Aliya Of Crestwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Crestwood, Illinois.
- Location
- 13259 South Central Avenue, Crestwood, Illinois 60418
- CMS Provider Number
- 145681
- Inspections on file
- 48
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Aliya Of Crestwood during CMS and state inspections, most recent first.
The facility failed to ensure medications were administered and documented according to professional standards and facility policy. For multiple residents, audit reports showed that numerous scheduled morning medications were documented as given several hours after their scheduled times, while the RN responsible stated that medications were likely given on time but signed out later, contrary to the requirement to document immediately after administration. In a separate case, a newly admitted resident with COPD, anxiety, and other conditions did not receive ordered medications, including anxiolytics and respiratory treatments, during the entire first day after admission, despite the medication list and prescriptions being provided at admission and emergency stock containing some of the ordered drugs. Admission paperwork was delayed in reaching nursing staff, the MAR showed no administration entries for several ordered medications that day, and the facility could not produce a policy for ordering medications for new admissions.
Two residents at risk for falls experienced deficient safety measures when one cognitively intact, bed‑bound resident with spastic quadriplegia fell from a low air loss bed during ADL care after a CNA turned him onto a urine‑soaked, slippery mattress and tucked clean linens without first drying the surface, and another dependent resident with hemiplegia, morbid obesity, and prior documented falls was repeatedly observed in bed without the thick floor mat specified in the care plan, instead having no mat or only a thin mat despite being unable to adjust the bed independently. Additionally, surveyors twice observed unsecured, partially filled oxygen cylinders lying on the floor of a unit storage room while other cylinders were properly racked, and staff, including an LPN and the DON, acknowledged that oxygen tanks are required to be secured in racks to prevent tipping and combustion.
Two residents experienced care issues when one newly admitted resident did not receive multiple ordered medications, including psychotropic and respiratory drugs, from the afternoon of admission until the following morning despite available orders and an emergency medication supply, and another resident’s witnessed fall from bed to the floor, observed by several CNAs and reportedly assessed on the floor by an LPN, was not documented as a fall in the record and did not result in an updated fall care plan, even though the resident later self‑reported the fall and head pain to nursing staff.
A resident with epilepsy was admitted on multiple anti-seizure medications, but the evening doses of three ordered drugs were not administered because two were not available and one, although present in the dispensing system, was not given. The nurse did not document the missed doses on the MAR or notify the NP that the medications were unavailable and not administered, despite facility policy requiring notification and documentation when orders cannot be followed. The next morning, the resident experienced a seizure and was sent to the hospital.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a deficiency.
Multiple residents experienced significant medication errors due to staff failing to administer the correct dose or to provide scheduled medications on time. In one case, a resident was only given part of a prescribed antidepressant dose, while others missed doses of critical medications such as anticoagulants and hypoglycemics. These errors were confirmed through medication records and staff interviews, indicating a failure to follow established medication administration procedures.
Staff failed to follow medication administration procedures, resulting in a medication error rate above 5%. Errors included administering the wrong dose of Escitalopram, giving an enteric-coated Aspirin instead of the prescribed chewable form, and dispensing Calcium Carbonate and Lactobacillus without proper dose verification. Nurses did not consistently check orders or ensure the correct medication and dose before administration.
A resident who was cognitively intact but dependent on staff for toileting and repositioning was left soiled and saturated with urine for extended periods on multiple occasions. Staff confirmed that incontinence care was not provided in a timely manner, with call lights left unanswered and care intervals exceeding facility policy. The resident expressed distress and concern for safety due to these lapses.
Three high-risk residents with significant cognitive and physical impairments experienced multiple falls, including one resulting in a facial fracture and intracranial hemorrhage, due to staff failing to provide adequate supervision, not following care plan interventions such as two-person assistance and proper chair positioning, and not effectively modifying fall prevention strategies after repeated incidents.
A facility failed to provide a written notice and explanation for a room change to a resident's representative, as required by their policy. The resident's sister and POA reported not being informed about the room change, and the facility could not produce documentation of the notice. The policy mandates written notification and an explanation for room transfers.
A facility failed to report an allegation of abuse involving a resident with dementia. A visitor informed an RN that a CNA allegedly slapped the resident on the knee, but the RN did not report this to the DON or Administrator. Consequently, the DON was unaware of the incident until several days later. The facility's policy requires immediate reporting of such allegations, which was not followed, leading to a deficiency.
The facility failed to maintain the roof's integrity, leading to ceiling cracks and water collection in two residents' rooms. Additionally, there was a significant accumulation of dust in ventilatory outlets throughout the facility, with no cleaning schedule in place. The maintenance staff acknowledged the roof issue had persisted for three years, and the medical director highlighted the potential health risks of excessive dust for residents.
The facility failed to follow its policies for food storage, cleaning, and hand hygiene, affecting all residents receiving food. Observations revealed a foul odor in the cooler, unlabeled food items, and improper hand hygiene practices. The Registered Dietitian confirmed the importance of labeling food and maintaining hygiene, which was not adhered to, compromising food safety.
The facility failed to store and label insulin pens according to its pharmacy policy. Unopened insulin pens for two residents were not refrigerated, and an opened pen for another resident lacked an open and expiration date. LPNs acknowledged the oversight, and the DON stressed the importance of proper labeling for drug safety.
A facility failed to notify a resident's family about a newly acquired sacral wound in a timely manner, despite the resident being at high risk for skin breakdown. The wound care nurse noted the resident's decline in condition and the development of moisture-associated skin damage, but documentation of timely family notification was lacking. The facility's policy requires educating the resident's representative about pressure ulcer prevention and treatment.
A facility failed to follow its skin care prevention policy and develop a care plan for a resident at risk of skin breakdown. The resident, who was readmitted from a hospital stay, developed a facility-acquired MASD sacral wound due to fragile skin, loose stools, and moisture in briefs. Despite being dependent on all ADLs and unable to reposition themselves, the resident's care plan did not address the risk for skin integrity alteration or actual skin impairment.
A facility failed to follow its tube feeding policy by not checking a resident's G-tube for residual before administering medications and bolus feeding. An RN was observed administering medications and feeding without checking the G-tube for residual or placement, contrary to the facility's policy and the resident's physician order. Interviews with LPNs and the ADON confirmed the expectation to check for residual before such procedures.
A facility failed to follow its enteral tube medication administration policy and physician orders for a resident with a gastrostomy tube. An RN did not flush the tube with water between medications and omitted a scheduled dose of omeprazole, failing to inform the resident. The resident, with a history of gastric ulcer and esophageal obstruction, later reported stomach discomfort. The medication administration record inaccurately documented the administration of omeprazole.
A resident with multiple health conditions, including osteoarthritis and obesity, fell out of bed due to inadequate assistance during bed mobility. The CNA provided care alone, despite the resident's care plan requiring three-person assistance. This resulted in the resident sustaining a rib fracture, shoulder contusion, and knee sprain.
The facility failed to respond promptly to call lights, affecting four residents. A family member reported a 45-minute wait for assistance, while another resident waited three hours. Observations showed staff passing by an illuminated call light without responding. The facility's policy requires prompt response, which was not followed.
Failure to Timely Administer and Document Medications and to Provide Medications for a New Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were ordered, administered, and documented in accordance with professional standards and facility policy. For 12 residents, medication administration records (MARs) and Medication Admin Audit Reports dated 4/22/26 showed that multiple scheduled morning medications on 4/08/26 were documented as given several hours after their scheduled times. Examples include medications due at 7:00am, 8:00am, and 9:00am being recorded as administered between late morning and late afternoon, with delays ranging from approximately 1.5 hours to over 8 hours. The medications involved included, among others, Docusate Sodium, Hydroxyzine, Levetiracetam, Furosemide, Loratadine, Gabapentin, Aspirin, calcium supplements, Nabumetone, Polyethylene Glycol, Magnesium Oxide, Eliquis, Memantine, Sucralfate, Amlodipine, Losartan, Carvedilol, Plavix, Tizanidine, Famotidine, Pyridoxine, Thiamine, Dapagliflozin, Protonix, Lexapro, Hydralazine, Ferrous Sulfate, Metformin, Baclofen, multivitamins, Cholecalciferol, Enalapril, Coreg, Lasix, Depakote, Duloxetine, and Centrum. On interview, the RN assigned to these residents for the 7:00am–3:00pm shift on 4/08/26 acknowledged responsibility for administering their medications. The RN stated a belief that the medications had been given on time but admitted to signing them out on the MAR later than when they were actually administered, explaining that it was the first day off orientation and the focus had been on getting all medications passed out on time. The RN also acknowledged that the expectation is to sign off medications immediately after administration. The facility’s Medication Administration policy, dated 2/2026, requires staff to verify the right medication, dose, route, resident, and time, to verify that medications are administered at the proper time, and to document each medication on the MAR as it is prepared and given, including remaining with the resident to ensure the medication is swallowed and documenting reasons if a medication is not given as ordered. A separate deficiency involved a newly admitted resident who did not receive ordered medications on the day of admission. This resident, with a history including COPD, hypokalemia, alcohol abuse with withdrawal, rheumatoid arthritis, hypothyroidism, and other conditions, was admitted alert and oriented and able to communicate needs. The resident and her daughter reported that no medications were received from the time of admission in the afternoon until the following morning, including anxiety medication and breathing treatments, and that the resident was upset and awake all night while the nurse reportedly stated she was working on the medications. Review of the MAR showed that several medications, including Mirtazapine scheduled at 2100, Ativan every 8 hours for anxiety, Ipratropium-albuterol for wheezing, Lomotil for diarrhea, and Albuterol inhaler as needed for wheezing, were not signed out as given on the admission date. Staff interviews and document review showed that the admission paperwork, including the medication list and five prescriptions, was brought in by the resident’s daughter and given to the admissions staff, scanned into the system, but not promptly forwarded to the nursing unit. The Admissions Director stated that the documents were scanned and that there was a delay before they were provided to nursing when requested. The DON stated that for new admissions, the nurse is supposed to send the medication list to the pharmacy after verifying medications with the physician and clarifying the expected time of arrival, and if medications do not arrive on time, the nurse is to obtain medications from the emergency box. The emergency medication list included Ativan, Ipratropium-albuterol, and Albuterol inhaler, which were among the resident’s ordered medications. The facility was unable to provide a policy on ordering medications for new admissions, and attempts by the surveyor to contact the afternoon and night shift nurses assigned to the resident on the admission date were unsuccessful.
Failure to Implement Fall-Prevention Measures and Secure Oxygen Cylinders
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and individualized fall‑prevention interventions for residents at risk for falls, as well as failure to properly secure oxygen cylinders. One cognitively intact resident with spastic quadriplegia, diabetes, hypertension, and an indwelling urinary catheter was identified as dependent for rolling in bed and at risk for falls, skin complications, and delayed wound healing. During provision of ADL care, a CNA raised the head of the resident’s bed to about 75 degrees and began a bed bath and linen change after discovering the mattress and sheet were wet from a leaking indwelling catheter. The CNA turned the resident onto his left side toward the window and tucked clean linen under him while the low air loss mattress remained wet with urine; the resident then slipped and fell between the bed and the window onto the floor. The CNA later acknowledged that the wet low air loss mattress was slippery and that she should have dried the mattress before turning the resident and tucking linen, and both another CNA and the DON stated it was not expected for a resident to fall during ADL care and that residents should not be rolled on a wet mattress. Another resident with multiple comorbidities including cerebral infarction, hemiplegia, pneumonia, oxygen dependence, kidney disorder, type 2 diabetes, hyperlipidemia, and morbid obesity, and who was on hospice and Enhanced Barrier Precautions, was also affected by deficient fall‑prevention practices. This resident was alert and oriented to person with a low BIMS score, required a Hoyer lift with two‑person assistance, and was unable to raise or lower the bed independently. Observations on multiple occasions showed the resident in bed without the thick floor mat that was care‑planned as a fall‑prevention intervention, despite documentation that the resident had experienced two falls, one in which he was found on the floor after trying to reach the bed remote and reported hitting his head and having bilateral lower extremity pain, and another in which he was again found on the floor on the right side of the bed. Although two thick mattresses were initially observed by the resident’s door and one was reportedly intended for this resident, they were removed, and only a thin floor mat was later observed in the room, contrary to the care plan specifying a mattress. In addition to fall‑related issues, the facility failed to ensure that oxygen cylinders were stored securely in accordance with its own policies and referenced standards. On the C Wing Unit 2 storage room, surveyors twice observed two partially filled oxygen tanks lying unsecured on the floor while seven other tanks were properly secured in racks. A housekeeping aide and an LPN each acknowledged that the unsecured tanks should be in the rack, with the housekeeping aide stating the need to avoid things exploding and the LPN stating the tanks should be in racks so they do not tip over and explode. The DON later confirmed that oxygen tanks should be on a rack so they are secured and protected from combustion, consistent with facility policy requiring oxygen cylinders to be stored in designated areas and protected from mechanical shock and falling objects.
Failure to Provide Timely Admission Medications and to Document Witnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a newly admitted resident received ordered medications upon admission and the failure to document a witnessed fall in another resident’s electronic health record. Resident R156, with a history including COPD, hypokalemia, alcohol abuse with withdrawal, rheumatoid arthritis, hypothyroidism, noninfective gastroenteritis, and chest pain, was admitted on 4/20/2026 between approximately 1:30 PM and 2:00 PM. The after-visit summary and scanned admission documents listed multiple medications, including gabapentin, ipratropium‑albuterol nebulizer, mirtazapine, albuterol inhaler, amlodipine‑benazepril, diphenoxylate‑atropine (Lomotil), levothyroxine, montelukast, pantoprazole, Trelegy Ellipta, nicotine patches, and thiamine. Despite this, the medication administration record showed that on 4/20/2026, mirtazapine, Ativan 1 mg every 8 hours for anxiety, ipratropium‑albuterol nebulizer, Lomotil, and albuterol inhaler were not signed out as given. On 4/21/2026, R156 and her daughter reported that the resident did not receive any medications from the time of admission the previous afternoon until the morning of 4/21/2026. R156 stated she was upset, was awake all night, and did not receive her anxiety medication or breathing treatment, and that the nurse on duty repeatedly told her she was working on the medications. The daughter stated she had handed the hospital medication list to the social worker on arrival and did not understand why medications were not provided on time. LPN V25 reported that R156 arrived around 2:00 PM, that she took initial vital signs and handed the resident off to the afternoon nurse, and that the medication list was not available at that time. V25 stated some medications were in the cart the following morning and that she was unsure why the 6:00 AM medications had not been given, but she administered them within the allowable time window. The Admissions Director (V44) stated that R156 arrived around 2:00 PM with paperwork including a medication list and five prescriptions, and that these documents were scanned into the system at 4:00 PM. V44 reported that the front desk failed to return the paperwork to the person transporting the resident to the unit and that the documents were given to nursing staff when they requested them. The DON (V2) stated that for new admissions, the nurse is supposed to send the medication list to the pharmacy after verifying medications with the physician and clarifying the expected time of arrival, and that if medications do not arrive on time, nurses are to use the emergency box, which contains Ativan, ipratropium‑albuterol, and albuterol. The facility was unable to provide a policy on ordering medications for new admissions when requested. The deficiency also includes the facility’s failure to document a witnessed fall for Resident R8. R8, who has diagnoses including type 2 diabetes mellitus, hypertension, and spastic quadriplegia, reported that on 3/16/2026 a CNA (later identified as V40) was changing him, placed him on his side facing the window, and that he then ended up on the floor, naked. He stated the CNA left him on the floor for about 35 minutes and later returned with other staff (V17 and V41) to pick him up. R8 reported that he informed an LPN (V16) the next day that he had fallen and that she told him he needed to go to the hospital. Multiple CNAs (V17, V40, and V41) later described seeing R8 on the floor between the bed and the window and stated that LPN V25 came into the room, assessed him on the floor, took vital signs, and then assisted with or directed his transfer back to bed. In contrast, LPN V25 stated that CNA V40 told her that R8 was slipping out of bed but that she (V40) was able to put him back in bed and that he did not touch the floor. V25 reported that she did not see CNAs V17 or V41 in the room, did not assess R8 on the floor, and that when she asked R8, he said he did not fall. The Administrator (V1) stated this was the first time he was hearing about the incident and noted that staff were giving different stories. The DON (V2) stated that all falls should be documented so that the physician and family can be notified and the care plan updated, and that documentation should occur immediately after a fall. R8’s records showed a fall entry dated 3/17/2026 documenting that the resident self‑reported to the nurse on duty that he had fallen the night prior, stating he fell from the bed, hit his head, and that his head was hurting. The note indicated that after investigation and an IDT meeting it was determined that no fall occurred because staff had no knowledge of the incident and that R8 was described as extremely confused and unable to get up unassisted. However, per the later statements of CNAs V17, V40, and V41, they all witnessed R8 on the floor and reported that V25 assessed him there. No progress notes were found for a witnessed fall on 3/16/2026, and the care plan, which already identified R8 as at risk for falls and required MD and family notification for any new fall, was not updated with a new fall or new interventions related to this event.
Failure to Administer Ordered Anti-Seizure Medications and Notify Practitioner
Penalty
Summary
The deficiency involves the facility’s failure to follow its Medication Administration Policy by not ensuring timely availability and administration of a resident’s ordered anti-seizure medications and not notifying the practitioner when the medications were not available. A resident with epilepsy was discharged from the hospital with orders for three anti-seizure medications: topiramate 200 mg twice daily, phenytoin (Dilantin) 200 mg twice daily, and oxcarbazepine 1,200 mg twice daily, with the next scheduled doses due in the evening. Record review showed that none of these medications were administered that evening as directed by the hospital discharge medication list. The DON stated that due to a holiday pharmacy delivery cut-off, only phenytoin was available in the facility’s medication dispensing system, and that the nurse should have attempted to obtain medications from the dispensing system and, if not available, notify the physician and family. The DON confirmed that the nurse did not notify the nurse practitioner that two of the three anti-seizure medications were not available and that no anti-seizure medications were given that evening. The nurse practitioner reported being notified only of the resident’s admission and not of the unavailability of the anti-seizure medications or the missed evening doses, and stated he was unaware of the pharmacy’s holiday cut-off. Review of the MAR confirmed that the ordered anti-seizure medications were not administered as scheduled on the evening in question, and there was no progress note documenting notification to the practitioner about the missed doses or unavailable medications. The following morning, a progress note documented that the resident’s concerned party insisted on calling 911 because the resident had a seizure, and later documentation showed the resident was admitted to a local hospital with seizure activity. The facility’s Medication Administration Policy required that if medication is not given as ordered, the reason must be documented on the MAR and the health care provider notified, that staff should obtain medications from contingency sources if not present, and that the physician must be notified in a timely manner if an order cannot be followed, with documentation in the medical record. These policy requirements were not followed in this case.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving missed or incorrect medication administration. In one instance, a resident with a physician order for Escitalopram 30mg daily was only dispensed a 20mg tablet by an LPN, despite the order specifying the need for both a 20mg and a 10mg tablet. The medication administration record indicated that 30mg was documented as given, but only 20mg tablets were available and dispensed for several days. This discrepancy was confirmed by both the LPN and the medication records. Additionally, several residents did not receive their scheduled morning medications on time, as indicated by the electronic medication administration record showing overdue doses for medications such as Eliquis, Tizanidine, Lamotrigine, Metformin, Baclofen, and Metoprolol Tartrate. Another resident, who was cognitively intact, reported missing medications during a night shift, including Xarelto, which was confirmed by the medication administration record and the Director of Nursing. Facility policy required verification of the right medication, dose, route, resident, and time, but these procedures were not followed, resulting in significant medication errors for multiple residents.
Medication Error Rate Exceeds 5% Due to Failure to Follow Medication Orders and Procedures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with 4 errors out of 37 opportunities, resulting in a 10.81% error rate. Staff did not follow policy and procedures for medication administration, including ensuring that medication orders included a prescribed dose and verifying the correct medication, dose, and form before administration. In one instance, an LPN prepared to administer only 20mg of Escitalopram to a resident whose order required a total daily dose of 30mg, as specified in the physician order sheet and EMAR. The nurse confirmed the discrepancy after being questioned by the surveyor. Another LPN dispensed an enteric-coated Aspirin 81mg tablet to a resident whose order specified a chewable form, and the nurse confirmed the difference between the prescribed and dispensed forms after reviewing the EMAR. Additionally, a third nurse prepared to administer a 500mg Calcium Carbonate tablet to a resident whose order was for 600mg with Vitamin D, and also administered a Lactobacillus capsule without a specified dose in the order. The medication administration policy required verification of the right medication, dose, route, resident, and time, and checking orders in case of discrepancies, but these procedures were not followed.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was cognitively intact but dependent on staff for toileting and repositioning was not provided timely incontinence care. The resident was frequently incontinent and required substantial or maximal assistance to roll and reposition in bed. On multiple occasions, the resident reported being left soiled and saturated with urine for extended periods, including one instance of 3.5 hours and another of over two hours. The resident expressed feelings of stress, frustration, and concern for safety due to being left in this condition and having to rely on a single staff member for care instead of the required two-person assist. Certified nursing assistants confirmed that the resident was found soiled and saturated with urine and bed linens on at least two separate occasions, with call lights left unanswered for over an hour. Documentation and staff interviews indicated that the resident was not a heavy wetter, and the amount of urine present suggested a lack of overnight care. Facility policy required incontinence care every two hours and appropriate skin care to prevent breakdown, but these standards were not met for this resident, as evidenced by the resident's own written complaints and staff observations.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to ensure that residents identified as high risk for falls were adequately supervised and that fall prevention interventions were properly implemented and modified after incidents. One resident with dementia, muscle wasting, and a history of falls was dependent on staff for all activities of daily living and required two-person assistance with transfers using a mechanical lift. Despite these needs, the resident was left unattended in a reclining chair while staff turned away to retrieve an item, resulting in the resident attempting to get up, falling forward, and sustaining a facial fracture and intracranial hemorrhage. Documentation and staff interviews revealed uncertainty about whether the chair was properly reclined, which was necessary due to the resident's poor trunk control, and that only one staff member was assisting at the time, contrary to care plan interventions requiring two-person assistance. Another resident with central nervous system cancer, muscle wasting, and morbid obesity, also identified as high risk for falls, experienced multiple unwitnessed falls both in her room and in common areas. Despite repeated incidents, interventions primarily consisted of reminders to staff to monitor and redirect the resident, with no significant modification to the care plan or supervision practices. Staff were educated not to leave the resident unattended, but the resident continued to be found on the floor after attempting to self-transfer, indicating that supervision and monitoring interventions were not effectively implemented. A third resident with dementia and generalized muscle weakness also experienced several falls, including unwitnessed incidents and falls from a reclining chair in common areas. The interventions following these falls were limited to reminders for staff to monitor the resident more frequently, but staff could not define what constituted adequate monitoring. The facility's fall prevention policy required evaluation and modification of care plans after falls, but the records and interviews indicated that interventions were not sufficiently individualized or adjusted in response to repeated incidents, and residents continued to be left unsupervised despite known risks.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to adhere to its policy regarding room changes by not providing a written notice and explanation for a room change to a resident's representative. The deficiency involved one resident, identified as R2, whose sister and Power of Attorney (POA) reported that the facility did not discuss the room change with her, nor did she receive a copy of the room change notice. Despite requests made to the Director of Nursing, Administrator, and Social Worker, the facility was unable to present documentation of the written notice or explanation for the room change. The facility's policy, dated November 1, 2023, requires that residents and their representatives be notified in writing of room transfers, including an explanation of the move, and be given the opportunity to see the new location and meet the new roommate.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not reporting an allegation of abuse involving a resident with dementia. On February 21, 2025, a visitor informed a Registered Nurse (RN) that a Certified Nursing Aide (CNA) allegedly slapped a resident on the knee. Despite this report, the RN did not communicate the allegation to the Director of Nursing (DON) or the Administrator. As a result, the DON was unaware of the incident until February 27, 2025. The facility's abuse prevention policy, dated March 2022, mandates that any incident, allegation, or suspicion of abuse must be reported immediately to the administrator or a designated individual in their absence. This failure to report the allegation promptly constitutes a deficiency in the facility's compliance with its internal reporting requirements.
Facility Fails to Maintain Roof Integrity and Ventilatory Cleanliness
Penalty
Summary
The facility failed to maintain the integrity of its roof, resulting in ceiling cracks and rusty discoloration in two residents' rooms, with water collection buckets placed underneath the cracks. Additionally, there was an abundant collection of black and dark grey powder-like particles on the ceilings, around and in the ventilatory outlets, and on smoke detectors in these rooms. These conditions were observed by the surveyor over two consecutive days, indicating a persistent issue that had not been addressed. The maintenance staff acknowledged the roof leakage and the need for repairs, stating that the issue had persisted for about three years. Furthermore, the facility failed to ensure dust-free ventilatory outlets in all residents' rooms throughout the facility. The housekeeping director admitted that there was no cleaning schedule in place at the time of the survey, although dusting was supposed to be done weekly. The medical director emphasized the importance of a homelike environment for the elderly residents, noting that excessive dust could lead to allergic reactions or exacerbate preexisting respiratory conditions. The facility's housekeeping guidelines were not being followed, as there were no daily cleaning assignments to maintain a clean and orderly environment.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to adhere to its policies and procedures for dietary food storage, cleaning, and hand hygiene practices, affecting all 123 residents receiving food from the facility. Observations in the main kitchen revealed a strong foul odor in the cooler, with two large boxes of meat covered in a red substance, indicating possible spoilage. Several food items, including a black bean burger, boxes of tomatoes, lettuce, cucumbers, dry cereals, and bagels, were found without labeled dates. Additionally, a large unmarked can of food was stored with other canned goods, and sauces from a previous event were not discarded. In the second kitchen, ham sandwiches and milk cartons were improperly labeled, and salad dressings were spilled, creating unsanitary conditions. A bin of clean serving ladles was found with a sticky brown substance, and a dietary aide was observed not performing hand hygiene after handling soiled dishes. The Registered Dietitian confirmed that dietary staff should not transition from handling soiled to clean dishes without performing hand hygiene and emphasized the importance of labeling food with received and used by dates to prevent serving expired foods. The facility's policies on food storage, kitchen operations, and hand washing were not followed, as evidenced by the presence of odors, unlabeled food items, and improper hand hygiene practices. These deficiencies highlight a failure to maintain a clean and sanitary environment in accordance with state and federal guidelines, potentially compromising food safety for the residents.
Improper Storage and Labeling of Insulin Pens
Penalty
Summary
The facility failed to adhere to its pharmacy policy regarding the storage and labeling of insulin, as observed during a survey. Specifically, unopened insulin pens for two residents were not stored in the medication refrigerator as required by the facility's policy. Additionally, these insulin pens were not labeled with an open date, which is necessary to track their usage and expiration. The surveyor noted that the pharmacy's prescription bags clearly indicated that the insulin should be stored in the refrigerator until opened, yet this was not followed. The Licensed Practical Nurse (LPN) on duty was unaware of when the insulin was received and acknowledged the oversight in storage and labeling. Furthermore, an opened insulin pen for another resident was found without an open and expiration date label. The LPN confirmed the absence of these labels and intended to contact the pharmacy for the expiration date. The Director of Nursing (DON) emphasized the importance of labeling insulin pens with both open and expiration dates to ensure drug safety and effectiveness. The facility's pharmacy policy mandates that unopened insulin should be refrigerated and labeled with an open date once used, but these procedures were not followed, leading to the deficiency.
Failure to Notify Family of Resident's Wound Development
Penalty
Summary
The facility failed to adhere to its skin prevention policy by not notifying a resident's family about a newly acquired wound in a timely manner. The resident, who was at high risk for skin breakdown, developed a moisture-associated skin damage (MASD) sacral wound due to factors such as loose stools, moisture in briefs from sweating, and fragile skin. The wound care nurse acknowledged the resident's high risk and noted a decline in the resident's overall medical condition, which included starting dialysis treatments after a hospital readmission. Despite discussing potential skin impairments with the family on an earlier date, the facility did not document timely notification to the family about the wound's development and changes in the treatment plan. The resident's medical records indicate that a skin assessment was conducted in the presence of a family member, and no skin impairments were noted at that time. However, subsequent evaluations revealed moisture-associated skin damage, and treatment was applied as ordered. It was not until a later date that another family member was informed of the wound status and treatment orders. The facility's skin care prevention policy emphasizes educating the resident's representative about pressure ulcer prevention and treatment, yet there was no documentation of timely communication regarding the wound's deterioration and treatment changes.
Failure to Develop Skin Care Plan for At-Risk Resident
Penalty
Summary
The facility failed to adhere to its skin care prevention policy and develop a person-centered care plan for a resident at risk of skin breakdown. The resident, who was readmitted from a hospital stay in November, experienced an overall decline in medical condition and developed a facility-acquired moisture-associated skin damage (MASD) sacral wound. The wound care nurse identified the resident as being at risk due to fragile skin, loose stools, moisture in briefs from sweating, and loose skin. Despite being dependent on all activities of daily living and unable to reposition themselves, the resident's comprehensive care plan did not include a risk for alteration in skin integrity or a care plan for actual skin impairment. The facility's policy required the nursing department to review all new admissions and re-admissions to implement a prevention plan based on the resident's activity level, comorbidities, mental status, and risk assessment, which was not done in this case.
Failure to Check G-Tube Residual Before Medication and Feeding
Penalty
Summary
The facility failed to adhere to its tube feeding policy by not checking a resident's gastrostomy tube (G-tube) for residual before administering medications and bolus feeding. This deficiency was observed when a registered nurse (RN) administered medications and a bolus feeding to a resident without checking the G-tube for residual or placement. The facility's policy, as well as the resident's physician order sheet, required checking for residual before such procedures. Interviews with licensed practical nurses (LPNs) and the assistant director of nursing (ADON) confirmed that the standard practice is to check for residual before administering medications and feedings. The failure to follow these procedures was noted during a survey, affecting one resident out of three reviewed for gastrostomy tubes in a sample of five.
Failure to Follow Enteral Tube Medication Administration Policy
Penalty
Summary
The facility failed to adhere to its enteral tube medication administration policy and physician orders for a resident, leading to a deficiency. On January 22, 2025, a registered nurse (RN) was observed preparing and administering medications for a resident with a gastrostomy tube. The RN crushed the medications and dissolved them in water but did not flush the gastrostomy tube with 5-10ml of water between each medication, as required by the facility's policy. Additionally, the RN did not administer the resident's scheduled omeprazole medication because it was not present in the medication cart and failed to inform the resident of this omission. The resident, who has a medical history including gastric ulcer, esophageal obstruction, and gastrostomy, later complained of stomach discomfort to a licensed practical nurse (LPN). The resident's physician order sheet indicated that omeprazole 20mg was to be administered via G-tube twice daily, with specific instructions to flush the G-tube with 30ml of water before and after medications, and 5ml between each medication. Despite this, the medication administration record inaccurately documented that the omeprazole was administered. The facility's failure to follow its medication administration policy and physician orders resulted in a deficiency.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to the plan of care for a resident requiring assistance with bed mobility, resulting in an avoidable accident. The resident, who was diagnosed with generalized osteoarthritis, repeated falls, neuropathy, morbid obesity, and other conditions, was assessed to need three-person assistance for bed mobility. However, on the day of the incident, a Certified Nursing Assistant (CNA) attempted to provide care alone, which led to the resident falling out of bed. The incident occurred when the CNA was changing the resident's bed linens. The resident was positioned on her right side, and as the CNA pushed the linen under her, the resident slid out of bed and fell to the floor. The resident, who was cognitively intact, reported pain and was subsequently diagnosed with a non-displaced left rib fracture, a left shoulder contusion, and a sprained left knee at the hospital. Interviews with facility staff revealed that the CNA did not check the resident's care card, which indicated the need for three-person assistance. The Director of Nursing and other staff members confirmed that the resident required significant assistance with bed mobility, and the failure to provide the appropriate level of assistance was identified as the root cause of the fall.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to monitor and respond to its call light system in a timely manner, affecting four residents. A family member of one resident, who was severely cognitively impaired and dependent on assistance for activities of daily living (ADL), reported waiting 45 minutes for staff to respond to a call light. The family member had to seek help at the nurses' station, and the administrator was informed of the delay. The call light system was noted to be visual only, without an audible alert, which may have contributed to the delay in response. Another resident, who was cognitively intact but dependent on ADL care, reported waiting three hours for assistance after pressing the call light. This resident's experience highlights a significant delay in response time, which was corroborated by the resident's account of pressing the call light at 9 AM and not receiving assistance until 12 PM. Additionally, another resident, also cognitively intact and requiring substantial assistance, reported waiting over an hour for help after a CNA turned off the call light and promised to return, but did not do so until the shift change. The surveyor observed a call light illuminated for a resident with mild cognitive impairment and dependent on ADL care, which was not addressed by several staff members passing by. The call light was eventually turned off by a CNA who admitted noticing it five minutes prior but was busy at the time. The facility's policy, which mandates prompt response to call lights, was not adhered to, as evidenced by the documented delays and resident complaints.
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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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