Rushville Nursing & Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Rushville, Illinois.
- Location
- 135 South Morgan Street, Rushville, Illinois 62681
- CMS Provider Number
- 145488
- Inspections on file
- 26
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Rushville Nursing & Rehab Ctr during CMS and state inspections, most recent first.
A resident with a history of CVA, hemiplegia, and moderate cognitive impairment experienced multiple falls due to the facility's reliance on education and signage as fall prevention interventions. Despite repeated incidents, staff did not implement interventions suited to the resident's cognitive deficits, and both the LPN and DON acknowledged the inadequacy of these measures.
The facility failed to follow infection control protocols, including hand hygiene and masking during a flu outbreak. A CNA did not wash hands after glove removal while caring for two residents with urinary catheters. Additionally, a hairdresser was observed without a mask during the outbreak, indicating a communication lapse. These actions compromised infection control efforts, potentially affecting all residents.
The facility failed to serve food at safe temperatures, with trays left unattended and food cooling before residents were present. A CNA confirmed this practice, and the Dietary Manager acknowledged frequent temperature complaints.
The facility failed to implement an effective antibiotic stewardship program, resulting in the inappropriate use of prophylactic antibiotics for several residents without documented symptoms or appropriate diagnoses. The Infection Prevention and Control Program's protocols were not followed, and the consultant pharmacist's reviews did not include antibiotic usage. The facility's leadership acknowledged the program's deficiencies.
A staff member was observed using a personal cell phone while assisting a resident with eating, contrary to the facility's policy prohibiting phone use during care. The resident, who is rarely understood, did not respond to questions. The DON and Administrator confirmed that staff should not use phones during care.
A resident with dementia and behavioral disturbances was over-sedated due to inappropriate use of psychotropic medication. Initially prescribed Risperdal orally, the medication was changed to a monthly injection after the resident refused the pill form. This led to significant sedation and a decline in physical functioning, as the resident slept for extended periods post-injection. The facility failed to monitor and adjust the medication use appropriately, resulting in the use of a chemical restraint.
A facility failed to conduct a PASRR Level II assessment after a resident experienced a significant change in mental health status. The resident, initially admitted without a serious mental illness diagnosis, was later hospitalized and returned with a new bipolar disorder diagnosis. Despite this change, the required PASRR was not completed, as confirmed by the Social Service Director and Administrator.
Two residents with indwelling urinary catheters were found with catheter bags and tubing in unsanitary conditions, contrary to the facility's policy. One resident's catheter bag was hanging from a wheelchair with tubing dragging on the floor, while another's catheter bag and tubing were resting on the floor. Both residents had care plans emphasizing infection control, which were not followed.
The facility failed to provide proper respiratory care for two residents by not adhering to the oxygen administration policy. One resident frequently removed their oxygen, and staff did not consistently reapply it or provide education. Another resident had overdue oxygen tubing changes, and both lacked required ear pads. The administration was unaware of the policy requirements.
A facility failed to ensure coordinated communication and availability of hospice documents for a resident with a terminal diagnosis. The hospice plan of care, election forms, and clinical notes were missing from the resident's record. Staff interviews revealed inadequate communication and documentation practices, with no specific hospice binder for the resident and hospice documents not scanned into the record. The hospice nurse also did not leave the plan of care or visit notes at the facility.
A resident with multiple health issues, including legal blindness and muscle weakness, fell and fractured her femur due to the facility's failure to use a gait belt during ambulation, as required by their policy. Staff confirmed the resident needed assistance with a gait belt and walker, but it was not used at the time of the fall, leading to hospitalization and surgery.
A resident's call light was not accessible while in bed, contrary to facility policy. The call light was clipped to a bedside commode, requiring the resident to get out of bed to reach it. A CNA confirmed the issue and cleaned the call light before handing it to the resident. An RN later affirmed that call lights should always be within reach.
A facility failed to complete a PASARR for a resident who was later diagnosed with Schizoaffective Disorder. Initially admitted with Guillain-Barre syndrome, the resident's medical record lacked a PASARR after the new diagnosis. The Social Service Director confirmed the oversight.
A resident with a diagnosis of Foot Drop did not receive a lower extremity ROM program, despite facility policies requiring such care. The resident was unable to flex her ankle joints and reported not receiving exercises from staff. The care plan only addressed upper extremity ROM, and the DON confirmed the absence of a lower extremity program.
A resident with vascular dementia and on anticoagulants sustained a bruise during a transfer due to staff not using a gait belt as per facility policy. Instead, staff held the resident's arm, leading to the injury. The resident's medical records indicate dependency on staff for transfers and a history of conditions that contribute to easy bruising.
A facility failed to document justification for a resident's use of two antidepressants, Bupropion and Paroxetine, as required by its Psychotropic Medications Policy. A nurse managing psychotropic medications was unsure of the reason for the duplicative therapy and confirmed the absence of documentation in the resident's medical record, despite the resident not posing harm to herself or others.
Failure to Implement Appropriate Fall Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement appropriate fall prevention interventions for a resident with a history of multiple falls and cognitive impairment. The resident, who had diagnoses including cerebrovascular accident (CVA), osteoarthritis, depression, diabetes, hemiplegia, and short-term memory deficits, experienced several falls over a period of months. Despite documented falls in both common areas and the resident's bathroom, the interventions implemented by the facility primarily consisted of education and signage, such as reminders to lock wheelchair brakes and to wear non-skid socks or shoes. These interventions were not tailored to the resident's cognitive limitations, as the resident had moderate cognitive loss and required substantial to maximal assistance with transfers. Staff interviews confirmed that the interventions were not appropriate for the resident's cognitive status. The restorative nurse and the director of nursing both acknowledged that education and signage were insufficient for a resident with cognitive impairment. The facility's own policies required ongoing assessment and the implementation of pertinent interventions to prevent subsequent falls, but the actions taken did not address the resident's specific needs, resulting in repeated falls and a failure to ensure a safe environment free from accident hazards.
Infection Control Lapses in Hand Hygiene and Masking During Flu Outbreak
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, specifically in hand hygiene and masking during an influenza outbreak. Observations revealed that staff did not perform hand hygiene after glove removal, as required by the facility's policies. This was noted in the care of two residents with indwelling urinary catheters, where a Certified Nursing Assistant (CNA) did not wash hands after removing soiled gloves and before donning new ones. This lapse in protocol occurred despite the facility's clear guidelines on hand hygiene, which emphasize washing hands after glove removal to prevent infection. Additionally, the facility did not enforce masking protocols during a flu outbreak, which could potentially affect all 71 residents. A sign at the facility entrance indicated that masking was recommended, yet a hairdresser was observed walking through the facility without a mask. The Infection Preventionist confirmed that not wearing a mask during a flu outbreak could put residents at risk. The hairdresser was unaware of the masking requirement, indicating a communication breakdown regarding infection control measures. The facility's policies on infection control, including hand hygiene and the use of personal protective equipment, were not followed, leading to potential risks of infection spread. The CNA involved in the care of residents with urinary catheters did not adhere to the hand hygiene protocol, and the lack of consistent masking during an influenza outbreak further compromised the facility's infection control efforts. These deficiencies highlight the need for strict adherence to established infection prevention protocols to protect residents from potential health risks.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and safe temperature for six residents. On the morning of April 8, 2025, breakfast trays for these residents were observed sitting on dining room tables with lids or other plates on top, despite the residents not being present. A Certified Nurse Aid/Transportation staff member, V4, confirmed that trays were routinely delivered to residents' regular spots regardless of their presence, and noted that the food was often not hot when served. This practice was confirmed by the Dietary Manager, V6, who acknowledged that food should only be served if residents are present. During the same morning, V6 was observed taking a tray to a resident's room, where the resident was found sitting in a recliner with her eyes closed. The food temperatures at that time were recorded as 89 degrees Fahrenheit for scrambled eggs and 88 degrees Fahrenheit for sausage, which are below the recommended serving temperatures. The Dietary Manager admitted that there were frequent complaints about food temperatures, attributing the issue to the loss of temperature once food leaves the steam table.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to properly implement and monitor an antibiotic stewardship program, as evidenced by the lack of identification, monitoring, and review of prophylactic antibiotic use for four residents. The Infection Prevention and Control Program, dated 2019, outlined the need for an antibiotic stewardship program, including protocols and a system to monitor antibiotic use. However, the facility did not adhere to these protocols, as the Infection Control Log showed that residents received prophylactic antibiotics without signs or symptoms of infection. The consultant pharmacist's Medication Regimen Review reports did not include antibiotic usage, and the Infection Report Summary lacked data on prophylactic antibiotic use. Specific cases included residents receiving antibiotics for urinary tract infection prophylaxis without documented symptoms or appropriate diagnoses. For instance, one resident had a physician's order for an antibiotic with no end date, and another had an order for an antibiotic without a documented reason. The facility's Quality Assurance Committee meetings did not address antibiotic usage, and the Infection Preventionist acknowledged that certain diagnoses, such as urge incontinence, did not require antibiotics. The facility's administrator and director of nursing admitted that the antibiotic stewardship program was incomplete and needed improvement.
Inappropriate Cell Phone Use During Resident Care
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by an incident involving a staff member's inappropriate use of a personal cell phone during resident care. The facility's policy on personal cell phone use mandates that phones must be turned off and stored away during work hours, and not carried on the employee's person while actively working. However, a Transportation/Certified Nurse Aid was observed using her phone to text while assisting a resident with eating, holding a utensil in one hand and her phone in the other. This occurred despite the facility's clear policy prohibiting phone use in resident areas. The resident involved, who was rarely or never understood according to their Minimum Data Set, did not respond to questions during the surveyor's visit. The Director of Nursing and the Administrator confirmed that staff should not be on their phones while providing care.
Inappropriate Use of Psychotropic Medication as Chemical Restraint
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications, resulting in the over-sedation and decline in physical functioning of a resident, identified as R12. R12 was admitted with diagnoses including conversion disorder with seizures, generalized anxiety, and unspecified dementia with behavioral disturbances. Initially, R12 was prescribed Risperdal 2 mg orally for unspecified dementia with behavioral disturbances. However, after an increase in aggressive behaviors and a subsequent psychiatric hospitalization, the medication was changed to Risperidone 125 mg administered subcutaneously once a month. Observations and interviews revealed that R12 exhibited behaviors such as agitation, cursing staff, restlessness, and hallucinations. Despite these behaviors, R12's Minimum Data Set (MDS) assessments documented no physical or verbal behavioral symptoms directed towards others, and no rejection of care. The facility's social services and nursing staff confirmed that R12's behaviors included false allegations and yelling during care, but there was no evidence of self-harm or aggression towards other residents. The change in medication form was due to R12's refusal to take the oral medication. The administration of the antipsychotic injection led to R12 experiencing significant sedation, as noted in nurse's notes and staff interviews. R12 was observed to sleep for extended periods post-injection, which contributed to a decline in her physical condition and ability to perform activities of daily living. The facility's failure to appropriately monitor and adjust the use of psychotropic medication for R12, in accordance with their own procedures, resulted in the use of a chemical restraint that was not required to treat medical symptoms or behavior manifestations of mental illness.
Failure to Conduct PASRR After Significant Change
Penalty
Summary
The facility failed to obtain a Preadmission Screening and Resident Review (PASRR) after a significant change in condition for a resident. The facility's admission policy requires that PASRR screens be valid and reviewed on admission, annually, and upon any significant change. The resident in question was admitted with diagnoses including conversion disorder with seizures, dementia, and anxiety, but no serious mental illness was documented at the time of admission. However, after being sent to the hospital due to increased behaviors and subsequently transferred to an inpatient psychiatric hospital, the resident returned with a new diagnosis of bipolar disorder and a prescription for Risperidone. Despite this significant change in the resident's mental health status, the facility did not conduct a repeat PASRR Level II assessment as required. The Social Service Director confirmed that the bipolar diagnosis was new following the hospitalization, and the Administrator acknowledged that a Level II PASRR should have been completed but was not. This oversight represents a failure to comply with the facility's policy and regulatory requirements for monitoring and assessing residents' mental health needs.
Failure to Maintain Sanitary Conditions for Indwelling Urinary Catheters
Penalty
Summary
The facility failed to ensure that indwelling urinary catheters were maintained in a sanitary manner for two residents, R41 and R119, who were reviewed for catheter care. The facility's Urinary Catheter Care policy, dated September 2005, specifies that catheter tubing and drainage bags should be kept off the floor to prevent urinary tract infections. However, observations revealed that R41's catheter bag was hanging from his wheelchair without a protective dignity bag, with the tubing dragging on the floor. Similarly, R119 was found in bed with the catheter drainage bag and tubing resting on the floor, also without a protective dignity bag. Both residents had physician orders for the use of a 16 FR/10cc balloon indwelling urinary catheter due to urinary retention. Their care plans included goals to manage catheter care appropriately to prevent infections and reduce the spread of infectious agents. The care plans also emphasized the importance of not allowing the catheter tubing or drainage system to touch the floor and following the facility's infection control policies. Despite these documented interventions, the facility did not adhere to its own procedures, as confirmed by the Administrator and Director of Nursing.
Failure to Adhere to Oxygen Administration Policy
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, R25 and R119, by not adhering to the established oxygen administration policy. For R119, who was readmitted with diagnoses including pneumonia and chronic lung disease, the facility did not consistently use ear pads or ensure the nasal cannula was in place, despite physician orders and care plans indicating the need for continuous oxygen. Observations revealed that R119 frequently removed the oxygen, and staff did not consistently reapply it or provide education on its necessity. Additionally, the care plan did not address R119's behavior of removing the oxygen, and staff confirmed non-compliance with the oxygen administration. For R25, the facility did not change the oxygen tubing and humidifier weekly as required, with labels indicating they were overdue for change. The staff confirmed the oversight, and there was also a lack of ear pads on the tubing. The facility's administration and DON were unaware of the policy requirement for ear pads for residents on continuous oxygen. These deficiencies highlight a failure to follow the facility's oxygen administration policy, potentially compromising the residents' respiratory care.
Lack of Coordinated Hospice Care and Documentation
Penalty
Summary
The facility failed to ensure coordinated communication and availability of required hospice documents for a resident receiving hospice care. The hospice services policy indicated that hospice staff should conduct assessments, develop a hospice plan of care, and maintain it in the medical record for interdisciplinary staff access. However, the facility did not have a hospice plan of care, election forms, physician certification of terminal illness, or clinical notes for the resident in question. The resident, who was admitted with a terminal diagnosis of dementia and age-related osteoarthritis with a pathological fracture of the femur, had elected hospice benefits, but their current care plan lacked specific hospice responsibilities or interventions. Interviews with facility staff revealed a lack of communication and documentation regarding hospice services. A Licensed Practical Nurse (LPN) stated that nurses assess residents at shift change to determine hospice status, but there was no specific hospice binder for the resident. The social services staff confirmed that hospice documents were not scanned into the resident's record. Additionally, the hospice nurse admitted to not leaving the resident's plan of care or visit notes at the facility, further contributing to the deficiency in hospice care management.
Failure to Use Gait Belt Results in Resident Injury
Penalty
Summary
The facility failed to utilize a gait belt during ambulation for a resident, resulting in the resident being hospitalized with a femur fracture that required surgical intervention. The facility's policy, dated April 2013, mandates the use of gait belts by all staff when ambulating or transferring residents with an unsteady gait. The resident in question had multiple diagnoses, including a displaced supracondylar fracture, muscle weakness, and legal blindness, and required substantial assistance for transfers and ambulation. Despite these needs, the resident was not wearing a gait belt at the time of the fall, which occurred when the resident attempted to pivot and sit too soon, leading to a fall and subsequent hospitalization. Interviews with facility staff confirmed that the resident required assistance with a gait belt and walker for ambulation. The Director of Nursing, Director of Rehabilitation, and Assistant Director of Nursing all acknowledged that a gait belt was not used during the incident. The resident also confirmed not wearing a gait belt at the time of the fall. The facility's failure to adhere to its own policy on gait belt usage directly contributed to the resident's fall and injury.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was accessible within a resident's reach, specifically for one resident (R9) out of a sample of 35. The facility's policy, revised in August 2008, mandates that call lights must be accessible to residents from their bed or other sleeping accommodation. On June 10, 2024, at 10:25 AM, R9 was observed lying in bed with the call light clipped to a bedside commode approximately three feet away, out of her reach. R9 expressed that she consistently had to get out of bed to access the call light, which should not be necessary. A Certified Nursing Assistant (V7) confirmed the call light was not within reach and proceeded to clean it before handing it to R9. On June 13, 2024, a Registered Nurse (V3) affirmed that call lights should always be within a resident's reach when they are in bed.
Failure to Complete PASARR for Resident with New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed for a resident who was later identified with a mental disorder. Initially, the resident was admitted with a primary diagnosis of Guillain-Barre syndrome, as documented on the OBRA-I Initial Screen form and the face sheet at the time of admission. However, the resident was later diagnosed with Schizoaffective Disorder. Despite this new diagnosis, the resident's medical record did not include a PASARR after the diagnosis of Schizoaffective Disorder. The Social Service Director confirmed that a PASARR was never completed following the diagnosis.
Failure to Provide Lower Extremity ROM Program for Resident with Foot Drop
Penalty
Summary
The facility failed to provide a lower extremity Range of Motion (ROM) program for a resident diagnosed with Foot Drop, resulting in a deficiency. The resident, who was observed sitting in a recliner with her feet elevated, was unable to flex her ankle joints and reported not receiving any exercises from nursing staff. Despite having a care plan that required active ROM for her upper extremities, there was no documented plan for her lower extremities, which is crucial given her diagnosis of Foot Drop. The Director of Nursing confirmed that the resident was not receiving physical therapy and did not have a ROM program in place for her lower extremities. The facility's policies on rehabilitative nursing care and ROM emphasize the importance of providing appropriate treatment to prevent further decrease in ROM, yet these were not followed for the resident's lower extremities. This oversight highlights a gap in the facility's implementation of its own policies, leading to the deficiency noted in the report.
Improper Transfer Technique Leads to Resident Injury
Penalty
Summary
The facility failed to safely transfer a resident, identified as R27, which resulted in a bruise on the resident's right hand and lower arm. The facility's Gait Belt policy mandates the use of gait belts during transfers to prevent injuries, specifying that staff should assist residents to stand by holding the belt at the waist. However, it was reported that staff held onto R27's arm during a transfer, contrary to the policy. This improper technique was identified as the cause of the bruising, as confirmed by R27's statement that staff held her arm when helping her up. R27 is a female resident with a history of vascular dementia, chronic obstructive pulmonary disease, chronic diastolic heart failure, and long-term use of anticoagulants, which can cause easy bruising. The resident's medical records indicate moderate mental impairment and dependency on staff for transfers. The incident was documented in R27's care plan and skin issue reports, noting the bruise's size and location. The Director of Nursing acknowledged the requirement for gait belt use and confirmed that staff should not hold a resident's arm during transfers.
Lack of Justification for Duplicative Antidepressant Therapy
Penalty
Summary
The facility failed to document justification for the use of duplicative antidepressant therapy for a resident reviewed for psychotropic medications. According to the facility's Psychotropic Medications Policy, residents should not receive psychotropic drugs unless necessary to treat a specific diagnosed condition, and efforts should be made to reduce or discontinue such medications when possible. The resident in question had current physician's orders for two antidepressants: Bupropion 200 milligrams daily and Paroxetine 40 milligrams twice daily. During an interview, a registered nurse responsible for managing psychotropic medications stated that the resident was not a harm to herself or others and rarely displayed adverse behaviors. The nurse was unsure why the resident was taking two antidepressants and confirmed that this information was not documented in the resident's medical record.
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.
