Alden Debes Rehab & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockford, Illinois.
- Location
- 550 South Mulford Avenue, Rockford, Illinois 61108
- CMS Provider Number
- 145142
- Inspections on file
- 45
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Alden Debes Rehab & Hcc during CMS and state inspections, most recent first.
Multiple residents did not receive their scheduled evening medications when the nurse assigned to a wing failed to report for the 6 PM–10 PM shift and facility leadership was not notified until the next day. Residents with conditions including diabetes, neuropathy, insomnia, depression, epilepsy, hypertension, hyperlipidemia, glaucoma, and pain missed ordered 8 PM doses such as insulin, pregabalin, trazodone, melatonin, antiepileptics, antihypertensives, and eye drops. Several cognitively intact residents reported not receiving their usual medications, with some describing insomnia, increased pain, and fatigue afterward. The DON, administrator, and an NP confirmed that residents are expected to be under continuous nursing care with medications administered as ordered, consistent with facility policy and the facility assessment requiring 24/7 licensed nurse coverage for medication administration.
A group of residents did not receive their scheduled evening medications when the agency nurse assigned to their wing failed to report for the 6 PM–10 PM shift, and no licensed nurse was covering the unit. MARs showed multiple missed doses, including insulin, psychotropic medications, cardiac medications, pain medications, and eye drops. Several residents reported they did not get their evening meds because there was no nurse present. CNAs on the wing stated they were told the nurse was running late, became busy with care, and either assumed the nurse eventually arrived or that others knew there was no nurse; they did not notify other staff or administration. The DON and Administrator both stated they were not informed of the nurse’s absence until the next day, and an LPN on another wing reported he did not learn of the situation until later that night, leaving the residents without a licensed nurse to administer their evening medications.
A resident with multiple comorbidities, functional limitations, and dependence on staff for ADLs was given numerous morning medications by an RN, who placed the pills and liquids on the bedside table and left without observing ingestion, then documented them as administered. The resident reported that nurses commonly leave medications at the bedside without supervision and that she has dropped or spilled pills, including when they were left while she was sleeping. Review of the medical record showed there was no MD order authorizing self-administration, and staff confirmed that self-administration requires a physician’s order per facility policy.
A resident’s scheduled morning medications, including insulin and multiple oral agents, were not administered within the facility’s required 1-hour window, resulting in an 80% medication error rate during an observed med pass. An RN checked the resident’s blood sugar and gave long-acting insulin, then brought 19 additional pre-poured medications into the room, administered only Flonase, left the rest on the bedside table, and documented them as given despite the eMAR showing them as overdue. Review of the MAR confirmed numerous 8:00 AM orders for once- and twice-daily medications, and staff acknowledged that medications highlighted red are overdue and that late twice-daily doses disrupt ordered spacing, contrary to the facility’s medication administration policy.
A nurse prepared 19 medications for a resident and left them in cups on top of an unlocked medication cart in the hallway while entering the resident’s room with only insulin to check blood sugar and administer the injection. The cart, positioned past the doorway and out of the nurse’s line of sight, left the prepared medications unattended and accessible. Another nurse confirmed this practice was not acceptable and that prepared medications should have been secured in the locked cart, contrary to facility policy requiring medications to be stored in locked compartments accessible only to authorized staff.
A resident with multiple chronic conditions, open surgical wounds, an indwelling catheter, and a colostomy was on contact isolation for an MRSA wound infection, with posted signage and facility policy requiring hand hygiene and use of gown and gloves upon room entry. An RN twice entered the resident’s room wearing only gloves to check blood sugar and administer insulin and other medications, and the RN’s sweater contacted the resident’s bedding on both occasions. A CNA later entered the same room without any PPE and touched the bedside table and bed rail while interacting with the resident. The resident reported that staff do not always wear a gown and gloves when entering the room, and the IP nurse confirmed that appropriate PPE should have been used to comply with contact precautions.
A resident on contact isolation for a blood infection reported being told by staff that she could not leave her room to shower and went about 11 days without a shower, during which she felt she smelled bad. CNAs stated that residents are to receive showers twice weekly and that residents on contact isolation can leave their rooms to shower, but one CNA acknowledged not assisting this resident with showering. An RN confirmed the resident’s isolation was later discontinued and she then received a shower, and that the resident had not been showered before that time. The resident’s care plan documented an ADL performance deficit with interventions for assistance with bathing and hygiene, and the facility’s bath/shower report showed she did not receive showers twice weekly as required by facility policy.
A resident with multiple comorbidities and mild cognitive impairment, care-planned as a fall risk and on a restorative bed mobility program requiring side rails for support, fell from bed during incontinence care when side rails and floor mats were not in place and the resident was instead holding onto the bedside table. While a CNA was turning the resident and reaching for supplies, the resident reported feeling weak, let go of the bedside table, and rolled off the bed, sustaining bruising and abrasions to the head, face, elbow, finger, and knee. Post-fall observation and staff interviews confirmed that required safety interventions, including side rails for bed mobility and floor mats, were not in use at the time of the incident, despite facility policy to assess hazards and implement appropriate fall-prevention measures.
A resident’s x-ray results were reported to the facility but were not promptly communicated to the nurse practitioner. An LPN checked the EMR once during the night and saw the results as pending, did not recheck later in the shift, and did not notify the NP. An RN later documented that results were relayed and the NP ordered hospital transfer, but the NP reported they were not notified by staff and only became aware of the results upon independently reviewing the EMR. The DON stated nurses are expected to check for x-ray results at shift start and end and immediately notify the NP when results are available.
Two residents with severe dementia were involved in an incident where one was observed placing his hand inside the other's diaper area in the activity room. The event was witnessed by another resident and an activity aide, who intervened and alerted staff. Both residents were unable to recall the incident due to cognitive impairment, and a body assessment found no injuries. The facility's failure to prevent this contact resulted in a deficiency related to abuse prevention.
A resident reported to family that a CNA had hit him, and the family informed facility management. Despite the facility's policy requiring immediate removal of staff accused of mistreatment, the CNA continued to work with the resident the next day. The DON did not return a call from the family seeking assurance that the CNA would not care for the resident, and the Operations Manager did not clarify the allegation or ensure proper action was taken.
A resident's family reported to the Operations Manager that a CNA was rough and allegedly hit the resident, but this allegation was not immediately communicated to the Abuse Coordinator or reported to the State Agency as required. The initial report was sent approximately 48 hours after the allegation, contrary to the facility's policy for immediate reporting.
The facility failed to ensure that call lights were within reach for three residents at risk for falls. One resident had the call light clipped to the opposite side of the bed, another had it clipped behind the bed, and a third had it coiled and clipped to the wall. All residents had care plans indicating a risk for falls due to weakness, with interventions to keep call lights accessible.
A resident with Parkinson's Disease suffered a third-degree burn after being handed a cup of hot coffee from an unregulated single-serving coffee maker. The coffee spilled onto her leg, causing a severe burn due to the high temperature. The facility failed to monitor the coffee temperature, leading to the incident.
Two residents in a facility experienced an incident of resident-to-resident abuse. One resident, with a history of schizoaffective disorder and aggressive behavior, physically assaulted another resident, who has schizophrenia and cognitive deficits. Despite the known risks and previous aggressive incidents involving the aggressor, the facility failed to prevent the assault, highlighting a deficiency in protecting residents from abuse.
A facility failed to document the notification of a Physician or NP when a resident's blood glucose levels were outside ordered parameters. The resident, with a history of diabetes and other complex conditions, had frequent instances of hypoglycemia and hyperglycemia. Despite the facility's policy, there was no documentation of notifications on several occasions, as confirmed by the DON and NP.
A resident with a right hand contracture and multiple medical conditions, including diabetes, was found with a long, thick nail causing pain. The resident reported inadequate hand cleaning, and a CNA noted the difficulty in cutting the nail, stating that nurses were responsible. The DON acknowledged the resident's frequent refusal of care and the lack of recent attention to the nail issue. The facility's policy for nail care, especially for diabetic residents, was not followed, as documented in the Treatment Administration Record.
A resident with venous stasis ulcers did not receive consistent application of dressings as ordered, leading to a deficiency in care. Despite physician orders for daily application of a support bandage, observations showed the resident's dressings were not applied, and staff interviews confirmed noncompliance and lack of documentation. The facility's policy on skin alterations was not followed, resulting in inadequate wound care management.
A resident with hemiparesis and hemiplegia did not receive necessary ROM therapy, leading to a decline in mobility. The resident's care plan required ROM exercises, but these were discontinued without explanation. The DON incorrectly assumed dressing the resident sufficed for ROM therapy. Incomplete assessments and task sheets further highlighted the facility's failure to provide adequate care.
A resident, dependent on staff for transfers, was injured during a mechanical lift transfer when only one CNA was present, contrary to the facility's policy requiring two staff members. The resident sustained a bruise to the eye when the lift's arm hit her. The incident was reported by the resident and confirmed by a nurse, highlighting a failure to adhere to safety protocols.
A facility failed to have physician orders for a suprapubic catheter and its care for a resident with a neurogenic bladder. The resident returned from the hospital without rewritten catheter orders until months later. The Director of Nursing admitted the orders should have been on the TAR to remind staff of the care needed. The resident's POS lacked catheter orders, and the MARs for April and May did not include catheter treatments. The facility's catheter care policy did not specify when to change the catheter, except when dislodged.
A resident with significant weight loss was not adequately assisted or encouraged with meals, leading to continued nutritional decline. Observations showed the resident often ate alone without necessary supervision, and meal documentation inaccurately reported food intake. Despite care plans and physician orders for fortified foods and supplements, these were not effectively administered, contributing to the resident's weight loss.
Two residents received incontinence care that did not adhere to infection control practices. A CNA placed soiled linens on a chair and did not change gloves before assisting a resident with other tasks. Another CNA placed soiled items on the floor before bagging them. These actions were against the facility's policies, which require soiled linens to be transported in closed bags and not placed on the floor to prevent cross-contamination.
A resident with multiple medical conditions was left in urine for hours after a staff member refused to assist her to the bathroom, causing emotional distress and embarrassment. The incident was reported by a CNA and corroborated by the resident's daughter, leading to the staff member's termination.
Missed Evening Medication Pass for Multiple Residents Due to Unstaffed Nursing Shift
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors when an entire wing of residents did not receive their scheduled 8:00 PM medications on 3/28/26. For 20 of 23 residents reviewed, including residents with conditions such as Type 2 diabetes, neuropathy, restless leg syndrome, hyperlipidemia, epilepsy, hypertension, depression, glaucoma, insomnia, and pain, the March 2026 MARs showed that ordered evening medications were not administered. One resident with intact cognition had physician orders for Lantus insulin, melatonin, and pregabalin at 8:00 PM for diabetes, insomnia, and pain, but the MAR showed these were not given on that date. Another cognitively intact resident with orders for nabumetone, Entresto, trazodone, and atorvastatin did not receive any 8:00 PM medications. A resident with epilepsy, hypertension, depression, and glaucoma did not receive ordered doses of Vimpat, metoprolol, mirtazapine, trazodone, and latanoprost eye drops. A facility list also showed that additional residents (R5–R20) did not receive their 8:00 PM medications that evening. Interviews confirmed that residents did not receive their evening medications because the nurse assigned to their wing for the 6 PM–10 PM shift did not show up, and facility leadership was not notified until the following day. One resident reported not receiving insulin, pain, or sleep medications, describing higher blood sugar the next morning, inability to sleep, and leg pain from neuropathy. Another resident reported not receiving evening medications for depression and insomnia and described poor sleep and fatigue the next day. A third resident stated she did not receive her evening medications but noted her pain was not severe that night, while another resident reported not getting any evening medications at all. The DON, administrator, and nurse practitioner each stated that residents are expected to be under the care of a nurse 24/7 and that medications are to be administered as ordered, with the nurse practitioner specifically noting that missing pain and sleep medications could cause increased pain and insomnia, and that missing an antiepileptic dose could increase seizure risk. Facility policies and the facility assessment indicated that medications are to be administered at the correct time by a licensed nurse and that skilled nursing, including medication administration, must be provided 24 hours a day, 7 days a week.
Missed Evening Medications Due to Absence of Licensed Nurse
Penalty
Summary
The facility failed to provide sufficient licensed nursing staff to meet residents’ needs when an agency nurse assigned to one wing for the 6 PM–10 PM shift did not report to work, resulting in 20 of 23 sampled residents not receiving their scheduled 8:00 PM medications on 3/28/26. Medication Administration Records (MARs) showed that one resident did not receive prescribed evening doses of Lantus insulin, Melatonin, and Pregabalin; another did not receive Melatonin and Trazodone; a third did not receive Nabumetone, Entresto, Trazodone, and Atorvastatin; and a fourth did not receive Vimpat, Metoprolol Tartrate, Mirtazapine, Trazodone, and Latanoprost eye drops. A facility list dated 3/28/26 showed that residents 5 through 20 on that wing also did not receive their 8:00 PM medications. Multiple residents reported that they did not get their evening medications that night because there was no nurse on the unit. The DON stated that each resident must be assigned to a nurse 24 hours a day, 7 days a week, and confirmed that the residents on that wing did not receive their 8:00 PM medications because the agency nurse scheduled from 6 PM–10 PM never arrived, and that she was not informed of the no‑show until the following day. The Administrator similarly stated that the residents did not receive their medications because the assigned nurse did not show up and that she was not notified until the next day. Two CNAs assigned to the affected wing reported that they were told the nurse was running late, became busy providing care, and either assumed the nurse eventually arrived or assumed others were aware there was no nurse; neither CNA notified any staff or administration that no nurse was present. An LPN assigned to a different wing stated he did not learn that the nurse had not shown up to cover the affected unit until 10 PM, and no one had reported the absence to him, leaving the wing without a licensed nurse to administer scheduled evening medications.
Failure to Supervise Medication Administration and Lack of Order for Self-Administration
Penalty
Summary
The deficiency involves the facility’s failure to supervise a resident during medication administration and to ensure that self-administration occurred only with a physician’s order. The resident was assessed as cognitively intact but with range of motion limitations in both upper and lower extremities and was dependent on staff for all other activities of daily living. Her admission record listed multiple diagnoses, including MRSA infection, local skin and subcutaneous tissue infection, disruption of an external surgical wound, chronic kidney disease stage 3A, chronic pain syndrome, major depressive disorder, generalized anxiety disorder, extracorporeal dialysis catheter, colostomy, anemia, bilateral hip osteoarthritis, lower abdominal pain, type II diabetes mellitus, and a healing right femur fracture. During a morning medication pass, an RN administered the resident’s insulin injection and nasal spray, then placed the remainder of her morning medications in cups on the bedside table and left the room without observing her take them. The unsupervised medications included 18 different drugs, such as clonidine, buspirone, amlodipine, ferrous gluconate, liquid protein supplement, glipizide, gabapentin, losartan, lorazepam, metformin, metoprolol, oxybutynin ER, terazosin, sertraline, senna-docusate, pantoprazole, Miralax in water, and milk of magnesia. The RN documented these medications as administered and moved the medication cart down the hall. Later, the resident reported that most nurses leave her pills on the bedside table without watching her take them, that she does not like this practice because she has dropped pills before, and that pills have spilled when left on the table while she was sleeping and bumped it. She also stated she is clumsy and sometimes drops a pill. Review of the resident’s orders confirmed there was no physician order permitting her to self-administer medications. Facility staff stated that residents allowed to self-administer must have a physician’s order, and the facility’s self-administration policy specified that residents may self-administer only according to a physician’s order and under specified conditions.
High Medication Error Rate Due to Late and Improperly Documented Administration
Penalty
Summary
The deficiency involves the facility’s failure to administer medications at the ordered time, resulting in an 80% medication error rate during a medication pass observation. On 3/3/26 between 8:44 AM and 9:18 AM, an RN was observed checking a resident’s blood sugar and administering long-acting insulin at 9:10 AM, then retrieving 19 additional medications that had been pre-poured for the same resident. At 9:12 AM, the RN administered only Flonase nasal spray and left the remaining medications on the bedside table before exiting the room. The electronic MAR showed the resident’s medications highlighted in pink/red, indicating they were overdue, yet the RN documented them as administered and moved the medication cart further down the hall. Record review of the March 2026 MAR showed multiple medications ordered for administration at 8:00 AM, including Lantus insulin, Flonase, clonidine, buspirone, amlodipine, ferrous gluconate, Pro T Gold, glipizide, gabapentin, losartan, lorazepam, metformin, metoprolol, oxybutynin ER, terazosin, sertraline, senna-docusate, pantoprazole, polyethylene glycol, and milk of magnesia, many of which were scheduled once or twice daily. Facility staff stated that medications should be administered within one hour before or after the ordered time, and that medications turning red in the system indicate they are overdue. Staff also stated that late administration of twice-daily medications affects spacing between doses and could affect therapeutic levels. The facility’s medication administration policy requires drugs to be administered in accordance with written physician orders and established procedures, which was not followed in this instance.
Unsecured Prepared Medications Left Unattended on Medication Cart
Penalty
Summary
The deficiency involves unsecured medications left unattended on a medication cart after being prepared for administration to a resident. On 3/3/26 at 9:10 AM, an RN (V5) prepared 19 different morning medications for a resident (R1) and placed them in several cups on top of the medication cart. The RN then entered the resident’s room carrying only the resident’s insulin to check blood sugar levels and administer the insulin. The medication cart, with the remaining 19 prepared medications on top, was pushed against the wall past the resident’s doorway and was not within the RN’s line of vision. During this time, another nurse, an LPN/Infection Preventionist (V4), was observed coming up the hall and was asked whether it was acceptable to leave medications on top of the cart when the nurse goes into a room. V4 stated it was not acceptable to leave medications on top of the medication cart unattended and later confirmed that, since the medications had already been prepared, they should have been placed back into the locked medication cart so other residents could not access or grab them. The facility’s policy dated 05/2025 requires resident-specific medications to be stored in a locked cabinet or cart accessible only to authorized staff, with Schedule II controlled medications stored under a double-lock system.
Failure to Use Required PPE for Resident on Contact Isolation
Penalty
Summary
The deficiency involves staff failing to follow the facility’s contact isolation and PPE requirements for a resident on contact precautions for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. The resident had multiple complex medical conditions, including chronic kidney disease, type II diabetes mellitus, chronic wounds, an indwelling urinary catheter, a colostomy, and multiple open surgical wounds to the abdomen and right lower extremity, placing her at increased risk for infection. Her care plan and physician orders specified single-room isolation with contact precautions for MRSA, and the facility’s posted signage outside her room directed all individuals to perform hand hygiene and don gloves and a gown before room entry, discarding them before exit. The facility’s written policy on contact precautions required hand hygiene prior to entering and exiting the room and mandated that all individuals entering the room use PPE appropriately, including gloves and a gown. Despite these requirements, surveyors observed multiple instances of noncompliance. An RN entered the resident’s room wearing only gloves to check blood sugar and administer insulin, during which the RN’s sweater touched the resident’s bedding. After being told by the IP nurse to wear proper PPE when entering the room, the RN re-entered the room again wearing only gloves to administer additional medications, and her sweater again contacted the resident’s bedding. Later, a CNA entered the same resident’s room without any PPE, touched the bedside table and bed rail, and interacted with the resident. The resident reported that staff do not always wear a gown and gloves when entering her room and stated she had an abdominal wound infection for which she was receiving antibiotics. The IP nurse confirmed that the resident was on contact isolation for MRSA of the abdominal wound and that the RN should have performed hand hygiene and donned both gown and gloves before entering the room.
Failure to Provide Required Showers and ADL Assistance During Contact Isolation
Penalty
Summary
The deficiency involves the facility’s failure to provide required assistance with activities of daily living, specifically bathing, to a resident who was unable to independently meet this need. Surveyors observed the resident in her room without an isolation sign posted and noted she had no shower stall in her bathroom. The resident reported that upon admission she was placed on contact isolation for a blood infection and was repeatedly told by staff she could not leave her room to shower, resulting in her not receiving a shower for approximately 11 days and feeling that she smelled bad. Certified nursing assistants stated that residents are supposed to receive showers twice a week and that residents on contact isolation can leave their rooms to shower, and one CNA acknowledged not assisting this resident with showering while she was in isolation. A registered nurse confirmed that the resident’s contact isolation was discontinued on a specific date and that she received a shower then, and that the resident had reported not receiving a shower prior to that time. The resident’s care plan documented an ADL performance deficit with interventions to assist with bathing and personal hygiene, and also noted contact isolation precautions, while the facility’s bath/shower report showed the resident did not receive showers twice weekly as required by facility policy, which states bathing is to provide cleanliness, comfort, and prevent body odors.
Failure to Implement Care-Planned Fall Prevention Interventions During Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to ensure that safety interventions were in place for a resident identified as being at risk for falls. The resident had multiple diagnoses including osteomyelitis, palliative care status, type 2 diabetes, heart disease, chronic kidney disease stage 3, hypertension, mild cognitive impairment, and lymphedema. Her care plan identified her as at risk for falls, with self-care deficits and a need for staff assistance with bed mobility, and included interventions such as using side rails for support and cueing her to grasp the side rail for positioning. A Restorative Nursing assessment documented that she was on a bed mobility program and would roll side to side during care and repositioning using side rails as needed, and that side rails were indicated as an enabler to promote independence. Despite this, staff interviews and observations confirmed that side rails were not in place prior to the fall, and the resident instead held onto the bedside table during care. On the date of the fall, a CNA reported providing incontinence care and rolling the resident to her side while the resident held onto the bedside table because side rails were not in place. The CNA stated that while reaching for a towel with one hand and maintaining one hand on the resident’s body, the resident let go of the bedside table, said she got weak, and rolled off the bed onto the floor on the right side, where the bedside table was located. The nurse on duty reported that when she entered the room after the fall, the floor mats were not on the floor and that she believed the resident hit her head on the bedside table. The fall incident report documented multiple injuries including a lump with swelling on the right forehead, right eye bruising, a chin abrasion, a small cut on the right elbow, a bruise and small cut on the right ring finger, and bruising to the left knee. Subsequent observation showed the resident in a large bariatric bed with a large dark purple/greenish bruise to the right eye/forehead area and a small laceration to the chin, with the bedside table on the right side of the bed and thick bilateral floor mats on the floor. The Restorative Nurse confirmed the resident should have had side rails for bed mobility, acknowledged that her strength varied day to day and that she should have something to hold onto when weak, and was unsure who was responsible for ensuring side rails were in place, despite the facility’s Management of Falls Policy requiring assessment of hazards and implementation of appropriate interventions to minimize fall risks.
Failure to Promptly Notify Practitioner of Radiology Results
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a practitioner of radiology results for one resident. The resident’s x-ray was performed on 1/5/26 at 6:37 PM, and the radiology report indicates the results were reported to the facility on 1/6/26 at 1:43 AM. The nurse practitioner ultimately reviewed the results on 1/6/26 at 4:59 PM. The facility’s nursing schedule shows that an RN and an LPN were assigned to the resident’s hall when the x-rays were ordered and when the results were received. The LPN reported checking the resident’s electronic medical record for updated x-ray results around 3:30 AM on 1/6/26 and stated that at that time the results still appeared as pending. The LPN did not check again for updated x-ray results for the remainder of the shift, despite being instructed that nurses should check for results at the end of each shift and notify the nurse practitioner immediately when results are received. The RN later documented in a nurse’s note on 1/6/26 at 5:30 PM that the x-ray results were relayed to the nurse practitioner, who then ordered the resident sent to the local hospital for further evaluation and treatment. However, the nurse practitioner stated that no facility staff notified them that the x-ray results had been uploaded prior to their own review at 4:59 PM on 1/6/26, and that earlier notification would have resulted in the resident being sent to the hospital earlier in the day. The Director of Nursing confirmed that the facility’s expectation is that nurses check for x-ray results at the beginning and end of their shifts and notify the nurse practitioner by call, text, or in person when results are available, to ensure the practitioner receives and reviews them.
Failure to Prevent Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect two residents with severe dementia from sexual abuse. One resident with Alzheimer's disease and a severely impaired BIMS score was observed by another resident and an activity aide making physical contact and placing his hand inside the diaper area of another resident, who was also severely cognitively impaired and on hospice care. The incident occurred in the activity room, where the resident was seen with his hand inside the other resident's pants, and staff were alerted by a witness. The staff intervened and separated the residents after the inappropriate contact was observed. Both residents involved were unable to provide details about the incident due to their cognitive impairments. The event was reported to facility management and a body assessment was conducted on the resident who was touched, with no injuries found. The care plan for the resident at risk for abuse noted interventions to keep her safe, but the incident still occurred. The facility's policy affirms residents' rights to be free from abuse, including sexual abuse, but the failure to prevent this incident resulted in a deficiency.
Failure to Remove Accused CNA from Resident Contact Following Abuse Allegation
Penalty
Summary
The facility failed to implement its Abuse Prevention Policy by not immediately removing a Certified Nurse Assistant (CNA) accused of mistreatment from resident contact. According to the facility's policy, any employee accused of mistreatment must be removed from resident contact immediately until the investigation is reviewed by the administrator or designee. In this case, a resident reported to family members that the CNA had hit him. The family relayed this allegation to the Operations Manager, who did not clarify the nature of the complaint with the resident and only reported that the CNA was 'rough' to the Assistant Administrator. The Assistant Administrator stated she was not informed of the specific allegation of being hit. Despite the report, the accused CNA continued to work as the resident's CNA the following day, as confirmed by timecard records and staff interviews. The Director of Nursing received a message from the resident's family member requesting a call back to ensure the CNA was not assigned to the resident, but did not return the call. As a result, the accused CNA maintained direct contact with the resident after the allegation was made, contrary to the facility's stated policy.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse in a timely manner to the State Agency, as required by its own policy. On a Sunday, a resident's stepdaughter and ex-wife informed the Operations Manager that the resident reported being hit by a CNA. The Operations Manager acknowledged receiving this information after 3 PM but did not report the allegation to the Abuse Coordinator. Instead, she only mentioned to the Assistant Administrator that there was an issue involving the resident's family, without specifying the abuse allegation. The Assistant Administrator confirmed that she was not informed of any abuse allegation that day. The Abuse Coordinator, who is also the facility Administrator, stated that he was not notified of the abuse allegation on the day it was reported by the family. The initial incident report was sent to the State Agency approximately 48 hours after the allegation was made, documenting that a family member reported a CNA had hit the resident and that the CNA was suspended pending investigation. The facility's abuse policy requires immediate reporting of such allegations to the Department of Public Health, but this was not followed in this instance.
Failure to Ensure Call Lights Within Reach for Residents at Risk of Falls
Penalty
Summary
The facility failed to ensure that residents at risk for falls had their call lights within reach, as observed in three out of six residents reviewed for safety. On the specified date, one resident was found sitting in a chair with the call light clipped to the opposite side of the bed, making it inaccessible. This resident's care plan indicated a risk for falls due to weakness and included an intervention to keep the call light within reach. Another resident was observed in a wheelchair with the call light clipped behind the bed, out of reach. This resident's care plan also noted a risk for falls due to generalized weakness, with a similar intervention to ensure the call light was accessible. A third resident was found with the call light coiled and clipped to the wall behind the bed, which a CNA later adjusted to be within reach. The facility's policy on fall management emphasizes assessing hazards and ensuring interventions are in place to minimize fall risks, which was not adhered to in these cases.
Resident Suffers Severe Burn from Unregulated Coffee Temperature
Penalty
Summary
The facility failed to ensure the safe serving of hot beverages, resulting in a resident, R1, suffering a severe burn. R1, who was cognitively intact and used a wheelchair for mobility, was involved in an incident where she was handed a cup of hot coffee by another resident, R2. The coffee, dispensed from a single-serving pod-type coffee maker in the counselor's office, was at a temperature that caused a third-degree burn when it spilled onto R1's left thigh. The incident occurred as R1 was being assisted by R2 to move her wheelchair, and the coffee was dropped during the exchange. R1's medical history included Parkinson's Disease, which contributed to her hand tremors and potentially affected her ability to handle the hot beverage safely. The wound resulting from the spill was extensive, measuring 12 to 14 inches in length and 5 to 6 inches in width, with nearly 100 percent of the wound covered in slough tissue. The wound care assessments confirmed the severity of the burn as third-degree, involving all layers of the skin and requiring significant medical attention. The facility's failure to monitor and regulate the temperature of the coffee from the single-serving coffee maker contributed to the incident. The coffee was found to be dispensed at temperatures significantly higher than the facility's regulated kitchen coffee machines, which were set to avoid burns. The lack of a process to measure and control the temperature of coffee from the single-serving machines on the unit was a critical oversight, leading to the severe injury sustained by R1.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident abuse, involving two residents. One resident, identified as R58, who has a history of schizoaffective disorder and aggressive behaviors, was observed to have physically assaulted another resident, R30, who has schizophrenia and cognitive communication deficits. The incident occurred when R58, who was known to have verbal and physical aggression issues, shoved and punched R30, causing him to fall to the ground. Despite the presence of staff and surveillance cameras, the facility did not prevent this incident from occurring. R58's behavioral history included multiple instances of verbal aggression, inappropriate behavior, and difficulty with redirection, as documented in his progress notes. These behaviors were known to the facility, as R58 had a care plan indicating his potential for verbal and physical aggression. Despite this, R58 was not adequately monitored or managed to prevent the assault on R30. The facility's failure to implement effective interventions and supervision for R58, given his documented history, contributed to the occurrence of the abuse. The facility's abuse policy emphasizes the protection of residents from abuse by anyone, including other residents. However, the policy's implementation was insufficient in this case, as the staff did not identify or mitigate the risk posed by R58's behaviors. The incident highlights a lapse in the facility's responsibility to ensure a safe environment for all residents, particularly those with known behavioral issues that could lead to conflict or harm.
Failure to Document Notification of Out-of-Range Blood Glucose Levels
Penalty
Summary
The facility failed to ensure that nursing staff documented the notification of a resident's Physician or Nurse Practitioner when the resident's blood glucose levels were outside the parameters ordered by the physician. This deficiency was identified for one resident, who was being treated for type II diabetes mellitus and was on insulin medication. The resident's blood glucose levels were frequently outside the ordered parameters, with instances of both hypoglycemia and hyperglycemia recorded over several months. However, there was no documentation in the nurse progress notes indicating that the Physician or Nurse Practitioner was notified of these out-of-range blood glucose levels on multiple occasions. The resident in question had a complex medical history, including diagnoses of schizoaffective disorder, encephalopathy, generalized anxiety disorder, and adult failure to thrive, and was assessed to have moderate cognitive impairment. Despite the facility's policy requiring notification of the Physician if blood glucose results were outside the given parameters, the Director of Nursing acknowledged that while nurses reported the levels to the Nurse Practitioner, they failed to document these notifications. The Nurse Practitioner confirmed the resident's condition as a brittle diabetic, indicating that the resident's blood glucose levels were difficult to manage, with significant fluctuations occurring with changes in insulin dosage.
Failure to Provide Adequate Nail Care for Resident with Contracture
Penalty
Summary
The facility failed to provide adequate care for a resident's right hand contracture and nails, as observed during a survey. The resident, who has a history of type 2 diabetes mellitus, Parkinson's disease, schizoaffective disorder, cellulitis of the right lower limb, spastic hemiplegia, adult failure to thrive, and a history of falling, was found with a contracted right hand and a long, thick nail on the right thumb. The resident reported that staff do not clean her right hand, and the nails were causing pain by cutting into her hand. A CNA acknowledged the difficulty in cutting the thick nail and mentioned that nurses were responsible for cutting the resident's nails, but the resident often refused care. The Director of Nursing (DON) confirmed that the resident frequently refuses care and that staff should re-approach later when care is refused. However, the DON was unaware of any recent discussions about the resident's nails and noted that the order for nurses to cut the resident's nails weekly was discontinued, as it should not have been in place. The Treatment Administration Record indicated that the nails were to be cut weekly by the night shift nurse, but this was not completed as documented. The facility's policy requires all residents to have clean, well-trimmed nails, with diabetic residents' nails to be cut by a nurse, which was not adhered to in this case.
Failure to Consistently Apply Dressings for Resident with Venous Stasis Ulcers
Penalty
Summary
The facility failed to ensure that a resident's dressings were consistently applied as ordered, leading to a deficiency in care. The resident, identified as R20, has multiple medical conditions including venous insufficiency and peripheral vascular disease, which require specific wound care management. Despite physician orders to apply a multipurpose support bandage to both lower extremities every morning and remove it at bedtime, observations and interviews revealed that these dressings were not consistently applied. On one occasion, R20 was observed with multiple open sores on her lower left leg, with drainage present, and reported that the dressings were not applied as scheduled. The facility's records showed that the treatment administration record for June 2024 did not document the completion of R20's leg wound dressing and support bandage on a specific date. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that R20 was noncompliant with her dressings, often removing them herself. However, there was a lack of documentation regarding these incidents and the reapplication of dressings. The facility's policy on skin alterations emphasizes the need for individualized care plans and appropriate treatment, which was not adhered to in this case.
Failure to Provide Range of Motion Therapy
Penalty
Summary
The facility failed to provide necessary services to prevent the decline in a resident's Range of Motion (ROM). The resident, who has hemiparesis and hemiplegia affecting her left side following a cerebral infarction, was supposed to receive ROM therapy as part of her care plan. However, the resident reported that the facility was not providing the ROM therapy, leading to a loss of mobility in her left arm. Observations confirmed that the resident's left arm was bent and close to her body, with a rolled-up washcloth in her hand, indicating a lack of proper ROM exercises. The Restorative Nurse acknowledged that the resident was on a restorative ROM program, which was discontinued in February 2024, without a clear reason. The Director of Nursing mistakenly believed that dressing the resident counted as ROM therapy. Additionally, the Restorative Nursing Assessments from February to June 2024 were incomplete, lacking documentation of goals, progress, or changes needed in the restorative plan. The resident's task sheet also did not list ROM under the restorative category, further indicating a lapse in the provision of necessary care to maintain or improve the resident's ROM.
Failure to Safely Transfer Resident with Mechanical Lift
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in an injury. The resident, who was cognitively intact and dependent on staff for transfers due to conditions such as morbid obesity, osteoarthritis, and congestive heart failure, was supposed to be transferred with the assistance of two staff members as per her care plan. However, during a transfer from her bed to a recliner, only one CNA was present, and the resident was injured when the arm of the lift hit her in the eye, causing a bruise. The incident was reported by the resident and confirmed by a Registered Nurse who observed the injury. The facility's policy mandates that two caregivers are required to operate the mechanical lift to ensure resident safety. Despite this policy, the CNA attempted the transfer alone, which led to the resident's injury. The Director of Nursing and other staff confirmed that the policy was not followed, and attempts to contact the CNA involved were unsuccessful.
Lack of Physician Orders for Suprapubic Catheter Care
Penalty
Summary
The facility failed to ensure there were physician's orders for a suprapubic catheter and its care for a resident with a neurogenic bladder, anxiety, agitation, and paranoia. The resident returned from the hospital in March 2023, but the catheter orders were not rewritten until June 26, 2024. The Director of Nursing acknowledged that the orders should have been documented on the Treatment Administration Record (TAR) to remind staff of the necessary care and to document its completion. The resident's Physician Order Sheet (POS) lacked orders for the suprapubic catheter prior to June 26, 2024, and the Medication Administration Records (MAR) for April and May 2024 did not include treatments for the catheter. The facility's Suprapubic Catheter Care Policy and Procedure from February 2011 did not specify when to change the catheter, except when it becomes dislodged, and indicated it should be replaced by a physician or nurse practitioner.
Failure to Assist and Document Nutritional Intake for Resident with Weight Loss
Penalty
Summary
The facility failed to ensure that a resident with significant weight loss, identified as R93, was adequately assisted and encouraged with meals. Observations revealed that R93 was often left to eat alone without assistance or verbal cueing, despite needing supervision or touching assistance for eating as indicated in the Minimum Data Set (MDS). On multiple occasions, R93's meal trays were not set up, and the resident did not consume significant portions of the meals, including fortified foods intended to supplement her diet. The documentation inaccurately reflected that R93 consumed 75-100% of her fortified potatoes, which was not the case. R93's weight log showed a significant weight loss of 7.5% from March 2024 to June 2024, with a history of gradual weight loss over six months. The resident's care plan and physician orders included fortified foods and supplements to address her nutritional needs, but these were not effectively administered or documented. The Registered Dietician (RD) and Director of Nursing (DON) acknowledged the need for accurate documentation and the importance of offering alternatives and assistance to residents with significant weight loss. The facility's Nutrition Care Significant Weight Loss policy outlines the procedure for addressing significant weight loss, including assessment by a Licensed Dietician and discussion with the interdisciplinary team. However, the facility did not adhere to these procedures, as evidenced by the lack of proper meal assistance and inaccurate documentation of R93's food intake. The failure to provide necessary support and accurate documentation contributed to the resident's continued weight loss and nutritional decline.
Infection Control Deficiencies in Linen Handling
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during incontinence care for two residents. In the first instance, a Certified Nursing Assistant (CNA) was observed providing care to a resident with severe cognitive impairment and multiple diagnoses, including hemiplegia and congestive heart failure. The CNA placed soiled linens on a chair instead of in a plastic bag and did not change gloves after handling the soiled items before assisting the resident with other tasks. This was contrary to the facility's policy, which requires soiled linens to be transported in closed impermeable bags and hand hygiene to be performed after contact with contaminated items. In the second instance, another resident with a history of type 2 diabetes, Parkinson's disease, and cellulitis, among other conditions, was observed during personal hygiene care. The CNA placed soiled items on the floor before eventually placing them in a clear plastic bag. The facility's policy mandates that soiled linen should not be placed on the floor to prevent cross-contamination. The Infection Preventionist confirmed that placing linen on the floor is against infection control practices, as it can lead to germs being spread throughout the facility.
Neglect Resulting in Resident Left in Urine for Hours
Penalty
Summary
The facility failed to ensure a resident's right to be free from neglect, resulting in a resident lying in urine for hours, causing embarrassment and emotional distress. The resident, an elderly female with multiple diagnoses including acute cystitis, acute kidney failure, and obstructive sleep apnea, reported that on the night of the incident, she used her call light to request assistance to go to the bathroom. However, a staff member responded with a nasty remark and did not assist her, leaving her to wet herself. The resident felt afraid to ask for further help and was embarrassed by the situation. The next morning, a CNA found the resident and her bed saturated with urine and reported the incident to the administrator, describing it as neglectful care. Interviews with staff and the resident's daughter corroborated the resident's account. The daughter reported that the call light was moved out of the resident's reach, and the resident was told to urinate in her undergarment. The facility's investigation confirmed that the staff member involved was not always pleasant and had been let go due to poor performance. The facility's abuse policy defines neglect as the failure to provide necessary goods and services to avoid physical harm or mental anguish, which aligns with the events described in this incident.
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A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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