hitting her head. The facility's policy of using a gait belt for transfers was not followed, contributing to the incident.
The facility failed to date prepared food items in the refrigerator and ensure dietary staff wore hair coverings, as observed during a survey. Undated food items, including salads and sandwiches, were found in the refrigerator, and a cook was seen with improper hair covering while handling food. These actions are against the facility's policies and have the potential to affect all 119 residents receiving an oral diet.
The facility failed to adhere to infection control protocols, with staff not following Enhanced Barrier Precautions (EBP) and hand hygiene practices. Instances included improper handling of soiled linen, inadequate hand hygiene during wound care, and lack of EBP signage for residents with medical conditions requiring such precautions. These deficiencies were observed across multiple staff members and residents, potentially increasing infection risks.
The facility failed to conduct timely care plan conferences and involve residents in their care plans, affecting four residents. A resident with a BIMS score of 15 reported not being invited to care plan meetings since their last conference over a year ago. Another resident with moderate cognitive impairment also reported never meeting with staff to discuss their care plan, with the last recorded meeting several years ago. The MDS Nurse and DON confirmed the lack of recent care plan meetings, highlighting a systemic issue in involving residents in their care planning process.
A resident reported an uncovered cable box receptacle with exposed wires in their room, which had been left unattended for 8 months. The Maintenance Director confirmed it should have been covered, and the LPN was unaware of the hazard. The Maintenance Log showed no reports of the issue, despite the facility's policy to maintain a hazard-free environment.
The facility failed to manage medications properly, with expired medications and loose pills found in a medication cart. An LPN noted the unreadable expiration dates and the risk of medication errors from loose pills. The DON confirmed the need to remove expired medications and discard loose pills, but a specific storage policy was not found.
A facility failed to maintain the privacy of a resident's urinary drainage bag, which was observed exposed and attached to the bed frame without a privacy bag. The resident, who is cognitively intact and has several medical conditions, expressed a preference for the bag to be kept in a privacy bag. A CNA confirmed the absence of the privacy bag, and the DON affirmed the importance of using privacy bags to promote dignity, as per facility policy.
A resident was found with an inhaler in her room without a proper assessment or doctor's order for self-administration. The facility failed to include self-administration in the resident's care plan, and staff acknowledged the oversight, noting the need for an assessment and specific order. The facility's policies require an interdisciplinary team assessment and physician's order for self-administration, which was not followed.
The facility failed to provide a homelike environment for two residents. One resident's room had a missing light fixture and an improperly sealed AC unit, which were reported but not addressed. Another resident had a broken dresser drawer that was not documented or fixed. These issues were not recorded in the maintenance log, indicating a lapse in communication and follow-up.
A facility failed to accurately complete the MDS for a resident with schizophrenia, incorrectly indicating no serious mental illness in the PASRR section. The MDS Nurse acknowledged the error, and the DON emphasized the importance of accurate MDS assessments for guiding care plans.
The facility failed to ensure medications were signed out when administered to two residents. A resident with cognitive impairments did not have several medications signed out in the eMAR, and the responsible nurse admitted to forgetting. Another resident's medication was administered but not signed out by an LPN, who acknowledged the risk of double dosing. The facility's policy requires licensed nurses to document medication administration immediately.
A facility failed to date a humidifier bottle for a resident receiving oxygen therapy. The resident, with multiple diagnoses including seizures and congestive heart failure, was observed with an undated humidifier bottle. A nurse confirmed the oversight, which contradicted the facility's policy requiring weekly and as-needed changes and dating of humidifier bottles.
A resident with dysphagia was given a turkey sandwich instead of the prescribed mechanical soft diet, risking choking and aspiration. The CNA did not communicate the resident's dietary needs, and the dietary staff did not verify the resident's identity or dietary requirements before providing the meal.
A resident's personal refrigerator was found at 44°F, above the facility's policy of 41°F or below, risking food spoilage. Staff were unsure who was responsible for monitoring temperatures, and records showed no monitoring on two days. The resident, who is cognitively intact, has a history of paraplegia and multiple stage 4 pressure ulcers.
A resident, who is cognitively impaired, experienced sexual abuse when another resident exposed themselves in the facility elevator. The incident was reported and substantiated, leading to the affected resident being moved to a different floor and placed under 1:1 supervision. The facility staff acknowledged the incident as a form of sexual abuse, highlighting a deficiency in protecting residents from abuse.
Failure to Supervise Identified Elopement-Risk Resident Leading to Unauthorized Exit
Penalty
Summary
The facility failed to provide appropriate supervision to prevent elopement for a resident who had been formally identified as an elopement risk and not safe for unsupervised community access. The resident was admitted with multiple medical and psychiatric diagnoses, including generalized anxiety disorder, major depressive disorder, substance use disorders, gait and mobility abnormalities, unsteadiness on feet, encephalopathy, and a history of falling. An elopement risk review completed shortly after admission documented that the resident was at risk for elopement, and a community survival skills assessment indicated the resident was not capable of unsupervised outside pass privileges. Nursing documentation noted the resident required constant redirection due to wandering the halls and entering other residents' rooms. The resident’s care plan identified elopement risk, including attempting to leave the facility without a responsible escort and wandering behaviors. On the day of the incident, multiple staff observed the resident exhibiting escalating exit-seeking and pacing behaviors. In the late afternoon, the resident attempted to leave through the 2nd floor back stairwell door, triggering the alarm, and was redirected back to his room by social services staff. Staff reported that later that afternoon and early evening, the resident was restless, pacing back and forth from hallway to hallway, dining room to his room, and was described as trying to escape using the back door stairwells. Despite these behaviors and the resident’s known elopement risk status, supervision was provided through a rotating CNA hallway/dining room watch system, and at the time of the actual elopement, there was no CNA specifically monitoring the hallway because the nurse was passing medications there. Staff interviews indicated that although there was an expectation that a staff member continuously monitor the hallway and dining room, this was not occurring at the moment the resident exited. Around the early evening, the 2nd floor back stairwell alarm sounded as the resident pushed through the door. A CNA heard another staff member telling the resident to stop and then heard the alarm, and the LPN on duty reported running after the resident down the stairwell and out the back door. The resident, wearing only a sweater, pants, and shoes without socks in cold, snowy weather, ran away from the facility despite the nurse’s verbal attempts to redirect him and brief physical attempt to hold him. The nurse, not wearing a coat, returned to the building due to the weather, and staff then began searching the surrounding area. The resident later reported that no one was watching him when he left, that he ran as fast as he could, and that he walked and ran for about an hour in the cold before sheltering in an apartment lobby, where a bystander called the police. Hospital records documented that the resident had been walking outside in shoes without socks, developed right foot pain, and was found to have callous and slight skin redness, for which he received Tylenol, Flexeril, and socks before being returned to the facility. The facility’s elopement binder already listed the resident as an elopement risk with his picture and face sheet prior to this event.
Failure to Prevent Resident-to-Resident Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse. An altercation occurred between two cognitively intact, ambulatory roommates, R4 and R6, both with psychiatric diagnoses. On the date of the incident, staff reported that R4 was verbally aggressive and loud toward R6, demanding that R6 turn off music playing from R6’s phone. R6 responded by pushing R4 in the face after R4 came onto his side of the room, threatened to break the phone, and verbally abused him. Staff, including LPNs, heard the verbal disagreement and later documented that both residents cursed at each other and that R6 admitted to pushing R4 away. The Administrator and Social Services Director both characterized the verbal aggression and pushing as forms of abuse, and the facility’s own investigation concluded that abuse occurred between the two residents. Interviews and progress notes show that staff were aware of escalating verbal conflict between the roommates but did not intervene in time to prevent the situation from becoming physically abusive. One LPN reported hearing R4 in the hallway having a verbal disagreement with co‑residents and that the residents became aggressive, agitated, and combative. The Social Services Director later stated that residents are supposed to be monitored by staff and that interventions should be taken before resident‑to‑resident issues escalate to aggression, acknowledging that when R6 pushed R4 and when R4 cursed at R6, these actions constituted abuse. The facility’s Abuse Prevention Program policy defines physical abuse as the infliction of injury on a resident other than by accidental means and verbal abuse as the use of disparaging or derogatory language, aligning with how the events were characterized by leadership. A separate incident involved R13, a deaf, nonspeaking resident with schizophrenia and unspecified psychosis, whose cognitive status was not scored on the MDS. R13 communicates with staff through written yes/no questions and written responses or head nods. During an interview using this method, R13 nodded yes when asked if he had been hit by R4, and indicated that he was afraid and hurt when R4 hit him. Nursing progress notes also document that R4 reported R13 had kicked him on the left leg. These documented resident‑to‑resident physical contacts, combined with the facility’s own abuse definitions and staff acknowledgments that such pushing, hitting, and verbal aggression are forms of abuse, demonstrate that the facility failed to ensure that residents remained free from physical and mental abuse by other residents.
Failure to Prevent Resident‑to‑Resident Physical Abuse Resulting in Head Trauma and Repeated Assaults
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by other residents, resulting in multiple substantiated abuse incidents. One resident with intact cognition and diagnoses including traumatic subdural hemorrhage, nasal bone fracture, schizophrenia, and bipolar disorder reported being physically assaulted in his room by another cognitively intact resident with schizophrenia and other psychiatric diagnoses. According to the injured resident, he initially went to the aggressor’s room to borrow a lighter, was told there was no lighter, and then returned to his own room. Shortly thereafter, the aggressor entered his room, demanded to know where his cigarettes were, and then punched him in the face repeatedly with a closed fist. A nurse heard a loud noise, saw the aggressor leaving the injured resident’s room, and found the injured resident lying on his bed with his face covered in blood. The injured resident was sent to the hospital and diagnosed with a subdural hematoma and a nasal bone fracture, with hospital documentation noting facial trauma including left periorbital swelling and a right nasal bone fracture. The aggressor in this incident had a documented history of mental illness, hallucinations, and delusions, and staff and the Psychiatric Rehabilitation Services Coordinator acknowledged that he had prior behavioral incidents with other peers, including breaking shelves at the nursing station and two prior incidents with another resident, though not as severe as the assault that caused the subdural hematoma and nasal fracture. Staff interviews indicated that when residents exhibit aggressive behavior they may be placed on one‑on‑one monitoring and receive psychiatric evaluation, and that staff are expected to monitor hallways, particularly at night, to prevent residents from wandering into other residents’ rooms. At the time of the assault, the aggressor was not on one‑on‑one monitoring, and the event occurred in the early morning hours when residents do not have scheduled smoking times. The administrator, who serves as the Abuse Coordinator, stated that it is not expected for residents to be physically abused by other residents and that the facility must keep residents safe, and the physician stated that abuse is not an expectation and that behaviors should be managed to maintain safety. Additional substantiated abuse incidents involved another resident with schizophrenia and severe cognitive impairment who physically struck two cognitively intact residents on separate occasions. In one incident, a cognitively intact resident with schizophrenia, hypertension, and unsteadiness on feet was sitting in the hallway after exiting the dining room when the cognitively impaired resident walked out of her room and, without provocation, struck him in the face with her hand. The LPN on duty heard the victim yell “stop hitting me,” saw the aggressor standing close to him making a fist, and separated them. The facility’s final incident investigation concluded that abuse was substantiated, determining that the resident was struck in the face by another resident. In another incident, a cognitively intact resident with osteoarthritis, hypertension, and psychosis was inside a public restroom when she opened the door as the same cognitively impaired resident was walking past. The aggressor was reportedly startled, began swinging her arms, and struck the resident in the face. Staff on the unit intervened immediately and separated the residents. The facility’s final incident investigation again substantiated abuse, concluding that the resident was struck in the face by another resident when the restroom door opened and the aggressor reacted by swinging her arms. Progress notes documented that the aggressor later, without event or provocation, hit another peer in the face and then became physically aggressive toward staff attempting to intervene. Across these events, the facility’s own Residents’ Rights document states that residents must not be abused physically, neglected, or exploited by anyone and that the facility must provide services to keep residents’ physical and mental health at their highest practicable levels. The Abuse Prevention Program Policy defines abuse as physical or mental injury inflicted upon a resident, including hitting, slapping, and kicking, and affirms residents’ right to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment. The administrator confirmed that the allegations involving the residents who were struck in the face were substantiated as physical abuse based on the nature of the incidents and resident statements, meaning that abuse occurred. Despite these policies and expectations, multiple residents were physically assaulted by other residents on different dates, including one incident that resulted in significant head trauma and facial fractures, demonstrating that the facility failed to protect residents’ rights to be free from physical abuse by other residents.
Failure to Notify Physicians Following Allegation of Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to notify residents’ physicians of an allegation of abuse as required by its Abuse Prevention Program Policy. One cognitively intact resident, R12, with diagnoses including osteoarthritis, hypertension, and psychosis, alleged on 11/04/2025 that another resident, R5, struck her in the face while she was exiting a public restroom on the second floor. A nurse on duty (V11, RN/Infection Preventionist) heard R12 say “don’t hit me,” found R12 near the nurse’s station and R5 by the bathroom door, and confirmed with R12 that she had been hit in the face. The facility’s Final Incident Investigation Report later documented that the allegation of abuse was substantiated and stated that the resident’s physician was made aware of the allegation and that R5 was sent to the hospital for evaluation per physician orders. Interviews and record review, however, showed that the required physician notifications were not completed or documented. V11 stated that she informed the Administrator (V1) that she was too busy to complete the abuse protocol and that V1 instructed LPN V14 to complete it, which included calling the family and physician for both the alleged victim and perpetrator. V11 acknowledged she did not call the family or physician for either resident. V14 stated she did not receive instructions from V1 to complete the abuse protocol and did not call the family or physician for either resident. Review of the electronic health record revealed no documentation that the physicians or psychiatrist were notified regarding the allegation involving R12 and R5, despite the facility policy requiring that physicians be notified of any incident and that the resident’s representative and physician be notified of the alleged incident and investigation. Further interviews confirmed that no psychiatrist notification occurred following R12’s allegation that R5 hit her. The Psychiatric Rehabilitation Services Director (V12) stated that when a resident makes an allegation of physical abuse, the psychiatrist should be called, and that if the nurse had called, it should have been documented in the electronic health record; V12 later confirmed that no psychiatrist notification was done. The Administrator (V1) stated that any time a resident is struck by another resident, the abuse protocol must be initiated immediately, including separating the residents, placing them on behavior monitoring, and notifying the physician and emergency contact person, and that if notification of the doctor is not documented, it means it did not happen. V1’s review of the reportable and census records also showed that, contrary to the written report, R5 was not sent to the hospital on the date of the incident, further evidencing that the physician notification and related orders described in the report did not occur. These findings demonstrate the facility’s failure to follow its own abuse protocol and policy requiring physician notification for incidents of alleged abuse.
Failure to Ensure Resident Visitation Rights in Shared Room
Penalty
Summary
The facility failed to ensure that a resident's right to full and equal visitation privileges was honored. A cognitively intact resident, who is bedbound and requires assistance with personal care, was denied visitation from her best friend after a roommate objected to the visitor's presence. The roommate, who has resided in the facility for many years, became upset and demanded that the visitor leave, believing the visitor to be a funeral director. Staff, including CNAs, LPNs, and the Social Services Director, responded by escorting the visitor out of the room, despite the resident's wishes to continue the visit. The resident expressed anger and frustration that her right to receive visitors was violated, especially since her friend assists her with essential tasks such as managing her link card, grocery shopping, and laundry. Multiple staff members acknowledged that the resident had an equal right to receive visitors in her room, as supported by facility policy. However, no alternative arrangements were made to facilitate the visit after the roommate's objection, and the visitor was not allowed to return. The Assistant Administrator did not follow up with the visitor or the resident to resolve the situation, and the resident's ability to receive her chosen visitor was not restored. Facility documentation and interviews confirm that the resident's visitation rights were not upheld in accordance with her preferences.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with six errors out of 25 opportunities, resulting in a 24% error rate. Multiple instances were observed where nursing staff did not administer medications according to physician orders. In one case, a nurse prepared and nearly administered an incorrect dose of Risperidone to a resident with dementia, initially placing 3.25 mg in the medication cup instead of the ordered 1.25 mg. The error was only partially corrected after review, and the correct dose was not immediately available. Another incident involved a resident with hypertension who was scheduled to receive Metoprolol Succinate ER 25 mg daily. The nurse withheld the medication due to a low blood pressure reading, despite there being no physician-ordered parameters to hold the medication. The nurse did not notify the physician of the withheld dose, nor did they inform the physician when a medication was unavailable for another resident. Additionally, a resident prescribed Sucralfate 1 gm/10 ml for gastrointestinal issues was nearly given an incorrect volume due to improper measurement technique, which was only corrected after intervention. Further, a resident was administered the wrong dosage of Simethicone due to the unavailability of the prescribed strength, with the nurse giving 125 mg tablets instead of the ordered 80 mg. The nurse was unaware of the dosage discrepancy and had already administered the incorrect dose earlier in the day. These events demonstrate repeated failures to follow medication administration protocols, including verifying correct dosages, ensuring medication availability, and communicating with physicians when deviations from orders occurred.
Failure to Provide and Document Required Hand Splints for Resident with Rheumatoid Arthritis
Penalty
Summary
The facility failed to provide hand splints for a resident diagnosed with rheumatoid arthritis, despite documented orders and care plan interventions indicating the need for bilateral hand splints as tolerated and for comfort. The resident reported that hand splints were previously applied by staff but went missing after a deep cleaning nearly a year prior, and were never replaced despite informing staff. Observations confirmed the resident's left fingers were closed inward, and the resident described ongoing weakness, particularly in the left hand, and the inability to keep the left fingers open without assistance. Interviews with nursing staff, restorative staff, and the Director of Nursing revealed that none had seen the resident with hand splints for an extended period, with some stating the splints had not been present for over a year. The facility's records, including the order summary and care plan, documented the need for splints and monitoring for their use and condition, but there was no documentation in the progress notes or ADL records regarding the application or presence of hand splints. The facility's policy required documentation and monitoring of such devices, which was not followed in this case.
Failure to Administer Medications Timely and According to Professional Standards
Penalty
Summary
The facility failed to administer medications in accordance with professional standards and scheduled times for two residents. One resident's morning medications, including Hydroxyzine Pamoate, Lamotrigine, Levetiracetam, Metoprolol Succinate Extended Release, and Potassium Chloride, were repeatedly given late, with documented instances of administration occurring several hours after the scheduled 9:00 AM time. On one occasion, the Metoprolol was withheld due to low blood pressure, but the other medications were still administered late. The Medication Administration Record and audit reports confirmed multiple late administrations over several days. Another resident reported that evening medications were administered late on several occasions, sometimes as late as almost 11:00 PM, despite being scheduled for 5:00 PM and 9:00 PM. Audit reports corroborated these claims, showing repeated late administration of medications such as Haloperidol, Vitamin C, Donepezil Hydrochloride, and Naproxen. The Director of Nursing acknowledged that new nurses may have contributed to the delays, and the facility's policy requires medications to be administered at the right time as ordered by the physician.
Failure to Report and Investigate Alleged Misappropriation of Property
Penalty
Summary
The facility failed to report and investigate an allegation of misappropriation of property involving a resident who reported a missing clock radio. The resident, who was cognitively intact according to the most recent MDS assessment, stated that the item was stolen and that the police had been involved. The resident informed staff about the missing item and the police visit, but there was no documentation of this incident in the resident's electronic medical record. Another resident confirmed that police had visited and inquired about any altercations, but denied any involvement. A Licensed Practical Nurse (LPN) acknowledged that the resident had called the police and mentioned something was taken, but did not provide details and the LPN did not report the incident to the facility's Abuse Coordinator, who is also the Administrator. The LPN stated she did not consider it abuse due to the lack of details, but recognized it should have been reported. The Administrator confirmed that all allegations, regardless of detail, must be reported immediately for investigation and state notification. Facility policy requires staff to report any suspicion or allegation of abuse, neglect, or misappropriation of property to the Administrator or supervisor, but this procedure was not followed in this case.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by peers, resulting in several incidents where residents were physically hit, pushed, or punched by other residents. In one case, a resident with a history of schizophrenia, bipolar disorder, and mobility issues was struck and pushed by another resident, leading to a fall and a laceration on the forehead that required eight stitches. The incident occurred when the aggressor confronted the victim over alleged theft, and no staff were present at the time to intervene. The staff became aware of the situation only after the injury had occurred, and the nurse on duty was not on the floor during the incident. In another incident, a resident reported being hit by another resident who wandered into their room. The staff responsible for monitoring the residents was on a lunch break and did not inform the nurse, leaving the floor without adequate supervision. The nurse was at the nurse's station and did not witness the altercation, only becoming aware after hearing a commotion. Both residents involved were later hospitalized. The facility's protocol for staff coverage during breaks was not effectively implemented, resulting in a lack of monitoring for residents known to require close supervision. Additional incidents included a resident being hit in the back of the head by another resident while lining up for a smoke break, and a resident physically attacking their roommate while on one-to-one monitoring for behavioral issues. In these cases, staff either witnessed the aftermath or were present but unable to prevent the abuse. The facility's policies on abuse prevention and behavior management were not adequately followed, as residents who posed a risk to others were not consistently separated or monitored to prevent harm.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in multiple incidents involving physical altercations between residents. In one incident, two female residents, both with mental health diagnoses and intact cognitive function as indicated by their BIMS scores, engaged in a physical altercation in an elevator. One resident reported being pushed and scratched by the other, leading to both residents exchanging blows and sustaining minor scratches. Staff on the unit heard raised voices and intervened, but were unable to separate the residents before the altercation escalated. Both residents were assessed and treated for their injuries, and the incident was substantiated as abuse by the facility. In a separate incident, another female resident with a history of schizoaffective disorder and chronic kidney disease was struck in the head by a peer in the dining room without provocation. The aggressor, who has severe mental illness and unscoreable BIMS, became agitated and refused to answer questions when staff attempted to interview her. Staff intervened immediately to separate the residents, and both were assessed with no injuries reported. The incident was also substantiated as abuse. In both cases, the facility's failure to prevent resident-to-resident physical abuse resulted in physical contact and minor injuries. The incidents involved residents with significant behavioral and mental health diagnoses, and staff intervention occurred only after the altercations had already begun. The facility's abuse prevention policy states that residents have the right to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment, but these incidents demonstrate a failure to uphold that standard.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure that medication was administered as scheduled per physician order for one resident. The resident, who is cognitively intact with a BIMS score of 15, had diagnoses including insomnia and anxiety disorder. On multiple occasions, medications were administered more than one hour past the scheduled time without notifying the physician. Specifically, Zolpidem Tartrate, Seroquel, and Tamsulosin were administered at 10:35 PM instead of the scheduled 9:00 PM, and other medications like Gabapentin and Hydralazine were given at 6:49 PM instead of 5:00 PM. There was no documentation in the electronic health records indicating that the physician was informed of these late administrations. Interviews with the resident and staff revealed further issues with medication administration. The resident reported not receiving Ambien one evening, despite it being available, and was informed by a nurse the following morning that the medication was indeed available. The Director of Nursing confirmed that medications should be administered within one hour of the scheduled time and that the physician should be notified if medications are given late. However, this protocol was not followed, as evidenced by the lack of documentation and communication regarding the late administration of medications.
Failure to Administer and Document Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure the availability and proper administration of anti-anxiety medication for a resident diagnosed with schizophrenia, paranoia, psychosis, anxiety, depressive disorder, and parkinsonism. The resident, who has moderate cognitive impairment, was not consistently receiving his prescribed medications, including anti-parkinsonism drugs, on several days in November 2024. This inconsistency in medication administration was not documented as per the facility's policy, which requires nurses to sign the Medication Administration Record (MAR) each time medication is given. The lack of documentation and administration of medication contributed to the resident's increased paranoia and psychotic behavior, leading to hospitalization. During an observation on January 9, 2025, it was noted that the anti-anxiety medication Hydroxyzine was unavailable in the medication cart and room, and the pharmacy was contacted to clarify its status. The resident expressed concerns about the inconsistency in receiving his medications, which he believed were not always administered correctly. The Director of Nursing acknowledged the importance of anti-anxiety medication in managing the resident's behavior and preventing recurrent issues, emphasizing the principle that if medication administration is not documented, it is considered not done.
Failure to Provide Adequate Assistance During Transfer Results in Resident Injury
Penalty
Summary
The facility failed to provide the required extensive assistance of two staff members during a manual bed-to-wheelchair transfer for a resident, resulting in the resident falling and sustaining a head injury. The resident, who has a history of traumatic brain injury, seizures, and falls, required substantial assistance for transfers due to impairments in both upper and lower extremities. Despite these needs, the transfer was attempted with inadequate supervision, leading to the resident hitting her head on a nightstand and requiring medical attention. On the day of the incident, the resident was in the dayroom and needed her incontinence brief changed. Two CNAs were involved in the process, but one left the room to prepare for incontinence care, leaving the resident with only one CNA. During this time, the resident attempted to stand and lost her balance, resulting in a fall. The CNA present was unable to prevent the fall, and the resident sustained a laceration on her head, necessitating hospital evaluation and treatment. Interviews with staff revealed inconsistencies in the transfer process and a lack of adherence to the facility's policy requiring two-person assistance for transfers. The CNAs involved did not use a gait belt, which is mandatory for all physical assist transfers according to the facility's policy. The incident highlights a failure to follow established procedures for safe resident handling, particularly for residents at high risk for falls.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation practices, as observed during a survey. In the walk-in refrigerator, several food items, including green leaf salads, cold cut sandwiches, and egg salad, were found without dates, indicating a lack of compliance with the facility's policy that requires all refrigerated food to be labeled with the date it was prepared. This oversight was acknowledged by a cook, who stated that the staff is aware of the requirement to date open and prepared items, but the cook from the previous night failed to do so. The Dietary Manager confirmed that all food in the refrigerator should be labeled and dated, and a Dietary Aide reiterated that refrigerated food items should be dated. Additionally, the facility did not ensure that dietary staff adhered to the policy of wearing hair coverings while handling food. A cook was observed pureeing food with a mask hanging at chin level and hair not fully covered, which is against the facility's policy that mandates hairnets and beard guards or masks as necessary. The Dietary Manager confirmed that everyone in the Dietary Department should have a hair net on, and the facility's policy documents that food and nutrition services employees must wear hair restraints at all times in the kitchen. These deficiencies have the potential to affect all 119 residents receiving an oral diet in the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by multiple observations of staff not adhering to Enhanced Barrier Precautions (EBP) and hand hygiene protocols. In one instance, a housekeeper was observed handling soiled linen without proper bagging and failed to perform hand hygiene after doffing gloves, subsequently touching clean linens. This was contrary to the facility's policy, which mandates that all linen be handled in a manner to prevent the spread of infection and that hand hygiene be performed upon removal of personal protective equipment. In another case, a registered nurse was observed performing wound care on a resident with multiple stage 4 pressure ulcers without completing hand hygiene between glove changes. The nurse repeatedly donned new gloves without washing hands, despite the facility's hand washing policy requiring hand hygiene immediately after glove removal. This oversight was acknowledged by the nurse and the Director of Nursing, who affirmed the importance of hand hygiene in preventing contamination and infections. Additionally, several residents who required Enhanced Barrier Precautions due to their medical conditions, such as indwelling catheters, feeding tubes, and wounds, did not have EBP signs on their doors. Staff were observed providing care without the appropriate use of gowns and gloves, as required by the facility's policy. This lack of adherence to EBP protocols was noted in multiple instances, with staff either unaware of the requirements or failing to follow them, potentially increasing the risk of infection transmission among residents and staff.
Failure to Conduct Timely Care Plan Conferences and Involve Residents
Penalty
Summary
The facility failed to conduct timely care plan conferences and involve residents in the development of their care plans, affecting four residents in a sample of 58. Resident 2, who is cognitively intact with a BIMS score of 15, reported not being invited to participate in care plan meetings since their last conference on June 20, 2023. The MDS Nurse could not recall any recent care plan meetings for this resident. Resident 27, with moderate cognitive impairment and a BIMS score of 12, also reported never having met with staff to discuss their care plan, with the last recorded care conference dated March 22, 2017. Similarly, Resident 59, who is cognitively intact with a BIMS score of 15, stated it had been over a year since their care plan was discussed, with the last meeting recorded on March 31, 2023. The MDS Nurse confirmed the lack of recent care plan meetings for these residents. The Director of Nursing affirmed that care plan meetings should occur quarterly and as needed, with residents and their families invited to participate. However, the facility's records and policies indicate a failure to notify residents and maintain records of care plan meetings, as evidenced by the outdated care conference dates and lack of sign-in sheets. This deficiency highlights a systemic issue in involving residents in their care planning process.
Uncovered Cable Box Receptacle Poses Hazard
Penalty
Summary
The facility failed to ensure a safe environment for a resident, identified as R82, by not covering a cable box receptacle, leaving wires and cable cord connectors exposed. This issue was observed on August 18, 2024, and the resident reported that the box had been uncovered for the entire 8 months of their stay in the room. The Maintenance Director acknowledged that the cable box should have been covered, and the Licensed Practical Nurse (LPN) was unaware of the hazard, indicating a lack of communication and reporting within the facility. The Maintenance Log for the first floor showed no reports of the uncovered cable box, despite the facility's policy emphasizing the importance of maintaining a hazard-free environment. The Administrator stated that receptacle testing is part of the preventative maintenance program, which includes checking for cracks and the condition of cover plates. However, the uncovered cable box was not addressed, highlighting a gap in the implementation of the facility's safety policies and procedures.
Medication Management Deficiency
Penalty
Summary
The facility failed to maintain proper medication management practices, as evidenced by the presence of expired medications and loose pills in the 3rd floor medication cart. During an observation, it was found that the medication cart contained twenty-three loose pills, and bottles of Bisacodyl 5mg and Ferrous Sulfate 325mg with unreadable expiration dates. A Licensed Practical Nurse (LPN) acknowledged the issue, stating that the faded expiration dates made it impossible to verify the medications' effectiveness, and emphasized that picking pills from the bottom of the drawer would constitute a medication error due to contamination and lack of identification. The Director of Nursing (DON) confirmed that expired medications should be removed from the carts to prevent reduced potency, which could alter the intended dosage. The DON also noted that loose pills should be discarded and medications reordered to ensure residents have an adequate supply. However, the facility was unable to locate a specific medication storage policy at the time of the survey. The facility's existing policy on labeling and dating medications, dated August 2018, requires medications to be used in accordance with the manufacturer's recommendations and mandates dating of certain medications when first opened.
Failure to Maintain Privacy of Urinary Drainage Bag
Penalty
Summary
The facility failed to ensure a resident's urinary drainage bag was kept privately, affecting one resident in a sample of 58. The resident, who is cognitively intact and has a diagnosis of paraplegia, flaccid neuropathic bladder, neuromuscular dysfunction of the bladder, and obstructive and reflux uropathy, utilizes an indwelling urinary catheter. On a specific date, the resident's urinary drainage bag was observed to be exposed and attached to the frame of the bed, without a privacy bag. The resident expressed a desire for the urinary drainage bag to be kept in a privacy bag. A Certified Nursing Assistant confirmed the absence of the privacy bag and acknowledged that it should have been used. The Director of Nursing also affirmed that urinary drainage bags should be kept in privacy bags to promote resident dignity. The facility's policy on dignity, dated January 2015, states that urinary catheter bags shall be covered.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident's ability to safely self-administer medication, specifically an inhaler for chronic obstructive pulmonary disease (COPD) and asthma. The resident, identified as cognitively intact with a BIMS score of 15, was found to have an inhaler in her room, which was given to her by a nurse without a proper assessment or a doctor's order allowing self-administration. The resident's care plan did not include provisions for self-administration of medication, and there was no documentation or order permitting the resident to keep the medication at her bedside. During the survey, the Assistant Director of Nursing and a Licensed Practice Nurse acknowledged the oversight, noting that the resident was not supposed to have the inhaler in her room without an assessment and a doctor's order. The Director of Nursing confirmed the necessity of an assessment, a specific doctor's order, and a care plan for self-administration to ensure the resident's safety and to inform staff of the care plan. The facility's policies and procedures require an interdisciplinary team assessment and a physician's order before a resident can self-administer medication, which was not followed in this case.
Failure to Maintain Homelike Environment for Residents
Penalty
Summary
The facility failed to maintain a homelike environment for two residents, R83 and R82, as observed during a survey. For R83, the light fixture in their room was missing a fluorescent tube light and cover, and the air conditioning unit was improperly sealed with a pillow. Despite R83 reporting these issues to the Assistant Director of Nursing two weeks prior, they were not addressed. The Maintenance Manager acknowledged being informed about the missing light cover but had not yet resolved the issue. The facility's maintenance log did not document these problems, indicating a lapse in communication and follow-up. For R82, a dresser drawer was missing, which the resident reported had broken a few days earlier. The Maintenance Manager admitted that the missing drawer did not provide a homelike environment, yet the issue was not recorded in the maintenance log. The Director of Nursing confirmed that damaged property in a resident's room would not constitute a homelike environment. Both cases highlight a failure to adhere to the residents' rights to a safe, clean, comfortable, and homelike environment as mandated by state and federal laws.
Inaccurate MDS Completion for Resident with Schizophrenia
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for a resident diagnosed with schizophrenia, unspecified psychosis, and bipolar disorder. The MDS, dated 7/3/2024, incorrectly indicated that the resident was not considered by the state Level II Preadmission Screening and Resident Review (PASRR) to have a serious mental illness. However, a Notice of PASRR Level II Outcome dated 9/02/2022 confirmed the resident's condition of schizophrenia, which should have been coded as 'yes' in section A1500 of the MDS. The MDS Nurse/Restorative Nurse, a Licensed Practical Nurse, acknowledged the error, stating that section A1500 should be coded as 'yes' for residents identified by PASRR as having a serious mental illness. The Director of Nursing emphasized the importance of accurate MDS assessments to guide the resident's care plan, noting that incorrect MDS completion could result in the facility not identifying all necessary care for the resident.
Failure to Sign Out Medications
Penalty
Summary
The facility failed to ensure that medications were properly signed out when administered to two residents, R71 and R91. For R71, who has a range of diagnoses including cognitive impairments, the issue was identified when the resident reported not receiving medications. Upon investigation, it was found that several medications, including Colace, Lidocaine Patch, Mirabegron, Multivitamin, Sertraline, Clonazepam, Gabapentin, Pregabalin, Prostat, and Vitamin C, were not signed as administered in the electronic Medication Administration Record (eMAR). The nurse responsible, V15, admitted to forgetting to sign them out, acknowledging the importance of signing medications to prevent errors. Similarly, for R91, who has chronic obstructive pulmonary disease and schizophrenia, the deficiency was noted when a surveyor requested to observe the administration of Breo Ellipta inhalation medication. The LPN, V16, admitted to administering the medication but failing to sign it out. The Director of Nursing, V2, confirmed that medications should be signed out immediately after administration to ensure accurate records and prevent potential double dosing. The facility's policy mandates that only licensed nurses prepare, administer, and record medications, emphasizing the importance of documentation on the Medication Administration Record (MAR).
Failure to Date Humidifier Bottle for Oxygen Therapy
Penalty
Summary
The facility failed to date the humidifier bottle for a resident who was receiving oxygen therapy. The resident, who has a range of diagnoses including seizures, hypertension, and congestive heart failure, was observed lying in bed with an oxygen cannula connected to a humidifier bottle that lacked a date. A registered nurse confirmed the absence of a date on the humidifier bottle and acknowledged that it should have been dated to track when it was last changed. According to the facility's policy, humidifier bottles should be changed and dated weekly and as needed, but this procedure was not followed in this instance.
Failure to Provide Correct Diet Consistency
Penalty
Summary
The facility failed to provide the correct consistency diet to a resident, identified as R100, who has multiple medical diagnoses including dysphagia, which increases the risk of choking and aspiration. R100's physician ordered a no added salt diet with mechanical soft, ground meat texture, and thin liquids consistency. However, during an observation, a Certified Nursing Assistant (CNA) provided R100 with a turkey and cheese sandwich, which was not consistent with the mechanical soft diet order. The CNA believed the sandwich was appropriate because the bread was soft, and stated that they were instructed to provide a turkey sandwich when R100 did not eat the meal provided. The Dietary Manager confirmed that R100's diet required the turkey meat to be chopped, as residents on mechanical soft diets typically have swallowing difficulties. The Director of Nursing (DON) acknowledged that providing the wrong food consistency could lead to aspiration. The facility's policy on mechanical soft diets specifies that meat should be mechanically ground unless otherwise indicated. The incident occurred because the CNA did not communicate the resident's dietary needs when requesting the sandwich, and the dietary staff did not verify the resident's identity or dietary requirements before providing the meal.
Failure to Monitor Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that personal refrigerators were maintained at safe temperatures, affecting one resident in a sample of 58. The resident, who is cognitively intact, has a medical history that includes paraplegia, flaccid neuropathic bladder, and multiple stage 4 pressure ulcers. During an observation, the resident's personal refrigerator was found to contain multiple containers of leftover food and beverages, with the thermometer reading 44 degrees Fahrenheit, which is above the facility's policy requirement of 41 degrees Fahrenheit or below. Staff interviews revealed uncertainty about who was responsible for monitoring the temperatures of personal refrigerators. A Certified Nursing Assistant confirmed the high temperature, and a Licensed Practical Nurse acknowledged that such a temperature could cause food to spoil. The Director of Nursing also expressed uncertainty about which staff should be monitoring these temperatures, although it was affirmed that temperatures should be checked at least daily. The facility's records showed no temperature monitoring was completed on two consecutive days, contributing to the deficiency.
Resident Exposed to Sexual Abuse in Facility Elevator
Penalty
Summary
The facility failed to protect a resident, referred to as R1, from sexual abuse and mental anguish. R1, who is cognitively impaired with a BIMS score of 10, experienced an incident where another resident, R2, exposed themselves to R1 in the facility elevator. R2, also cognitively impaired with a BIMS score of 12, admitted to the exposure, which was reported by a CNA to the facility's administration. The facility's investigation substantiated the allegation of abuse. Following the incident, R1 expressed feelings of being punished and isolated, as they were moved to a different floor and placed under 1:1 supervision. R1 reported feeling afraid to participate in activities due to the presence of R2, who had previously made inappropriate comments and gestures. The emotional impact on R1 was evident, as they were observed crying and expressing distress over the situation. The facility's staff, including LPNs, the Social Services Director, and the Assistant Director of Nursing, acknowledged the incident as a form of sexual abuse. The facility's policy on abuse prevention and resident rights emphasizes the residents' right to be free from abuse and to be treated with dignity and respect. Despite these policies, the incident occurred, leading to a deficiency in ensuring a safe environment for R1.
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.
