Aliya Of Glenwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Glenwood, Illinois.
- Location
- 19330 South Cottage Grove, Glenwood, Illinois 60425
- CMS Provider Number
- 145758
- Inspections on file
- 59
- Latest survey
- April 26, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Aliya Of Glenwood during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow the written menu and did not prepare or serve the planned dinner rolls at a lunch meal for all residents receiving food from the kitchen. The cook reported not realizing dinner rolls were on the menu, and the dietary manager confirmed the rolls remained in the freezer and were not baked. Several residents, including individuals with CHF, type 2 DM, dementia, prior CVA with hemiplegia, dysphagia, osteomyelitis, paraplegia, and other chronic conditions, reported they did not receive a dinner roll and would have wanted one. Facility policy requires use of standardized cycle menus, planned and revised by the RD and dietary manager, to provide nourishing meals that meet residents’ nutritional needs and preferences.
The facility failed to ensure meals were palatable, attractive, properly cooked, and maintained at safe serving temperatures, and did not consistently follow its own dietary policies. Multiple residents with various chronic conditions, including DM, CHF, dementia, and neurologic impairments, reported that food was often burnt or undercooked, bland, and usually lukewarm rather than hot. Surveyors observed sausages and other items on a steam table at 60–65°F with no visible steam or water under the pans, mechanically altered meats that were dry and unappealing, and pureed meatloaf that appeared orange, coarse, and burnt around the edges. A test breakfast tray showed cold or lukewarm eggs, biscuits, and sausage, with only oatmeal at a higher temperature. Staff admitted they had not taken required food temperatures, temperature logs were blank, a thermometer used for temping was inaccurate, and the steam table had been operated with insufficient water. The kitchen also lacked a scale to verify meat portions, and a grievance about cold soup and inadequate portion size was documented as resolved without any investigation of temperature or quantity concerns.
Surveyors found that the facility failed to maintain sanitary conditions in the kitchen and to ensure proper hair restraints during food preparation. Inspectors observed stained ceiling tiles, old grease and dirt on walls above the steam table, food debris on the steam table, trash and debris near a floor drain, and a broken ventilation vent with heavy dust accumulation over food prep and dish areas. Despite these findings, food continued to be plated and prepared on the steam table without the area being cleaned, and a cook was observed preparing food with visible, unrestrained facial hair until reminded by the Dietary Manager to use a beard guard.
A resident with moderate cognitive impairment and multiple chronic conditions alleged that a former roommate physically assaulted him at night, repeatedly striking his left chest and causing ongoing rib pain. An LPN reported hearing a loud verbal altercation, removing the resident from the room, and being told by the resident that the roommate had slapped him, after which she assessed the resident and notified the former DON and the physician. The former roommate denied any physical altercation. The incident was not documented in the abuse reportable binder, facility leadership reported being unaware of it, and no investigation or required report to the state health department was initiated, despite facility policy requiring documentation, investigation, and timely reporting of all abuse allegations.
The facility failed to follow its staffing policy and facility assessment-based CNA ratios, resulting in inadequate CNA coverage on a night shift and a resident fall. Due to call-offs, only five CNAs were present for a census of 136 residents, with CNAs assigned between 25 and 33 residents each. A CNA reported that more help was needed to ensure proper nursing care and that some work was not completed. The DON acknowledged that there was not an appropriate number of staff available to meet resident needs at the time of the incident, despite the facility’s assessment tool specifying lower CNA-to-resident ratios for post-acute and LTC units on night shift.
A resident with significant medical conditions and limited use of the left arm reported that she previously used bilateral side rails for bed mobility but, after a bed change, no longer had both rails and had only a left side rail despite repeatedly requesting a right side rail to assist with repositioning. Therapy documentation showed she had effectively used bilateral side rails for bed mobility, and staff confirmed that side rails were later placed per her request but that no restorative assessment was completed and the care plan was not updated as required on admission, quarterly, and with changes. This resulted in a failure to develop and implement a complete, person-centered care plan addressing the resident’s need for assistive bed devices.
A resident with multiple medical conditions, including respiratory failure and end stage renal disease, and with limited use of the left upper extremity, reported that previously available bilateral side rails used for bed mobility were removed after a bed change, leaving her unable to reposition herself without a right side bed rail. She later received only a left side rail and repeatedly requested a right side rail to assist with repositioning. Therapy records documented that she had used bilateral side rails effectively for bed mobility and had specific ROM and bed mobility recommendations. The restorative nurse and DON acknowledged that no restorative assessment was completed upon admission or with the change in condition, despite facility policies requiring restorative and bed rail assessments, including a Restorative Comprehensive Assessment/side rail review, upon admission, quarterly, and with significant changes in function.
A resident with multiple chronic conditions, including respiratory failure, anxiety disorder, end-stage renal disease, and anemia, did not receive a prescribed daily Pregabalin 50 mg pain medication for several days, despite it being ordered for morning administration. The resident reported asking staff about the missing medication in the cart and avoided using a PRN Hydrocodone-Acetaminophen 5-325 mg due to constipation. Review of the MAR and controlled drug records confirmed multiple missed doses, while interviews with the Administrator and DON showed that facility policy requires nurses to obtain unavailable medications from an electronic dispenser or contingency supply, contact the pharmacy as needed, and document reasons for missed doses on the MAR, which was not done.
The facility failed to coordinate and follow through on dental services and recommendations for three residents, including one with dementia and documented oral pain, one cognitively intact resident awaiting upper dentures after extractions, and another resident identified as a poor candidate for dentures who might try a new denture. Care plans and dental consults called for arranging dental care, monitoring oral problems, and pursuing denture fitting, but staff did not ensure timely appointments, did not document or track follow-up visits, and did not communicate dental recommendations to the appropriate departments. Key staff, including the HIM Director and DON, were unaware of specific residents’ dental needs, and the residents were not consistently placed on the facility’s dental list, contrary to the stated process that Social Services, nursing, and the dentist would coordinate and document dental care in the EMR.
The facility failed to maintain functional handicap door push buttons at the main entrance and did not ensure timely reporting or documentation of malfunctions. A family member and front desk staff reported that a main entrance handicap button had not worked for months, and maintenance staff confirmed that all three front entrance buttons were inoperable during a surveyor inspection, despite a resident who uses a motorized wheelchair reporting intermittent function. Surveyors repeatedly found the outside front entrance button nonfunctional even after reported repairs, while maintenance logs documented door checks but did not specifically include the handicap buttons, and routine checks were not completed as stated in the facility’s preventative maintenance policy.
Two residents became involved in a verbal and physical altercation that escalated to one resident punching the other in the face, causing visible redness. One resident reported being hit in the eye during the argument and denied striking back, while the other resident admitted to punching his roommate and described concurrent agitation, verbal aggression, and threats toward staff. A CNA first noticed the red mark on the injured resident’s face and notified a nurse, and subsequent documentation, including a behavioral hospital record, identified the aggressor as a danger to others with psychosis and aggression, despite an existing facility abuse policy prohibiting abuse and mistreatment.
A cognitively intact male resident admitted for skilled therapy, with chronic pain and multiple comorbidities, repeatedly informed staff that he avoids bread, rice, noodles, pasta, corn, breaded foods, and flour because he believes they worsen his joint pain. His diet ticket clearly listed a No Added Salt diet with explicit restrictions against these items, yet during an observed meal a CNA reviewed only the ticket, failed to verify the tray contents, and served Caribbean Jerk chicken that was breaded with bread and flour. The resident became visibly upset, declined a substitute meal, and reported that this problem had occurred repeatedly despite discussions by him and his family. The RD and regional dietary consultant confirmed that the recipe contained bread and flour and that staff are expected to follow tray tickets, while other staff and the DON stated that meal tickets and resident preferences must be checked and honored in accordance with facility dietary policies.
Nursing staff did not consistently complete or document physician-ordered dressing changes for four residents with complex medical needs, as evidenced by missing initials on the Treatment Administration Record and lack of supporting documentation, despite facility policies requiring such care and documentation.
A resident receiving hospice care and identified as high risk for abuse was subjected to repeated verbal abuse, threats, and intimidation by a roommate with a history of criminal behavior and moderate cognitive impairment. Despite ongoing derogatory name-calling, threats of harm, and physical intimidation, staff failed to recognize or respond to the abuse, and background checks for the abusive resident were incomplete or missing. The affected resident experienced ongoing fear and emotional distress, with no effective intervention from facility staff.
A resident with moderate cognitive impairment and a history of criminal behavior was able to keep a BB gun in their possession due to the facility's failure to perform an admission inventory and lack of routine checks of personal belongings. The weapon was only discovered after a staff member searched the resident's items following suspicious behavior, revealing gaps in the facility's supervision and adherence to its own policies.
A resident with bilateral lower extremity burns and a history of chronic pain reported severe pain during the night and requested pain medication, but the night nurse did not provide the prescribed medication, failed to assess the pain level, and did not retrieve medication from the convenience box as required by facility policy, resulting in inadequate pain management.
Two residents did not receive their prescribed medications as ordered due to unavailability, despite facility policy requiring staff to obtain medications from the convenience box if not present. One resident missed doses of a beta blocker for several days, and another did not receive pain medication when requested, resulting in unmanaged pain. Nursing staff acknowledged not following procedures to retrieve the medications.
A resident with multiple comorbidities and moderate risk for skin impairment developed an unstageable sacral wound that was not promptly reported to a physician or NP by staff. The LPN applied a dressing without obtaining treatment orders, and the care plan was not updated until several days later, resulting in a lack of documented wound care and failure to follow facility protocols.
Staff and visitors failed to consistently follow infection control policies, including proper placement of isolation precaution signs and use of PPE, for several residents on contact and enhanced barrier precautions. Observations included missing signage, staff providing high-contact care without gowns or gloves, and a visitor entering an isolation room without PPE, despite facility policies requiring these measures.
A resident with multiple chronic conditions did not receive prescribed PRN antihypertensive medication, timely vital sign assessments, or blood glucose monitoring as ordered. Staff failed to document changes in the resident's condition and did not consistently follow up on abnormal findings, resulting in the resident becoming unresponsive and requiring hospitalization for septic shock and pneumonia.
Nursing staff did not consistently monitor or document required assessments, vital signs, and blood glucose levels for two diabetic residents, despite physician orders and facility policy. Lapses included missing blood glucose records for multiple shifts and lack of documentation following changes in condition, with staff unable to confirm or recall if assessments were performed or recorded.
A resident with multiple serious health conditions received hydromorphone for pain, but nursing staff failed to document the administration of this narcotic on the Medication Administration Record (MAR), recording it only on the Controlled Substance Record. Staff interviews confirmed that both records should have been completed, and the omission was attributed to unreported computer issues. This resulted in incomplete and inaccurate medical records, as confirmed by the DON and hospice nurse.
The facility failed to ensure meals were served at an appetizing temperature, affecting five residents. Residents reported receiving cold dinners, and temperature logs for dinner were not recorded on several dates. A new cook admitted to not documenting temperatures, despite knowing the requirement. The facility's food safety policy mandates logging temperatures for each meal to ensure safety.
A resident with multiple health conditions, including diabetes and peripheral vascular disease, experienced a delay in incontinence care, leading to moisture-associated skin dermatitis. The resident, who is frequently incontinent and requires assistance, reported long wait times for care despite using the call light. The facility's failure to conduct timely skin assessments and report new skin concerns contributed to the development of the skin condition.
A resident with multiple diagnoses, including diabetic neuropathy and opioid dependence, did not receive physician-ordered Oxycodone for over five days due to a change in facility ownership and pharmacy provider. The resident, who frequently experiences severe pain, only received acetaminophen during this period, affecting their sleep and rest. The ADON was unaware of the issue, and the facility could not provide records to show the medication was available during the transition.
A resident with dementia and a high fall risk experienced multiple falls due to inadequate supervision in an LTC facility. Despite being identified as needing close monitoring, the resident was left unsupervised, resulting in significant head injuries from falls. The facility's failure to implement effective fall prevention strategies contributed to these incidents.
A facility failed to follow its skin care prevention policy, leading to a resident developing three facility-acquired non-pressure wounds on the right foot and ankle. The resident, unable to move independently, was dependent on staff for care. Despite efforts by the wound care nurse, the facility did not consistently monitor and document the resident's skin condition, resulting in the resident being hospitalized with osteomyelitis, necrotic right heel ulceration, and sepsis. Hospital records indicated severe sepsis and necrotic right heel ulcer with wet gangrene, with the limb deemed unsalvageable.
A resident with severely contracted lower extremities and high risk for skin breakdown developed a facility-acquired pressure ulcer due to ineffective pressure-relieving interventions. Despite signs of bruising and discoloration, there was no documentation of nurse assessments or monitoring as required by the facility's skin care prevention policy and physician orders. The resident was hospitalized with a serious condition, presenting with a pressure wound with the hamstring tendon exposed.
The facility failed to reconcile controlled medications across all medication carts, with missing entries and signatures on narcotic count forms. Nurses did not perform required counts or report discrepancies, leading to unaccounted discrepancies in medication counts.
The facility failed to securely store medications, with unlocked medication refrigerators and improper storage of non-medical items like food. Additionally, a nurse left a medication cart unlocked and unattended during administration, violating facility policies.
The facility failed to follow infection control protocols during medication administration and equipment use. A nurse did not perform hand hygiene between resident contacts and did not disinfect medical equipment like pulse oximeters and BP machines after each use. Additionally, enhanced barrier precautions were not followed during IV medication administration, and nebulizer masks were improperly stored. These actions indicate systemic issues in infection control practices.
The facility failed to document the administration of the pneumonia vaccine for five residents. The Infectious Preventionist confirmed the absence of documentation, stating that vaccines should be offered upon admission and recorded when given. Facility policy requires offering and documenting immunizations as per CDC and regulatory guidelines.
A resident receiving wound care for a left heel ulcer was not provided privacy, as the wound nurse did not close the door or draw the privacy curtain, leaving the resident visible from the hallway. The nurse acknowledged the oversight, and the DON confirmed that privacy should be maintained during care. The facility could not provide a Privacy Policy related to treatment procedures.
The facility failed to conduct criminal history background checks within 24 hours of admission for three residents. Staff interviews revealed that the checks were delayed due to lack of access to request the necessary information. Additionally, one resident's name was not checked on the Illinois Sex Offender website until days after admission, contrary to the facility's policy.
A resident was found with long, dirty fingernails and expressed a desire for nail care, which staff reportedly did not provide. An LPN noted the resident sometimes refused nail care, but the DON stated that refusals should be documented in a care plan, which was not done. The resident, who is alert and verbal with several medical conditions, had no documented refusal of care plan, contrary to facility policy.
The facility failed to complete a smoking assessment and care plan for a resident who smokes, despite being listed as a smoker and requiring assistance. Additionally, the facility did not conduct fall investigations or update the care plan for another resident who experienced multiple falls. These deficiencies were identified through observations, interviews, and record reviews, highlighting lapses in adherence to facility policies on smoking safety and fall management.
Two residents in an LTC facility experienced significant medication errors. One resident received an IVPB medication at an incorrect flow rate due to an RN following incorrect practices. Another resident, with type 2 diabetes, had insulin doses held without a physician's order, despite high blood glucose levels. These errors highlight failures in adhering to physician orders for medication administration.
A resident on hospice care lacked a physician order for hospice services, and the facility failed to access hospice staff documentation of visits, affecting coordinated care. Despite a visit log indicating hospice nurse and CNA visits, documentation was missing, and the facility's policy requires such documentation for effective communication and care.
A resident with a history of falls and severe dementia sustained a left hip fracture due to the facility's failure to follow the care plan and fall protocol. Despite being identified as a fall risk, the resident was found alone in his room, not dressed appropriately, and not under supervision as required. Staff acknowledged the oversight, and the fracture was confirmed by diagnostic reports.
A resident dependent on staff for activities of daily living was found in bed without clothing, in a soiled brief, and with soiled linen. The resident's roommate noted a lack of assistance with meals and hygiene. The Director of Nursing confirmed the resident's need for full assistance, which was not provided according to the facility's policy.
The facility failed to develop a care plan addressing a resident's drug use history, resulting in the resident being found unresponsive and later pronounced dead due to a drug overdose. Despite the resident's significant medical history, the care plan lacked interventions for drug use, and staff did not observe any signs of active drug use.
Failure to Follow Written Menu and Serve All Planned Food Items
Penalty
Summary
The deficiency involves the facility’s failure to follow its written menu and provide all items listed, specifically dinner rolls at a lunch meal, for 137 residents who receive food from the kitchen. The facility’s menu cycle indicated that the lunch on 4/25/2026 was to include meatloaf, green beans, mashed potatoes, a dinner roll, bread pudding, and a beverage. During observation of meal preparation and service, there were no dinner rolls in the plating area, and residents in the dining room were served lunch trays without a dinner roll or an appropriate substitute. The cook stated they did not know dinner rolls were on the menu and therefore did not prepare any, and the dietary manager confirmed that staff forgot to make the rolls and that they remained in the freezer. The dietary manager also affirmed that following the menu is important so staff can calculate how many calories residents are receiving and ensure adequate nutrition. Multiple residents confirmed they did not receive a dinner roll and would have wanted one. One resident with diagnoses including congestive heart failure, type 2 DM, malignant neoplasm of bone, schizophrenia, anxiety disorder, monoclonal gammopathy, Alzheimer’s disease, hypertension, hyperlipidemia, and depression, and a BIMS score of 8 indicating cognitive impairment, stated they had eaten lunch and did not receive a dinner roll but would have wanted one. Another resident with diagnoses including cerebral infarction, hemiplegia/hemiparesis of the left non-dominant side, hypertension, dysphagia, type 2 DM, malignant neoplasm of the skin, and major depressive disorder, and a BIMS score of 15 indicating intact cognition, also confirmed not receiving a dinner roll and wanting one. A third cognitively intact resident with diagnoses including osteomyelitis of vertebra, hypertension, type 2 DM, anemia, neuromuscular dysfunction of bladder, and paraplegia commented that the cognitively impaired resident usually does not eat much and was probably still hungry, and also stated they would have wanted a dinner roll with lunch. The facility’s policy on standardized menus states that nourishing, palatable meals will be provided to meet residents’ nutritional needs, that standardized cycle menus are planned in advance and utilized, and that menus are revised by the registered dietician and dietary manager based on resident preferences, underscoring that the written menu is to be followed.
Failure to Provide Palatable, Properly Cooked, and Safely Held Meals
Penalty
Summary
The deficiency involves the facility’s failure to prepare and serve food that was palatable, attractive, and maintained at safe and appetizing temperatures, as well as failure to follow its own policies for temperature monitoring and standardized menus. Multiple cognitively intact residents reported longstanding concerns about the quality, taste, and temperature of meals. One resident with diagnoses including type 2 DM with neuropathy, emphysema, heart failure, and hepatomegaly stated the food had "not been good" for a long time, reported repeatedly voicing concerns to several administrators without change, and described food as overcooked or burnt and, at times, undercooked or frozen. This resident produced photographs taken in the facility showing burnt pancakes and grilled cheese sandwiches with 50–75% of the surface blackened, an undercooked grilled cheese with raw tomato and onion next to lightly buttered bread, and plain toast with hash browns that appeared light white, unseasoned, stiff, and undercooked/frozen. Surveyors directly observed meal service problems in the kitchen and dining room. During a lunch service, a cook was seen plating Polish sausages from a steam table where the sausages were of ununiform color and doneness, ranging from light tan to dark golden brown and leathery, and the mechanically altered sausage appeared ground and dry. The cook stated the sausages had been boiled and that darker ones were more done because they stuck to the bottom of the pan, acknowledged the very done sausages did not look appetizing, and admitted not checking food temperatures before plating or serving. No steam or heat was observed around the steam table, and when temperatures were finally checked at the surveyor’s request, the Polish sausage, pureed sausage, and baked beans measured between 60–65°F. The dietary manager confirmed the expectation that cooks should take temperatures when cooking is finished, during holding, and right before serving, and that hot foods should be held at 135°F. The manager also confirmed there was no water/steam under the pans at that time and that the food should not have been served at those temperatures. Additional observations showed ongoing issues with palatability, temperature, and appearance. Several residents eating lunch reported their meals were not warm, describing them as lukewarm, lacking seasoning, bland, and generally not good, with one resident comparing the food to cat food and another stating the food was usually not very warm. A test breakfast tray prepared under observation showed the biscuit at 94°F, sausage patty at 101.5°F, eggs at 90.5°F, and oatmeal at 147.5°F; the surveyor found the biscuit and eggs cold, the sausage lukewarm, and only the oatmeal significantly hotter. On another day, pureed meatloaf on the steam table appeared orange, coarse, dry, pate-like, and burnt/blackened around the edges, which the dietary manager agreed was not how it should look. A cook also acknowledged that pork portions for renal diet residents looked dry and burnt around the edges, were of varied sizes, and could not be portioned with a scoop as required; the kitchen did not have a working scale to verify meat portions. The facility’s own records and staff interviews demonstrated noncompliance with established dietary policies. The temperature log for one of the observed days was blank, and the cook confirmed that breakfast temperatures had not been taken. The dietary manager admonished the cook and stated staff knew they should be taking temperatures. When thermometers were checked in ice water, one thermometer used for food temping read approximately 25°F lower than other calibrated thermometers, and the dietary manager stated that even after reheating, the food only reached 120°F with the other thermometers, confirming it had not been at the required temperature. A maintenance director later reported that a service company found no mechanical issues with the steam table and attributed the prior temperature problems to insufficient water in the table, noting only about half an inch of water had been present when at least three inches were needed to generate steam. A resident grievance about cold soup and inadequate soup portion was documented as resolved without any investigation or action regarding soup temperature or portion size, despite facility policies requiring nourishing, palatable meals, adherence to standardized menus, and daily recording of food temperatures to ensure proper serving temperatures.
Unsanitary Kitchen Conditions and Lack of Hair Restraints During Food Preparation
Penalty
Summary
Surveyors identified unsanitary food preparation and kitchen conditions affecting the facility’s food service. During a kitchen tour, they observed large black patches of stains on ceiling tiles, old brownish grease or dirt covering about 30% of the wall area above the steam table, food debris stuck to the steam table, and wrappers and debris near the drain by the steam table. A broken ventilation vent with significant accumulated dust was noted over the food preparation and dish area. The Administrator and Dietary Manager confirmed these observations, and the Administrator acknowledged that the kitchen needed to be cleaned. A cook later confirmed that the ceiling and wall stains appeared to be old grease and acknowledged that the area was not clean. Despite these identified conditions, the kitchen had not been cleaned when a cook was observed plating food on the steam table shortly after the initial tour. On a subsequent observation, another cook was seen preparing food on the steam table with visible, unrestrained facial hair. The Dietary Manager confirmed this observation and instructed the cook to wear a beard guard. These conditions and staff practices were inconsistent with the FDA Food Code requirements for hair restraints, clean and sanitized food-contact surfaces, and adequate, clean ventilation systems to prevent grease, dust, and debris accumulation in food preparation areas.
Failure to Investigate and Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow its abuse policy by not investigating an alleged physical abuse incident involving a cognitively impaired male resident with multiple chronic medical conditions, including chronic respiratory failure, COPD, major depressive disorder, asthma, hypertension, type 2 diabetes, difficulty in walking, and abnormal posture. The resident, who had a BIMS score of 12/15 indicating moderate cognitive impairment, reported that a few weeks prior his former roommate beat him up at night, punching him more than six times in the left lower chest area and causing what he described as a broken rib. He stated he was angry that he was moved to another room instead of the roommate and reported that staff did not assess his left ribs, which he said continued to hurt. Review of the facility’s abuse reportable binder for January through March did not show an incident report for this event. An LPN confirmed that on a late evening in January she heard a loud verbal altercation between the resident and his roommate, entered the room, and immediately removed the resident. The LPN stated the resident told her the roommate had slapped him, and she reported assessing the resident and notifying the former DON and the resident’s physician. The former roommate denied ever fighting with, punching, or slapping anyone. The current Administrator and DON stated they were unaware of the incident, and the Assistant Administrator confirmed that no investigation had been initiated. The Regional Nurse Consultant and Assistant Administrator acknowledged that an investigation should have been started and reported to the state health department immediately, in accordance with the facility’s abuse policy, which requires that all incidents and any allegation involving abuse be documented, investigated, and reported within specified time frames.
Inadequate CNA Night-Shift Staffing Leading to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient CNA staffing on a night shift to meet resident needs in accordance with its own Facility Assessment Tool and Staffing Policy, resulting in a resident fall. On the night in question, the facility’s midnight census was 136 residents, and the facility was scheduled to have eight CNAs but had only five due to call-offs. The DON and Assistant Administrator stated that having five CNAs for a census of 136 should not impede resident care. However, the daily assignment sheet for that night documented that three CNAs on the A and B wings each had 25 residents, the CNA on Unit C had 33 residents, and the CNA on Unit D had 28 residents. The DON acknowledged that there was a resident incident/fall at 1:40 a.m. and that there was not an appropriate number of staff available to meet the needs of the residents. A CNA who worked the 11:00 p.m. to 7:00 a.m. shift reported having 25 residents assigned and stated that CNAs needed more help to ensure proper nursing care was completed, and that some work was not completed. The facility’s Assessment Tool, last updated in August 2025, specified that staffing and resource needs should be based on a holistic approach considering resident acuity, ADLs, personal preferences, and psychosocial needs, and set direct care CNA ratios for post-acute units at 1:12 and LTC units at 1:18 on night shift. The facility’s Staffing Policy, reviewed in May 2025, stated that appropriate numbers of staff must be available to meet resident needs. Despite this, the nursing management team’s handling of call-offs resulted in staffing levels and CNA-to-resident assignments that did not align with the facility’s own assessment-based staffing parameters, contributing to the fall of one resident.
Failure to Care Plan for Assistive Bed Devices for Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete, person-centered care plan addressing a resident’s need for assistive bed devices, specifically side rails for bed mobility. A resident with acute and chronic respiratory failure with hypoxia, anxiety disorder, end stage renal disease, and anemia reported that she previously had bilateral side rails and used them for bed mobility, but after a bed change she no longer had both rails. She stated she had received only a left side bed rail over a week prior and had repeatedly asked staff for a right side bed rail to help with repositioning and scooting up in bed. During interview, the resident demonstrated she was unable to use her left arm and could only grasp with her right hand, and that she could not turn or reposition herself without a right side bed rail. Staff interviews and record review showed that the facility did not complete the required restorative assessment or update the care plan to reflect the resident’s need for assistive bed devices. The Restorative Nurse stated that side rails were placed per the resident’s request on a specific date but acknowledged that no restorative assessment was completed, even though such assessments and corresponding care plan updates should occur on admission, quarterly, and as needed. Occupational therapy documentation from an earlier treatment encounter indicated that the resident had bilateral side rails and used them effectively for bed mobility. The DON confirmed that her expectation is that care plans be completed on admission, quarterly, and as needed when changes occur, and the facility’s care plan policy requires development of a baseline, person-centered care plan within 48 hours of admission, including ADL needs. Despite these requirements and the documented and observed need for bilateral side rails, the care plan did not fully address the resident’s assistive bed device needs.
Failure to Complete Restorative and Bed Rail Assessments for Resident With Limited ROM
Penalty
Summary
The deficiency involves the facility’s failure to complete required restorative and bed rail assessments upon admission and with changes in condition for a resident with limited mobility and range of motion (ROM). The resident, who has diagnoses including acute and chronic respiratory failure with hypoxia, anxiety disorder, end stage renal disease, and anemia, reported that she previously had bilateral side rails to assist with bed mobility, but after a bed change they were removed. She stated she received a left side bed rail about a week prior to the survey and had repeatedly asked staff for a right side bed rail to help with repositioning and scooting up in bed. She demonstrated that she was unable to use her left arm, could grasp only with her right hand, and could not turn or reposition herself without a right side bed rail. Interviews and record review showed that the restorative nurse acknowledged that side rails were placed per the resident’s request on 3/3/26 and that no restorative assessment had been completed, despite the facility policy requiring restorative screening upon admission, quarterly, and with any significant change in function. The DON confirmed that a restorative assessment and care plan should be completed upon admission, quarterly, and as needed for changes. Occupational therapy documentation from 2/6/26 indicated the resident had bilateral side rails and used them for bed mobility with partial/moderate assistance, and therapy recommendations dated 2/16/26 included passive ROM to the left upper extremity, active ROM to the right upper and lower extremities, and bed mobility (rolling left and right). Facility policies required assessment for restorative programs and bed rails/side rails upon admission, quarterly, and upon significant change, using a Restorative Comprehensive Assessment/Side rail review, but this process was not completed for this resident as required.
Failure to Provide Ordered Pain Medication and Follow Medication Administration Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Medication Administration policy, resulting in a resident not receiving a prescribed pain medication for multiple days. The resident reported not receiving her ordered Pregabalin 50 mg oral capsule, taken every morning for pain, for more than five days and stated she had asked staff why the medication was not in the medication cart. Review of the Medication Administration Record (MAR) for the month showed that Pregabalin was not given on six specific dates, and the Controlled Drug Record indicated the last dose was administered several days before those missed doses. The resident also stated she avoids using her PRN Hydrocodone-Acetaminophen 5-325 mg due to constipation issues. Interviews with facility leadership confirmed expectations that when a medication is not available in the nurse’s cart, nurses should obtain it from the electronic medication dispenser or contingency supply and contact the pharmacy if needed, as well as document reasons for missed doses on the MAR and notify the provider when required. The Administrator stated that nurses are able to locate medications in the facility’s electronic medication dispenser when they are not in the cart. The DON explained that a “9” on the MAR indicates the medication was not given and that nurses are expected to retrieve medications from the emergency supply and notify the physician if a refill is needed. The facility’s written Medication Administration policy requires that if a medication is ordered but not present, staff must check for misplacement, call the pharmacy, and obtain it from contingency or convenience stock if available, and document reasons for any missed doses on the MAR, which did not occur in this case.
Failure to Coordinate and Follow Through on Dental Services and Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to provide routine and 24-hour emergency dental care, follow its own dental services policy, implement care plan interventions, and ensure that dental recommendations were followed for three residents, potentially affecting 143 residents. For one resident with dementia and a BIMS score of 8, the care plan identified oral/dental problems related to edentulous tooth infection/pain and directed staff to coordinate dental care and monitor for symptoms. A handwritten note from the resident’s family requested a dental follow-up on a specific date, but there was no corresponding progress note documenting a dental visit or follow-up. Although a later progress note documented that the resident left for a dental appointment, the actual plan of care and follow-up information were not included, and the resident’s name did not appear on the facility’s dental list for several subsequent months. The Health Information Management Director reported not receiving information about the follow-up appointment, not knowing of any upcoming dental appointment for the resident, and having no communication with the resident’s daughter for approximately five months. Another resident, cognitively intact with a BIMS score of 15, had a care plan noting dental/mouth problems and an intervention to consider a dental consult as indicated. Progress notes documented that the resident returned from a dental appointment with a referral for dentures, was scheduled to return for denture fitting, and was awaiting follow-up for upper denture fitting. A later dental consult documented that the upper quadrants had no teeth and did not indicate any denture steps selected. During observation, the resident appeared to be missing all upper teeth and reported that upper teeth had been removed months earlier, that the dentist had indicated three visits would be needed for denture fitting, and that the facility had not set up the necessary appointment. The Administrator stated that the dentist was not accepting the resident’s insurance and that only after obtaining a list of in-network providers were staff in the process of scheduling an appointment, indicating a prolonged delay between the referral and arranging denture services. A third resident, with moderate cognitive impairment and a BIMS score of 9, had a prior dental consult indicating a well-fitting denture. A subsequent dental consult documented that the resident was a poor candidate for dentures due to lack of natural bone but could enroll for dental care at the facility to try a new denture. The Health Information Management Director stated that no one had provided any information about the need for new dentures, and the DON reported being unaware that the resident might require those services. The facility’s Dental Services policy, reviewed in the same time frame, required that documentation by the dentist be recorded in the medical record and that nursing document dental issues in the EMR. Interviews with the Social Service Director and DON described an expectation that residents be screened for dental services, that treatment plans be followed, and that dental orders and consults be communicated and documented, but the records and staff statements showed that these processes were not consistently carried out for the three residents.
Failure to Maintain Functional Handicap Door Push Buttons at Main Entrance
Penalty
Summary
The facility failed to keep essential entrance equipment, specifically the front entrance handicap door push buttons, in safe working condition and failed to ensure staff reported malfunctions. A family member reported that the main entrance handicap door did not open when the button was pressed, and the lead receptionist stated that one of the front entrance push buttons had not been working for a few months, while another unit entrance button was working. When questioned, the maintenance staff initially stated that no one had reported any issues with the handicap push buttons. Upon inspection with surveyors, the maintenance staff confirmed that all three front entrance handicap push buttons were not working, even though they believed the doors had been functioning days earlier. A resident who uses a motorized wheelchair and has intact cognition reported that the buttons had worked during a recent family visit, suggesting intermittent function. Subsequent observations by surveyors showed that, after the maintenance staff stated the buttons were working again, only two of the three front entrance buttons functioned, with the outside front entrance button still failing to open the door. On multiple occasions, surveyors pressed the outside front entrance handicap push button and the door did not open, despite an invoice indicating that repairs had been made and rusty connections found. The maintenance staff later acknowledged that the outside button was again reported as not working and that a replacement pad had been ordered. Review of the facility’s logbook showed that door operations, including locks, gates, and alarms, were tested and documented twice weekly, but the handicap push buttons were not specifically included on the form. The maintenance staff stated that they checked the handicap buttons weekly but did not have them listed on the documentation and also admitted that the usual checks were not performed on the most recent Monday or Tuesday, contrary to the facility’s preventative maintenance policy that requires scheduled and documented maintenance of equipment to ensure a safe, operable environment.
Resident-to-resident physical altercation resulting in facial injury
Penalty
Summary
The facility failed to protect a resident from physical resident-to-resident abuse when one resident punched his roommate in the face, causing a red mark. One resident reported that he and his former roommate were yelling at each other and that the roommate hit him in the eye, resulting in redness; he denied striking the other resident and later stated he felt safer and satisfied after a room change. The other resident admitted he had a verbal and physical altercation with his roommate, acknowledged punching him in the jaw/face, and reported having redness on his own cheek from being hit. Progress notes from the date of the incident document that the aggressor resident was observed in his room agitated, verbally aggressive, combative, yelling, using profanity, and verbally threatening staff, and that he was unable to be redirected despite several attempts to console him. The facility’s initial reportable indicated that the aggressor resident allegedly made unwanted physical contact with his roommate, with redness noted on the right side of the roommate’s face, and that the aggressor was petitioned to the hospital for evaluation. A behavioral hospital record for the aggressor resident documented a treatment plan problem of danger to others with psychosis, noting aggression at the nursing home, including punching and attacking his roommate, and describing his admission as a direct transfer from the nursing home due to psychosis and aggression, with the resident’s own chief complaint being, “I punched someone.” The final reportable summary of investigation stated that, after staff and resident interviews, the roommate reported that the aggressor struck him in the face, and a CNA had initially alerted the nurse to the red mark on the roommate’s face. Despite the facility’s written abuse policy prohibiting abuse and affirming residents’ rights to be free from abuse and mistreatment, this resident-to-resident physical altercation occurred, resulting in documented injury to the affected resident.
Failure to Honor Resident’s Documented Dietary Preferences for Bread and Breaded Foods
Penalty
Summary
The deficiency involves the facility’s failure to consistently honor a resident’s clearly documented dietary preferences, resulting in the resident being served food that he had repeatedly requested to avoid. The resident is an adult male admitted for skilled therapy services with diagnoses including vertebrogenic low back pain, PTSD, atrial fibrillation, chronic low back pain, depression, polyneuropathy, and a cardiac pacemaker. His MDS showed a BIMS score of 12, indicating intact cognition, with no acute change in mental status or disorganized thinking. From admission, the resident and his family repeatedly informed staff that he avoids bread, rice, noodles, pasta, corn, breaded foods, and flour because he believes these foods worsen his chronic joint pain. During an observation, the resident stated that he did not find the food very good and was particularly concerned about being served bread or breaded foods, which he described as “like a poison” to his joints. He reported that despite multiple discussions with staff since admission, he continued to receive these items and that his wife brought food from home several times a week so he would have food he could eat. While the surveyor was interviewing him, a CNA entered to deliver his lunch tray. The CNA was observed reviewing the meal ticket but did not compare the actual food items on the tray to the ticket. When the resident removed the cover, he found a piece of breaded chicken, became visibly sad and frustrated, and declined an offered substitute meal, stating that this problem “always happens.” Review of the meal ticket for that tray showed that the resident’s diet order included No Added Salt (NAS), regular texture, and a specific written restriction of “No Rice, Noodle, Pasta, Rice, Corn, Bread, Breading on food, Flour,” along with a listed menu of Caribbean Jerk Chicken, steamed rice, black beans, pineapple, and beverage. The regional dietary consultant confirmed that the Caribbean Jerk chicken recipe uses bread and flour for coating and acknowledged it should not have been served to this resident given the documented preferences on the ticket. The RD stated that preferences are written on the tray ticket and are expected to be followed, and that the error should have been caught in the kitchen before the tray was sent. Staff interviews, including with CNAs, a dietary aide, and the DON, confirmed that facility practice and expectations are to check meal tickets, verify that trays match residents’ diets and preferences, and send incorrect trays back to the kitchen. One CNA admitted that on the day of the observation she was “moving too fast” and failed to check the food items against the ticket, resulting in the resident receiving breaded chicken contrary to his documented dietary preferences. Facility policies, including the Dietary Standardized Menu Policy and OnTray Dietary Policies and Procedures, state that the facility will make reasonable efforts to provide appetizing food based on individual assessment and plan of care, support residents’ rights to personal dietary choices, and follow each resident’s preferences to the extent nutritionally and medically possible. Despite these policies and the clear documentation of the resident’s preferences on the meal ticket, the resident was served breaded chicken that contained bread and flour. This event, combined with the resident’s and family’s reports of multiple prior communications about his preferences, demonstrates that his dietary preferences were not consistently followed.
Failure to Complete and Document Physician-Ordered Dressing Changes
Penalty
Summary
The facility failed to follow its own policies and procedures, implement care plans, and adhere to physician orders regarding dressing changes for four residents. Documentation review revealed that for each of these residents, there were multiple instances where nursing staff did not sign the Treatment Administration Record (TAR) to indicate that ordered dressing changes were completed. Interviews with facility staff, including the wound care nurse and the Director of Nursing, confirmed that if the TAR is not signed, it is assumed the treatment was not performed, and no alternative documentation was found to show the dressings were changed as ordered. The residents involved had complex medical histories, including diagnoses such as displaced femur fracture, diabetes mellitus, heart failure, end stage renal disease, chronic kidney disease, and wounds requiring specialized care. Physician orders for these residents specified detailed wound care regimens, including daily or scheduled dressing changes, wound assessments, and documentation requirements. Despite these orders, the TARs for each resident showed missing staff initials on multiple dates, and in some cases, there was no supporting documentation in progress notes to indicate the treatments were completed. Facility policies required consistent implementation of wound care protocols, including documentation of each dressing change and regular wound assessments. The failure to document or perform these dressing changes as ordered was acknowledged by both the wound care nurse and the Director of Nursing during interviews. The Infection Preventionist also emphasized the importance of timely dressing changes to prevent infection and further wound complications. The facility's own policies and residents' rights documents underscored the necessity of providing care as ordered and maintaining accurate records, which was not done in these cases.
Failure to Protect Resident from Ongoing Verbal and Psychological Abuse
Penalty
Summary
The facility failed to protect a resident from repeated verbal and psychological abuse by another resident, in violation of its abuse prevention policy. One resident, who was on hospice care and at high risk for abuse, was subjected to ongoing derogatory name-calling, threats of physical harm, and intimidation by his roommate. The abusive resident, who had a history of criminal behavior and moderate cognitive impairment, repeatedly called the other resident disparaging names, threatened to choke and slap him, and physically kicked his bed. These incidents were corroborated by interviews with the affected resident and a third roommate, who confirmed the ongoing verbal abuse and threats. Despite the ongoing conflict and clear distress experienced by the abused resident, facility staff failed to identify or respond appropriately to the situation. Interviews with staff members, including an LPN and a nurse's aide, revealed that they either did not recall or denied witnessing any inappropriate behavior, arguing, or name-calling between the residents, even though the incidents were reported to have occurred in their presence. The administrator and social services consultant also indicated that they were unaware of any abuse or did not have complete background check results for the abusive resident, whose criminal history screening and fingerprint results were missing or incomplete at the time of admission and during the incidents. The facility's policies required immediate reporting and investigation of abuse allegations, as well as interventions to ensure resident safety. However, these procedures were not followed, and the resident continued to experience fear, anxiety, and emotional distress as a result of the ongoing abuse. Documentation showed that the resident felt unsafe, wrote notes expressing fear for his life, and reported his distress to staff, but no effective action was taken to protect him or address the abusive behavior.
Failure to Perform Admission Inventory Allows Resident to Possess Weapon
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision by not performing a required inventory check for a resident upon admission. As a result, the resident was able to possess a BB gun within the facility, which was not detected until a staff member searched the resident's belongings after noticing suspicious behavior and the smell of smoke. The facility's own policy requires an inventory of personal effects upon admission and updates when items are brought in or removed, but there was no documentation of an inventory list for this resident, nor evidence that belongings were checked after the resident returned from hospital visits or potential passes out of the facility. The resident involved had a history of criminal behavior and was assessed as moderately cognitively impaired. The care plan indicated the need for appropriate supervision and observation, but the facility did not routinely check residents' belongings unless there was suspicion. Staff interviews revealed that the BB gun was not listed on the resident's inventory at admission, and there was uncertainty about whether the resident had left the facility and returned with new items. The facility did not have a process in place to check for contraband when residents left and returned, and staff were unable to produce documentation of the resident's inventory or records of out-of-facility passes. The facility's contraband policy prohibits weapons and requires staff to act if there is suspicion of contraband, but does not mandate routine checks. The BB gun was only discovered after a staff member searched the resident's belongings due to suspicious circumstances, not as part of a standard procedure. The lack of an initial and ongoing inventory check allowed the resident to keep a weapon in their possession, which was only addressed after it was found by chance.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
A resident with a history of low back pain, venous thrombosis, embolism, post-traumatic stress syndrome, and bilateral lower extremity burns reported significant pain during the night and requested pain medication. The resident informed a CNA of her pain, which was rated as 8 out of 10, but the night shift nurse was unable to provide the prescribed pain medication, stating it was not available and would be delivered in the morning. The nurse did not retrieve the medication from the convenience box, as was expected by facility policy, and did not assess or document the resident's pain level at that time. Facility records showed that the resident had an active order for oxycodone-acetaminophen to be administered every four hours as needed for pain, and the care plan included interventions to administer pain medication as ordered. The facility's pain management policy required pain to be assessed at least once every shift and documented using appropriate pain scales. Despite these policies and orders, the resident's pain was not effectively monitored or treated during the incident, resulting in a failure to provide safe and appropriate pain management.
Failure to Provide Timely Access to Prescribed Medications
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered as ordered for two residents. For one resident with a history of heart failure and hypertension, the beta blocker Toprol XL 50mg was not administered from 8/8 to 8/11 because the medication was not available. The nurse on duty during those days stated that although she contacted the pharmacy for delivery, she did not retrieve the medication from the convenience box as required. The resident's care plan included interventions to administer medications as ordered for altered cardiac function, but the medication was marked as 'not available' in the electronic medication administration record for the missed dates. Another resident, diagnosed with low back pain, venous thrombosis, embolism, and post-traumatic stress syndrome with burn wounds, did not receive prescribed pain medication when requested during the night. The nurse confirmed that the pain medication was not available and, despite checking with the pharmacy and offering an alternative, did not obtain the medication from the convenience box. The resident reported a pain level of 8 out of 10 at the time. Facility policy requires staff to check for misplaced medications, contact the pharmacy, and obtain medications from the contingency or convenience box if available, but this protocol was not followed in these instances.
Failure to Implement Timely Wound Care Orders and Update Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to implement appropriate measures for the care and management of an unstageable sacral wound in a resident with multiple comorbidities and a rapidly declining condition. The wound was first observed by a Certified Nurse Aide and a Licensed Practical Nurse, but neither notified the Nurse Practitioner or physician to obtain treatment orders at the time of discovery. The LPN cleansed the area and applied a dry border gauze dressing without obtaining proper medical orders or updating the care plan. Documentation shows that there was no treatment administration record or physician orders for wound care for the month in which the wound was identified, and the care plan was not updated until several days later. Interviews with facility staff, including the Wound Care Nurse, Director of Nursing, and Administrator, confirmed that the expected protocol was not followed. The facility's own policies require prompt notification of a health care provider and updating of care plans when a new wound or change in skin condition is identified. The resident was at moderate risk for skin impairment and had diagnoses including encephalopathy, dysphagia, dementia, and atrial fibrillation. The lack of timely notification, absence of treatment orders, and failure to update the care plan directly contributed to the deficiency in pressure ulcer care and prevention.
Failure to Follow Infection Control Policies for Isolation Precautions and PPE Use
Penalty
Summary
The facility failed to adhere to its infection control policies regarding the placement of isolation precaution signs and the use of personal protective equipment (PPE) for residents on contact and enhanced barrier precautions. Multiple instances were observed where required signage was missing or not properly displayed, and staff or visitors entered rooms without donning appropriate PPE as mandated by facility policy. For example, a hospice account executive was seen in a resident's room on contact isolation for E. coli without wearing any PPE, despite clear signage instructing the use of gloves and gowns before entry. In another case, two CNAs provided high-contact care to a resident on enhanced barrier precautions, including dressing and urinary catheter care, without wearing isolation gowns. One CNA admitted uncertainty about the resident's precaution status and the requirements for enhanced barrier precautions. Additionally, a resident with a colostomy, who should have been on enhanced barrier precautions, had no signage at her door for several days, and the infection preventionist acknowledged the oversight, attributing it to the sign being flipped backward. A further deficiency was noted when a resident with a recent room change and an active order for contact isolation due to VRE in the urine had no signage or PPE supplies at the new room entrance. The infection preventionist only brought the necessary sign and PPE bin after being questioned by the surveyor. The facility's own policies require clear signage and the use of PPE for both transmission-based and enhanced barrier precautions, but these protocols were not consistently followed for several residents, as evidenced by direct observation and staff interviews.
Failure to Administer PRN Medication and Monitor Resident Condition
Penalty
Summary
Staff failed to administer prescribed PRN antihypertensive medication, assess and document vital signs, and monitor blood glucose as ordered for a resident with multiple complex medical conditions, including diabetes, hypertension, and heart disease. The resident exhibited a change in condition, including poor appetite, diminished lung sounds, and respiratory symptoms, but there was a lack of timely follow-up, assessment, and documentation by nursing staff. Orders for blood pressure and blood glucose monitoring were not consistently followed, with significant gaps in documentation and administration of medications. Despite the resident showing signs of respiratory distress and confusion, vital signs and blood glucose checks were not performed or recorded as required. When the resident's condition worsened, including unresponsiveness and shallow respirations, staff delayed in administering PRN blood pressure medication and failed to consistently monitor and document the resident's status. Communication with the physician was attempted, but there was confusion among staff regarding the availability of PRN medications and the appropriate steps to take when the physician could not be reached. Ultimately, the resident became unresponsive and required emergency intervention, including intubation and hospitalization for septic shock and healthcare-associated pneumonia. The lack of adherence to physician orders, incomplete documentation, and insufficient assessment contributed to the resident's deterioration and the need for acute medical care.
Failure to Monitor and Document Diabetic Assessments and Vital Signs
Penalty
Summary
Nursing staff failed to meet professional standards of practice by not adequately monitoring and documenting resident assessments, vital signs, and blood glucose levels for diabetic residents. For one resident with multiple diagnoses including type 2 diabetes, chronic kidney disease, and severe dementia, there were significant lapses in documentation. The resident was sent to the hospital for altered mental status and unstable vital signs. Documentation showed a high blood glucose reading upon return to the facility, but there were missing blood glucose records for several shifts prior to the incident, despite physician orders for twice-daily monitoring. Nursing staff could not recall or locate documentation of required assessments or blood glucose checks, and one nurse admitted to not knowing the protocol for documentation when the order was to monitor. Another resident with diagnoses including type 2 diabetes, hypertension, and dysphagia also experienced lapses in monitoring and documentation. Physician orders required blood glucose monitoring twice daily, but the last documented readings and vital signs were several days apart, with no records for multiple shifts. When congestion was noted during a medication pass, the nurse contacted the physician and received new orders but did not document any assessment or vital signs following this observation. The nurse later stated she thought she had documented the assessment but could not confirm it in the record. Facility job descriptions for nursing staff require adherence to physician orders, monitoring and documentation of resident care, and recognition and documentation of significant changes in resident condition. Despite these requirements, the records reviewed showed repeated failures to document required assessments, vital signs, and blood glucose levels, directly contravening both physician orders and facility policy.
Failure to Document Narcotic Administration on MAR
Penalty
Summary
The facility failed to accurately document the administration of a narcotic medication for a resident with multiple complex diagnoses, including type 2 diabetes, stage 4 chronic kidney disease, heart failure, and a neoplasm of the cerebral meninges. The resident, who was only alert to self and unable to answer questions about medication, had an active order for hydromorphone to be administered as needed for pain or shortness of breath. Although the Controlled Substance Record showed that the medication was administered on several occasions, there was no corresponding documentation on the Medication Administration Record (MAR) for those times in January and February. Interviews with nursing staff and the Director of Nursing confirmed that facility policy requires documentation of narcotic administration on both the Controlled Substance Sheet and the MAR, but this was not done for the resident in question. Nursing staff acknowledged the requirement to document in both records and cited ongoing computer system issues as a reason for the lack of MAR documentation, though these issues were not reported to management. The hospice nurse also reported relying on the MAR to verify pain medication administration and noted discrepancies between the MAR and the Controlled Substance Record. Facility policy clearly states that all medications must be documented on the MAR at the time of administration, but this was not followed, resulting in incomplete and inaccurate medical records for the resident.
Failure to Record Food Temperatures Leads to Cold Meals
Penalty
Summary
The facility failed to ensure that meals were served at an appetizing temperature, affecting five residents who were reviewed for dietary services. Residents expressed concerns about receiving cold dinners on several occasions, with some describing their meals as ice cold by the time they were served. The Resident Council President also noted that food was often served cold, and residents were tired of complaining about it. This issue was specific to dinner service and was ongoing, as reported by the residents. Upon review of the temperature logs for meal services, it was discovered that temperatures for dinner were not recorded on several dates. The Dietary Manager, who was absent during these dates, confirmed that a new cook was on duty and had not been documenting the temperatures as required. The cook admitted to forgetting to log the temperatures, despite knowing the importance of doing so. The facility's food safety policy requires that temperatures be logged for each meal to ensure food safety, but this was not adhered to during the specified period.
Failure to Provide Timely Incontinence Care Leads to Skin Dermatitis
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who is dependent on staff for activities of daily living, including incontinence care. This resident, who has a history of Peripheral Vascular Disease, Chronic atrial fibrillation, and Diabetes Mellitus with Diabetic Neuropathy, was assessed as frequently incontinent of bowel and bladder function and required physical assistance from nursing staff for hygiene. Despite being alert and coherent, the resident expressed frustration over the lack of responsiveness from nursing staff when using the call light for assistance. The resident reported waiting over an hour for care after using the call light, which was deactivated by staff without providing the necessary care. This delay in care led to the development of moisture-associated skin dermatitis, characterized by reddened skin with small, scattered openings in the groin area. The resident's electronic health record indicated a moderate risk for developing skin issues, but there was no documentation of skin assessments in the week leading up to the incident. During a skin integrity observation, the Wound Care Coordinator noted the skin condition as a new concern, which had not been reported by the nursing staff. The facility's Skin Care Prevention Policy requires that dependent residents be assessed for changes in skin condition and that any redness or non-blanching erythema be reported to a nurse, who is responsible for alerting the healthcare provider. The policy also mandates cleaning the skin at the time of soiling and using a topical agent as a moisture barrier for incontinent residents. However, these measures were not adequately implemented, leading to the resident's skin condition.
Failure to Provide Ordered Pain Medication Due to Pharmacy Transition
Penalty
Summary
The facility failed to provide physician-ordered pain medication for a resident experiencing pain, which was a deficiency identified during a survey. The resident, who is cognitively intact and frequently experiences pain with a score of eight out of ten on the pain scale, was admitted with diagnoses including peripheral vascular disease, Type II Diabetes Mellitus, Diabetic Neuropathy, Opioid Dependence, and Hypertension. The resident had an active order for Oxycodone 10-325mg to be administered every eight hours as needed for pain. However, due to a change in facility ownership and pharmacy provider, the Oxycodone was unavailable for more than five days, during which the resident only received acetaminophen, affecting their ability to sleep and rest. The Assistant Director of Nursing (ADON) stated that there was no interruption in pharmacy services during the transition, and they were unaware of the resident's concerns about the unavailability of Oxycodone. The facility was unable to provide the drug control sheet for the period before 11/13/24 to show the medication was available, and the Medication Administration Record indicated that Oxycodone was not administered from 11/4/24 to 11/13/24. The facility's pain management policy emphasizes a commitment to resident comfort and effective pain management, but the failure to provide the ordered medication contradicted this policy.
Inadequate Supervision Leads to Multiple Falls and Injuries
Penalty
Summary
The facility failed to adequately supervise a resident diagnosed with dementia and identified as a high fall risk, resulting in multiple falls and injuries. The resident, who had a history of falls and severe cognitive impairment, experienced three falls within a forty-five-day period. The first incident occurred when the resident was found face down on the side of her bed, although no injuries were noted at that time. Subsequent falls resulted in significant injuries, including lacerations to the back of the head requiring sutures and staples. The second fall was unwitnessed and occurred at the nurse's station, where the resident was left unsupervised. The resident attempted to stand from her wheelchair, causing it to tilt backward, leading to a head injury. Despite being identified as a high fall risk and requiring close monitoring, the resident was left without direct supervision, and staff were not present at the nursing station at the time of the fall. The facility's investigation determined that the fall was due to the resident's impulsive behavior, but interventions to prevent such incidents were not effectively implemented. The third fall happened during a change of shift when the resident attempted to stand and sit back down but missed the wheelchair, resulting in another head injury. Although staff were nearby, they were occupied with other tasks and unable to prevent the fall. The resident's care plan included interventions such as placing the resident in a high-visibility area and using anti-tippers on the wheelchair, but these measures were insufficient to prevent the falls. The facility's failure to provide adequate supervision and implement effective fall prevention strategies contributed to the resident's repeated falls and injuries.
Failure to Prevent and Monitor Non-Pressure Wounds
Penalty
Summary
The facility failed to adhere to its skin care prevention policy, resulting in a resident developing three facility-acquired non-pressure wounds on the right foot and ankle. The resident, who was unable to move independently and had contracted legs, was dependent on staff for repositioning and care. Despite the wound care nurse's efforts to manage the resident's skin condition, including obtaining orders for wound cleaning and dressing, the facility did not consistently monitor and document the resident's skin condition. This lack of consistent monitoring and documentation contributed to the deterioration of the resident's wounds. The resident's medical records indicated that there were no weekly skin observations documented between 8/9/24 and 9/1/24, when the resident was hospitalized. The CNAs documented discoloration, redness, and a skin tear on various dates, but there was no corresponding documentation of nurse assessments for these abnormalities. The nurse practitioner noted bruising and discoloration on the resident's right foot and left knee, but could not confirm if these were trauma-related. The resident's treatment administration record showed missed treatments for the right ankle wound and right foot blister on specific dates. The resident was eventually hospitalized with a serious condition, including osteomyelitis, necrotic right heel ulceration, and sepsis. The hospital records noted severe sepsis, necrotic right heel ulcer with wet gangrene, and osteomyelitis, with the limb deemed unsalvageable due to extensive necrosis. The facility's failure to implement effective interventions and monitoring led to the resident's severe condition, as evidenced by the hospital's findings and the facility's documentation lapses.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to implement effective pressure-relieving interventions for a resident with severely contracted lower extremities, who was at very high risk for skin breakdown and dependent on staff for all activities of daily living. This resulted in the resident developing a facility-acquired pressure ulcer on the left posterior distal thigh due to pressure from a posterior mold splint on the left lower leg. The resident was subsequently hospitalized with a serious condition, presenting with a pressure wound to the left posterior distal thigh with the hamstring tendon exposed. The report highlights several instances of inaction and lack of documentation by the facility staff. Despite the presence of bruising and discoloration noted by the nurse practitioner and CNAs, there was no documentation of nurse assessments for these skin abnormalities. Additionally, the facility's skin care prevention policy required dependent residents to be assessed for changes in skin condition, but there was no evidence of monitoring or reporting of the bruising and discoloration to the resident's left knee or skin to the left thigh area. The physician order sheet also required monitoring of the left lower extremity cast and surrounding areas for signs of skin breakdown, but this was not documented in the resident's medical record.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to properly account for the usage, disposition, and reconciliation of controlled medications across all four medication carts reviewed. During the survey, it was observed that the shift change narcotic count forms were incomplete, with missing entries and signatures for several days in June 2024. The registered nurses responsible for the medication carts were unaware of the discrepancies and did not perform the required narcotic counts at the beginning and end of their shifts, as per facility policy. Specific instances of discrepancies were noted, such as tampered medication cards and incorrect remaining tablet counts for residents' medications, including Tramadol, Lorazepam, and Oxycodone. In one case, a small pink tablet was found loose in the narcotic drawer, which was identified as Oxycodone. The nurses involved were unable to explain these discrepancies and did not report them to the Director of Nursing (DON) as required by the facility's policy. The facility's policy mandates that all controlled substances be counted each shift by both the off-going and on-coming licensed nurses, with any discrepancies reported in writing to a supervisor. However, the survey revealed that this procedure was not consistently followed, leading to unaccounted discrepancies in the controlled substance counts. The Director of Nursing confirmed the requirement for shift counts and reporting of discrepancies, but the survey findings indicated a systemic failure to adhere to these protocols.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications in accordance with professional principles and manufacturer recommendations. During an inspection, it was observed that the medication refrigerators in Units A, B, C, and D were unlocked, contrary to the facility's policy that requires them to be locked at all times. Additionally, non-medical items such as thickened dairy and an employee's salad were found stored in the medication refrigerators, which is against the facility's policy that prohibits the storage of food in these refrigerators. The medication refrigerator in Unit C and D was also noted to be overflowing with medications, indicating improper organization and storage. Furthermore, a registered nurse was observed leaving a medication cart unlocked and unattended in the hallway while administering medication to a resident. The nurse left the medications in a plastic cup and water on the resident's bedside table, instructing the resident to take it while she stood by the door. This action violated the facility's policy that mandates medication carts to be locked when out of sight during medication administration. The Director of Nursing confirmed these observations and acknowledged the breaches in protocol.
Infection Control Deficiencies in Medication Administration and Equipment Use
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during medication administration and medical equipment usage. Observations revealed that a registered nurse did not perform hand hygiene between resident contacts and failed to disinfect medical equipment such as pulse oximeters and blood pressure machines after each use. Additionally, the glucometer was not disinfected according to the manufacturer's recommendations, as it was not kept wet with disinfectant wipes for the required duration. These lapses in protocol were observed during interactions with multiple residents, indicating a systemic issue in infection control practices. Further deficiencies were noted in the implementation of enhanced barrier precautions (EBP) during intravenous medication administration. A registered nurse did not don a gown, as required by the facility's policy, when administering medication to a resident with a central line. This oversight was observed despite signage indicating the need for EBP, highlighting a failure to follow established protocols for preventing the transmission of multidrug-resistant organisms (MDROs). The facility also failed to properly store nebulizer masks, as observed with two residents whose masks were left uncovered on dressers without being placed in plastic bags. This practice contradicts the facility's policy, which mandates that nebulizer masks be stored in bags and changed weekly to minimize infection risk. The facility was unable to provide a policy on the disinfection of medical equipment, further underscoring the lack of adherence to infection control standards.
Failure to Document Pneumonia Vaccination for Residents
Penalty
Summary
The facility failed to ensure proper documentation of immunization administration for five residents, identified as R13, R17, R40, R55, and R71. During a record review and interview, it was found that these residents did not have documentation indicating they received the pneumonia vaccine. The Infectious Preventionist, identified as V3, provided the immunization records and confirmed the absence of documentation for the pneumonia vaccine for these residents. V3 stated that vaccines should be offered upon admission and documented in the resident's immunization record when administered. The facility's policy mandates that all residents and staff be offered and encouraged to receive immunizations as recommended by the CDC and relevant regulations, with appropriate documentation including consents, refusals, historical, and administration records.
Failure to Ensure Privacy During Wound Care
Penalty
Summary
The facility failed to ensure privacy during wound care treatment for a resident, identified as R40, who was observed receiving treatment for a left heel wound. The wound nurse, V19, conducted the treatment without closing the door or drawing the privacy curtain, leaving R40 visible from the hallway. This lack of privacy was acknowledged by V19, who admitted that the door should have been closed during the procedure. The Director of Nursing, V2, confirmed that staff are expected to maintain privacy by closing doors and drawing curtains during resident care. Despite requests, the facility was unable to provide a Privacy Policy related to treatment procedures. R40's medical history includes Type 2 Diabetes Mellitus and Peripheral Vascular Disease, and the care plan specifies daily wound care for a pressure ulcer on the left heel.
Failure to Conduct Timely Criminal Background Checks
Penalty
Summary
The facility failed to perform criminal history background checks within 24 hours of admission for three residents, identified as R118, R322, and R323, out of a sample of 26. During a record review, it was noted that the Criminal History Information Response Process for these residents was initiated after the 24-hour window. Interviews with the Admissions Director and the Administrator confirmed that the checks should have been completed within 24 hours, but the staff did not have access to request the necessary information in time. For R322, it was also noted that the resident's name was not checked on the Illinois Sex Offender website until several days after admission. The facility's policy, titled 'Abuse Policy and Prevention Program,' mandates that a criminal history background check be requested within 24 hours after the admission of a new resident and that the resident's name be checked on the Illinois Sex Offender Registration website. The failure to adhere to these procedures was identified during the survey, highlighting a deficiency in the facility's admission process and compliance with its own policies.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care and maintain hygiene for a resident, identified as R98, who was observed with long and dirty fingernails. During an observation, R98 expressed a desire to have his fingernails cut, stating that the staff does not cut them. A Licensed Practical Nurse (LPN), identified as V12, mentioned that R98 sometimes refuses nail care. However, the Director of Nursing (DON), identified as V2, stated that nail care should be provided by Certified Nursing Assistants (CNAs) and that any refusal should be documented in a care plan. A review of R98's medical records showed no indication of a refusal of care or nail care refusal care plan, despite the resident being alert and verbal with several medical conditions, including primary osteoarthritis and hemiplegia following a cerebral infarction. The facility's policy requires nail care to be offered on shower days and as needed, with refusals to be reported to a nurse, but this was not followed in R98's case.
Deficiencies in Smoking Safety and Fall Management
Penalty
Summary
The facility failed to accurately complete a smoking assessment and formulate a care plan for a resident who smokes, identified as R55. Despite being listed as a smoker by the Director of Nursing and confirmed by the Social Service Director and Activity Director, R55's smoking assessment inaccurately indicated that he does not smoke, and no care plan was formulated for smoking safety. R55, who requires assistance when smoking, was admitted with diagnoses including Diabetes Mellitus type 2, a fractured right toe, osteoarthritis, and dependence on renal dialysis. The facility's policy requires a smoking safety assessment to determine the level of assistance needed, but this was not completed for R55. Additionally, the facility failed to initiate fall investigations and update the fall care plan for another resident, R46, who experienced multiple falls. R46 had fall incidents on several occasions, but no documentation of fall investigations or updates to the care plan were noted. The Minimum Data Set/Care Plan Coordinator acknowledged that the care plan should have been updated after the interdisciplinary team investigated the falls. R46 was admitted with a diagnosis of cerebral infarction affecting the right dominant side and had a history of falls prior to admission. The facility's policy mandates that care plans be updated with new interventions based on root cause analysis after each fall, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medication as ordered by the physician, resulting in significant medication errors for two residents. For one resident, the RN prepared and administered an IVPB medication of Meropenem at an incorrect flow rate of 200 instead of the prescribed rate of 100, leading to improper infusion over one hour. This error was due to the RN following incorrect practices observed from other nurses rather than adhering to the physician's order. The resident had been readmitted with a diagnosis of osteomyelitis and required precise medication administration to manage the infection. Another resident experienced issues with insulin administration. The RN held the resident's insulin doses without a physician's order, despite the resident's blood glucose levels indicating the need for insulin. The resident, diagnosed with type 2 diabetes mellitus, had a physician's order for blood glucose monitoring before meals and insulin administration with meals. However, the RN delayed or omitted insulin administration based on the resident's eating habits, which was not in accordance with the physician's orders. This resulted in multiple instances where insulin was not administered as required, potentially affecting the resident's diabetes management.
Failure to Obtain Physician Order and Document Hospice Visits
Penalty
Summary
The facility failed to obtain a physician order for a resident on hospice care and did not access hospice staff documentation of visits to ensure coordinated care and communication. This deficiency was identified during a survey involving a resident who was admitted with diagnoses including dementia without behavioral disturbance and a benign neoplasm of the pituitary gland. Despite being on hospice care, there was no active physician order for hospice evaluation or care in the resident's chart. Additionally, the hospice binder at the nursing station contained a visit log from a hospice nurse and CNA but lacked documentation or notes of these visits. The Director of Nursing (DON) and the Social Service Director (SSD) were informed of the absence of a physician order and the missing hospice documentation. Both acknowledged that there should be a physician order for hospice services and that hospice documentation should be accessible for coordinated care. The SSD indicated that the hospice service provider maintains a binder for each resident, but was unable to locate the necessary documentation of visits from the log. The facility's policy on hospice care emphasizes the importance of communication and documentation between the LTC facility and hospice provider to ensure resident needs are met continuously.
Failure to Follow Fall Protocol Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a plan of care was followed for a resident, identified as R1, who was at risk for falls. The facility did not review information on past falls, attempt to determine the cause of falls, or anticipate and meet the resident's needs. This failure resulted in R1 sustaining a left hip fracture of the femur head. Observations and interviews revealed that R1, who has a history of falls and unspecified severe dementia with behavioral disturbances, was not adequately supervised or dressed appropriately, which contributed to the incident. Despite being identified as a fall risk, R1 was found alone in his room, contrary to the care plan that required him to be at the nurse's station or in activities. The facility's fall prevention and management policy, revised in January 2024, emphasizes the need to evaluate residents at risk for falls and modify care plans as necessary. However, the staff did not adhere to these guidelines. On multiple occasions, staff members acknowledged R1's fall risk but failed to ensure his safety by not following the established protocol. The incident report and diagnostic radiology report confirmed the fracture, and the Director of Nursing and Administrator both acknowledged the oversight in R1's care, noting that the cause of the fracture was unknown but suspected to be due to a fall.
Failure to Provide Adequate ADL Assistance to a Dependent Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for a resident identified as dependent on staff for care. On May 9, 2024, a resident was observed in bed without clothing, in a soiled incontinent brief, and with soiled bed linen. The resident's roommate reported that the resident is often left leaning, with dirty clothing, and without assistance during meals. A nurse acknowledged the resident's confusion and dependency on staff, but was unaware of the resident's specific needs. A CNA confirmed that the resident was not soiled during morning rounds but required assistance with dressing. The Director of Nursing confirmed that the resident is alert but confused, requiring full assistance with dressing, meal setup, and incontinence care. The resident's medical history includes type 2 diabetes mellitus with diabetic neuropathy, cerebral infarction, absence of bilateral lower extremities, and vascular dementia with severe psychotic disturbance. The care plan highlights the resident's need for assistance with eating, toileting, hygiene, and ensuring fresh water availability. The facility's policy mandates that all nursing personnel provide a program of activities of daily living to maintain residents at their maximal level of functioning, which was not adhered to in this case.
Failure to Address Resident's Drug Use History in Care Plan
Penalty
Summary
The facility failed to develop a resident-specific care plan with interventions to address a resident's history of drug use. This deficiency resulted in the resident being found unresponsive and non-breathing, and subsequently pronounced dead at the hospital. The resident, who was cognitively intact with a BIMS score of 14, had a history of anoxic brain damage secondary to a drug overdose and was admitted with diagnoses including poisoning by unspecified drugs and functional quadriplegia. Despite these significant medical histories, the resident's care plan did not include any interventions for drug use history. On the day of the incident, the resident was last observed alert and sleeping at approximately 7:50 am. Later, a Certified Nursing Assistant (CNA) found the resident unresponsive with purple fingertips and open eyes. A code blue was called, and CPR was initiated until emergency services arrived and transferred the resident to the hospital. The death certificate later confirmed the cause of death as a drug overdose due to toxic effects of Fentanyl and Cocaine. Interviews with staff and a friend of the resident revealed that there were no visible signs or suspicions of active drug use, and the facility had not found any drugs on the resident. During the investigation, the Director of Nursing (DON) and the Social Service Director acknowledged that the resident's care plan did not document any interventions for the history of drug use. The Social Service Director admitted that in hindsight, the resident should have been care planned for drug use. The facility's policy on comprehensive care plans mandates the development and implementation of a person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs. However, this policy was not followed in the case of the resident, leading to the tragic outcome.
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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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