Axiom Healthcare Of Mount Vernon
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Vernon, Illinois.
- Location
- 1700 White Street, Mount Vernon, Illinois 62864
- CMS Provider Number
- 145517
- Inspections on file
- 28
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Axiom Healthcare Of Mount Vernon during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, muscle wasting, poor coordination, and dependence on staff for ADLs and mobility was pushed into her room by a nurse and left behind a closed door after being noisy in a common area. CNAs reported hearing the resident faintly yelling and knocking from inside the room and stated the resident could not open the door independently. Subsequent assessments documented bruising to the resident’s finger and a large bruise on the chest, which multiple staff believed the resident could not have self-inflicted, given her limited strength and prior history of only small self-caused bruises. The resident repeatedly pointed to the injured areas and stated that a nurse hurt her, and a police report later identified the resident as the victim and the nurse as the offender in the incident.
A cognitively impaired, wheelchair-dependent resident with severe intellectual disability and multiple physical limitations was repeatedly confined to her room by a nurse, who pushed her into the room and shut the door because the resident was loudly vocalizing in the lobby. CNAs later found the resident in her room with the door closed, faintly yelling and knocking, and reported that she lacked the strength to open the door herself. The resident’s roommate heard commotion and the door being closed while the resident remained inside making noise until other staff opened the door. Afterward, staff observed bruising and swelling to the resident’s finger and bruising to the chest, and the resident persistently indicated that a nurse had hurt her and shut her in her room, consistent with the facility’s definition of involuntary seclusion.
Staff failed to promptly notify law enforcement after substantiating that a nurse pushed a severely cognitively impaired, fully dependent resident into her room, leading the resident to bruise a finger while knocking on the door. The resident had multiple physical and intellectual disabilities and was identified as at moderate risk for abuse. Although facility policy required contacting law enforcement when there is reasonable suspicion that a crime was committed by a non-resident, the administrator delayed reporting the incident to police, initially believing they had to wait for the state health department investigation, resulting in late external reporting of the abuse.
A resident with severe cognitive impairment, physical disabilities, and dependence on staff for ADLs was found with bruising to a finger and a large bruise on the chest after a night when a nurse reportedly pushed the resident into a room and shut the door, leaving the resident inside and unable to open the door. Multiple CNAs, nurses, and another resident reported hearing or observing the resident being shut in the room, later finding the resident angry, pointing to her chest and finger, and repeatedly stating that a nurse hurt her. Staff consistently stated that the resident did not have the strength to cause such a large chest bruise and did not have a history of making false accusations, although she occasionally caused small bruises to herself. The facility documented the chest bruise as a sizable injury with pain but focused its investigation on involuntary seclusion and the finger injury, did not fully interview all involved staff, and produced no evidence that the large chest bruise or the resident’s repeated abuse allegations were thoroughly investigated, despite a policy requiring investigation of all suspicious injuries of unknown source and all abuse allegations.
The facility did not provide enough nursing staff to meet resident needs, resulting in long call light response times and delays in care, especially during night shifts. Residents with significant mobility and care requirements reported waiting extended periods for assistance, sometimes having to call out for help or seek staff themselves. Staff interviews and records confirmed frequent understaffing, with only one or two CNAs present for 47 residents during some shifts, making it difficult to provide timely care and complete necessary tasks.
Staff did not consistently use or change required PPE when caring for COVID-19 positive residents, and COVID-positive individuals were not always isolated from those who were negative. Some residents with COVID-19 were observed in shared rooms with uninfected roommates and in common areas without masks. Additionally, vital signs for COVID-positive residents were not monitored or documented every shift as required by facility policy.
The facility did not have a qualified, certified Infection Preventionist overseeing the infection prevention and control program. The staff member performing most infection control duties had not completed required certification or received training, and the Administrator, though certified, was not involved in the program. Facility records indicated a certified IP should be in place, but this was not the case for the 44 residents present.
A resident with severe cognitive impairment and multiple comorbidities died from positional asphyxiation after being found with their head and neck trapped between a loose bed rail and mattress. The facility failed to attempt alternatives before bed rail use, did not complete required assessments or obtain physician orders, and used old equipment without following manufacturer guidelines. Staff lacked training and documentation was incomplete, with no incident report made after the fatal event.
A resident with a history of Type 2 Diabetes Mellitus and multiple comorbidities experienced persistently high blood sugar readings that exceeded the facility's glucometer range. Despite observable changes in condition and repeated 'HI' readings, staff did not seek emergency care, instead administering insulin and waiting for physician response. Communication breakdowns, lack of staff training, and incomplete documentation contributed to the resident's deterioration and subsequent death from probable diabetic ketoacidosis.
A resident with a history of sepsis, peritonitis, and dialysis dependence experienced severe respiratory distress after untrained staff administered an excessive volume of dialysate during a manual peritoneal dialysis procedure. Miscommunication, lack of training, and failure to follow physician orders resulted in the resident being hospitalized and intubated for respiratory failure.
A resident with severe cognitive impairment, legal blindness, and total dependence on staff experienced an unwitnessed fall from bed after the removal of a side rail, with no new fall prevention interventions implemented. Staff confirmed that no alternative measures such as alarms or fall mats were put in place, and the resident was later hospitalized with head injuries. The facility's failure to update fall interventions after the incident did not meet its own fall prevention policy requirements.
The facility did not ensure that a physician reviewed residents' care plans or signed and dated orders, as all such documentation was completed by a nurse practitioner. The Medical Director did not make patient rounds or sign progress notes, despite contractual obligations, affecting all residents.
The facility did not ensure that residents were seen by a physician at the required intervals, with the Medical Director only attending quarterly meetings and not making rounds. Instead, a Nurse Practitioner conducted rounds intermittently, and several residents reported never seeing a physician or only rarely seeing the Nurse Practitioner. Medical record reviews confirmed the absence of physician progress notes for multiple residents.
A resident with a critically high blood sugar was reported to an LPN, who attempted to contact the on-call physician but only reached voicemail and was advised by the DON to wait for a callback. The LPN was unfamiliar with the facility's electronic communication system and had not been trained on its use. A nurse later received physician orders after repeated attempts. The medical director confirmed he was unreachable due to a silenced phone, resulting in a lack of 24-hour physician coverage as required.
The facility did not provide enough nursing staff to meet residents' daily needs, leading to missed scheduled showers and delays in assistance with activities of daily living (ADLs). Multiple cognitively intact residents reported going extended periods without bathing, and staff confirmed that frequent short-staffing made it impossible to complete all required care tasks.
The facility did not serve meals according to the planned menus, frequently substituting items due to missing ingredients without proper documentation or approval from the RD. Staff reported confusion with food ordering and recipe management, and residents expressed dissatisfaction with the quality, variety, and temperature of meals. Several residents with significant medical needs, including malnutrition and diabetes, were affected by the lack of adherence to menu planning and substitution policies.
The facility did not provide food at appropriate temperatures due to a broken steam table, resulting in multiple residents consistently receiving cold and unappetizing meals. Staff and residents confirmed the ongoing issue, and the administrator acknowledged the equipment had not been repaired due to lack of funds. The deficiency affected all residents, with food temperatures falling below the facility's own standards for palatability.
The facility failed to investigate and report a resident death, did not seek emergency services for a resident with a critical change in condition, and did not implement new fall interventions after a fall. Staff lacked training on emergency procedures, peritoneal dialysis, and change of condition protocols. The administrator was unfamiliar with regulatory requirements and her own licensure status, and the medical director was not regularly present or available for communication. These failures affected the care and safety of all residents.
The facility did not conduct ongoing effective communication training for direct care staff, as required by its own assessment and training protocols. Review of in-service records and staff interviews confirmed the absence of this training, potentially affecting all 50 residents in the facility.
The facility did not conduct ongoing QAPI training for all staff, as confirmed by record review and staff interview. In-service documentation lacked evidence of QAPI training, and the Regional Director of Operations acknowledged that the training was not completed. Fifty residents were present in the facility at the time.
The facility did not conduct ongoing Compliance and Ethics training for all staff, as confirmed by both record review and staff interview. Documentation of such training was absent, and the Regional Director of Operations acknowledged that the training was not completed. This affected all 50 residents in the facility.
The facility did not complete the required annual in-service training and competency assessments for CNAs, as confirmed by record review and staff interview. This deficiency potentially affected all 50 residents in the facility.
The facility did not conduct ongoing behavioral health training for all staff, as required by regulations and the facility assessment. Review of in-service records showed no documentation of such training, and the Regional Director of Operations confirmed that it had not been completed. At the time of the survey, 50 residents were present in the facility.
Several residents who required staff assistance for ADLs, including showering and toileting, experienced significant delays or missed care due to frequent short staffing and equipment issues, such as a single mechanical lift battery. Staff and resident interviews, along with documentation, confirmed that scheduled showers were often not completed and residents sometimes waited extended periods for help, with staff acknowledging they could not meet all care needs during understaffed shifts.
Two residents did not have their physician notified as required: one missed multiple doses of IV antibiotics due to pharmacy and communication issues, and another experienced a significant change in condition with extremely high blood glucose that was not effectively communicated to the physician. Staff interviews revealed a lack of training on notification protocols and use of the facility's communication system.
A resident admitted with multiple serious diagnoses, including abdominal abscess and sepsis, did not receive several ordered doses of IV Vancomycin and Unasyn due to the facility's failure to promptly communicate medication orders to the pharmacy during a transition to electronic records. The DON confirmed the missed doses were caused by not sending required phone or fax orders, resulting in delayed delivery and administration of critical antibiotics.
Two residents did not receive prescribed IV antibiotics and sliding scale insulin as ordered due to medication unavailability and incomplete order entry. One resident missed multiple doses of IV antibiotics after admission because the pharmacy did not receive the orders, and the other did not receive sliding scale insulin for diabetes management until the day of discharge, despite high blood glucose readings and communication from the resident and physician. Facility policy requiring timely administration and physician notification for missed doses was not followed.
Two residents in the facility experienced significant deficiencies in pressure ulcer care. One resident developed a Stage 3 pressure ulcer due to the lack of prescribed pressure-relieving devices, while another resident's unstageable pressure ulcer worsened due to the absence of a necessary protein supplement. The facility failed to implement care plans and communicate supply issues, leading to these deficiencies.
The facility failed to ensure RN coverage for 8 consecutive hours daily, affecting all 48 residents. Nursing schedules showed multiple days without the required RN presence from April to November. Interviews with the DON, an RN, and the Administrator confirmed the ongoing issue. The facility's policy mandates compliance with professional standards, which was not met.
The facility failed to prepare food according to the planned menu and recipe, affecting all 48 residents. A family member raised concerns about poor food quality, and a cook admitted to using incorrect ingredients for the Chicken Cordon Bleu Casserole. Another cook had to substitute the planned sweet and sour pork due to unavailable ingredients. This led to uncertainty about the nutritional content of meals served.
The facility's kitchen was found to be unsanitary, with issues such as a propped open door, a damaged window screen, and improper food storage. Observations included expired and unlabeled food, incomplete temperature logs, and a cooler with cloudy water and food items. The administrator acknowledged the refrigerator had been out of service and emphasized the need for cleanliness and pest prevention.
The facility did not hold required quarterly QAPI meetings, as the administrator could not provide documentation for meetings in early 2024. No evidence of meeting minutes or attendance was found, despite the facility's QAPI Plan requiring quarterly meetings with records maintained. This deficiency potentially affects all 48 residents.
A facility failed to notify a resident's representative in writing about hospital transfers. The resident, initially admitted in 2021, was sent to the emergency department for choking and later admitted to the hospital with preseptal cellulitis. The administrator acknowledged the absence of bed hold or discharge notices and was unsure why notifications were not sent, despite the facility's usual practice.
A facility failed to notify a resident's representative in writing of the bed hold policy during hospital transfers. The resident, initially admitted in 2021, was transferred to a hospital twice in 2024 for choking and preseptal cellulitis. The administrator admitted the absence of notifications and was unsure why the representative was not informed, despite the facility's policy requiring such notification at the time of transfer.
A facility failed to accurately code the MDS assessment for a resident with schizophrenia due to a miscommunication regarding the resident's Level II PASRR status. The LPN responsible for the MDS was unaware of the resident's PASRR status, leading to incorrect documentation. The DON expected accurate coding, but the oversight resulted in a deficiency in the assessment process.
A resident with Parkinsonism, Diabetes Mellitus Type 2, and Dementia did not receive timely toileting assistance, remaining in a wheelchair for extended periods without peri care. The resident's adult brief was found saturated with urine, and CNAs admitted to not checking or changing the resident due to being reassigned or starting shifts later. Facility policy requires checks every two hours, which was not followed.
A resident with Parkinsonism, Diabetes Mellitus Type 2, and Dementia was not provided with necessary restorative care to maintain or improve mobility. Despite a care plan to prevent immobility complications, the facility lacked an active restorative program, resulting in the resident not receiving daily range of motion exercises. Observations showed the resident in soiled clothing and not repositioned for long periods, with staff confirming the absence of a restorative program for two years.
A resident with ESRD requiring dialysis experienced a lack of communication between the facility and the dialysis center, resulting in a delay in receiving prescribed medication. The resident also did not receive the prescribed double protein portions with meals, despite it being listed on her meal card. The DON acknowledged poor communication with the dialysis center, and the dialysis nurse confirmed multiple attempts to communicate the new medication order to the facility.
A facility failed to implement a gradual dose reduction (GDR) for a resident on lorazepam, despite a consultant's recommendation and acceptance by a nurse practitioner. The resident's POA opposed the reduction, and the RN documented this without notifying the physician. The facility's policy requires GDRs unless clinically contraindicated, but the reduction was not pursued due to the POA's wishes, leading to a deficiency.
A resident with multiple health conditions was mistakenly given Eliquis, an anticoagulant, despite a discontinuation order due to anemia and a positive occult blood test. The error was discovered by an RN, and the Assistant Director of Nursing admitted to missing the discontinuation order during record checks.
The facility failed to follow infection control protocols for two residents. A resident with pressure ulcers and a catheter was not placed under enhanced barrier precautions, and staff performed wound care without PPE. Another resident required suctioning, but the nurse used a contaminated yankeur due to a lack of proper equipment and policy. These actions led to deficiencies in infection control practices.
The facility failed to provide enough dietary staff, resulting in delayed meal services for all 29 residents. Observations showed breakfast and lunch were served late, with insufficient staff in the kitchen. Residents and staff confirmed the delays, citing inadequate staffing as the cause. The Dietary Manager struggled to retain staff, and the DON acknowledged previous citations for this issue.
The facility failed to serve meals on time, affecting all 29 residents. Breakfast and lunch services were consistently delayed, with some residents receiving meals on Styrofoam due to insufficient kitchen staff. Both residents and staff confirmed frequent meal delays, and the DON acknowledged the issue as a recurring problem.
The facility failed to serve meals on time as per their designated schedule, affecting all 27 residents. Observations and interviews revealed that meals are consistently late due to a shortage of kitchen staff, with lunch service starting 25 minutes past the scheduled time. Residents and family members reported difficulties in planning around meal times, and the Dietary Manager confirmed the need for additional staff.
The facility failed to investigate abuse allegations involving three residents. One resident reported being shoved by another, but the administrator dismissed the incident. Another resident reported verbal abuse by a CNA, but the investigation was incomplete. Anonymous reports of neglect were also not investigated. The facility's policy requires thorough investigations, which were not conducted, leading to a deficiency.
A resident with multiple medical conditions and Stage 2 pressure injuries did not receive wound care as per physician's orders. The treatments were supposed to be administered every 12 hours, but were only done once daily due to a transcription error by the DON, leading to inadequate care.
A facility failed to monitor a resident's food intake, leading to significant weight loss. The resident, with multiple health conditions, had incomplete meal intake documentation for several days. The Dietary Manager delayed placing meal intake sheets due to staffing issues, and CNAs were not specifically assigned to document meal intakes, resulting in gaps in records.
The facility failed to provide 8 hours of daily RN coverage, affecting all 27 residents. The Administrator and DON acknowledged the shortage and ongoing recruitment efforts. A review of nursing staff schedules for March, April, and May 2024 revealed specific dates without the required RN coverage.
The facility failed to ensure that the physician visited and examined residents at the required intervals, affecting three residents with various medical conditions. Staff confirmed that the physician had not been visiting regularly, and the Medical Director cited non-payment as the reason for his absence.
Resident Physically Forced Into Room and Left Secured, Resulting in Bruising and Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by staff, resulting in physical injury and involuntary seclusion. The resident had severe cognitive impairment, muscle wasting and atrophy, lack of coordination, severe intellectual disabilities, abnormal posture, and age-related osteoporosis, and was dependent on staff for most activities of daily living and transfers, using a wheelchair. The resident’s care plan documented impaired cognitive function and communication problems but did not identify the resident as being at risk for abuse, despite an abuse/neglect screening that classified the resident as at moderate risk for abuse. An event record documented bruising on the resident’s right hand and extensive bruising on the left chest, with vocal complaints of pain. Multiple staff interviews described that during a night shift, a nurse pushed the resident into her room and shut the door because the resident was yelling in the lobby. Night shift CNAs reported that the nurse locked the resident in her room several times, and they repeatedly had to let the resident out. Staff stated that the resident could not open the door independently due to poor upper body strength. When day shift staff arrived, they heard the resident faintly yelling and knocking from inside the room, opened the door, and found the resident very upset. The resident consistently pointed to her chest and finger and stated "nurse hurt me" or similar phrases to various staff members. Staff observations and statements indicated that the bruising to the resident’s chest and finger was not consistent with the resident’s known behavior of occasionally causing only small, fingerprint-sized bruises to herself. Several CNAs and nurses reported seeing a large, painful-appearing bruise on the resident’s chest and a bruise on the finger, and they expressed that the resident did not have the strength to cause such injuries by poking or knocking. The resident’s roommate recalled hearing commotion between the resident and a staff member, followed by the door being closed while the resident remained in the room making noise, and later other staff opening the door to let the resident out. Administrative staff and the former DON acknowledged being informed that the nurse had taken the resident to her room and closed the door, and that it was confirmed the resident was placed in the room and closed in there, even though the resident was not capable of opening the door. A police incident report identified the resident as the victim and the nurse as the offender in relation to this event.
Involuntary Seclusion and Resulting Injuries to a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from involuntary seclusion. The resident was admitted with severe intellectual disability, muscle wasting and atrophy, lack of coordination, abnormal posture, and osteoporosis, and was documented as severely cognitively impaired with a BIMS score of 5. The resident was dependent on staff for most ADLs, used a wheelchair, and required supervision or assistance for mobility. The care plan documented impaired cognitive function and communication problems, and an abuse/neglect screening identified the resident as at moderate risk for abuse, although the care plan did not reflect an abuse risk. On the night in question, multiple staff accounts and the facility’s final report to the state agency indicated that the nurse on duty pushed the resident into her room and shut the door because the resident was yelling in the lobby as other residents passed by. CNAs from the night and day shifts reported that the resident had been up front hollering, then was later found in her room with the door shut, faintly yelling and knocking, and that they had to open the door to let her out. Staff consistently stated that the resident did not have the strength or capability to open the door independently. The resident’s roommate reported hearing commotion between the resident and a staff member, followed by the door being closed while the resident remained in the room making noise, until other staff opened the door and the resident left. Following the incident, staff observed bruising and swelling to the resident’s left index finger and bruising to the chest. The facility’s final report documented that the investigation revealed the nurse had pushed the resident into her room and shut the door, and that the resident reported knocking on the door, which was associated with bruising to her finger. Multiple staff interviews documented that the resident repeatedly pointed to her bruised areas and door, saying variations of “nurse hurt me,” “nurse my room,” and “nurse door.” The facility’s abuse policy defined unreasonable confinement or involuntary seclusion as separation of a resident from others or confinement to the room against the resident’s will, and the incident was characterized as abuse involving involuntary seclusion of the resident in her room multiple times.
Failure to Timely Notify Law Enforcement of Substantiated Staff-to-Resident Abuse
Penalty
Summary
Facility staff failed to timely notify law enforcement of an alleged staff-to-resident abuse incident involving a resident with severe cognitive impairment and multiple physical disabilities. The resident had diagnoses including muscle wasting and atrophy, lack of coordination, severe intellectual disabilities, abnormal posture, and age-related osteoporosis, and was dependent on staff for oral hygiene, toileting, dressing, footwear, and personal hygiene. An abuse/neglect screening identified the resident as at moderate risk for abuse. An incident on 3/24/26 was documented as an injury of unknown origin with bruising to the resident’s left index finger. The facility’s final report to the state agency later documented that the on-duty nurse had pushed the resident into her room and shut the door because the resident was yelling in the lobby as other residents passed by, and that the resident reported knocking on her door in her room, which resulted in bruising her finger. Abuse was substantiated by the facility’s investigation. Despite substantiating abuse and having a policy requiring contact with local law enforcement when there is reasonable suspicion that a crime has been committed in the facility by a non-resident, the facility did not promptly notify law enforcement. The administrator stated that the abuse was reported to the police on 4/1/26 or 4/2/26 and acknowledged that, during the investigation, reporting to police had slipped her mind until a corporate employee reminded her. A police officer reported that a police report was made on 4/1/26 and that the administrator had told him they could not file a police report until the Department of Public Health had investigated. The police incident report, printed on 4/7/26, documented that the incident was reported on 4/1/26 at 10:45 a.m. and identified the resident as the victim and the agency nurse as the offender. This sequence of events demonstrates that law enforcement was not notified immediately after the reasonable suspicion and subsequent substantiation of abuse, contrary to the facility’s abuse and retaliation prevention and reporting policy.
Failure to Thoroughly Investigate Large Chest Bruise and Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate significant bruising and potential staff-to-resident abuse for one cognitively impaired resident. The resident had severe intellectual disability, muscle wasting, abnormal posture, osteoporosis, and was dependent on staff for most ADLs and transfers, using a wheelchair. An abuse/neglect screening identified the resident as at moderate risk for abuse, but the care plan did not document the resident as being at risk for abuse. An incident was identified involving an injury of unknown origin, initially focused on bruising to the resident’s left index finger, and the facility opened an event record documenting a bruise on the right hand and a large bruise on the left chest with vocal complaints of pain. Multiple staff interviews and observations described events in which a night nurse took the resident from the lobby to her room, shut the door, and left her inside, while the resident was heard faintly yelling and knocking. CNAs reported that the resident was repeatedly found shut in her room and had to be let out, and that the resident was angry and immediately stated that the nurse hurt her, pointing to her chest and finger. Staff consistently stated that the resident did not have the strength to cause the large chest bruise herself, that she was not capable of opening the door, and that while she occasionally caused small, fingerprint-sized bruises, she did not have a history of making false accusations against staff. The resident’s roommate reported hearing commotion and yelling between the resident and a staff member, followed by the door being closed and the resident making a lot of noise until other staff opened the door. Despite these reports and the documented large bruise on the resident’s chest, the facility’s investigation and final report focused only on the finger injury and involuntary seclusion, without thoroughly investigating the chest bruise or the resident’s repeated statements that the nurse hurt her. The Administrator acknowledged that the chest bruise was not initially present but was later documented as a 5-inch by 5-inch bruise with pain, and further acknowledged not investigating that bruise and being unable to explain why it was not investigated after discovery. The former DON stated that a complete skin assessment should be done at the beginning of an investigation and that the chest bruise should have been documented and investigated, and also stated that the resident’s statements that the nurse hurt her should have been taken seriously. The facility was unable to produce any evidence that the bruise on the resident’s chest or the resident’s statements were thoroughly investigated, despite a policy requiring that any incident or allegation involving abuse, neglect, or mistreatment result in an investigation, including injuries of unknown source that are suspicious due to their extent or location. The facility’s own policy on Abuse and Retaliation Prevention and Reporting required that any incident or allegation involving abuse or mistreatment result in an internal investigation, and defined injuries of unknown source as those not observed or not explainable by the resident and suspicious due to extent, location, or pattern. The large chest bruise, documented in the event record and repeatedly described by staff as extensive and painful in appearance, met the criteria for an injury of unknown source. However, the facility did not conduct or document a thorough investigation into the cause of this bruise, did not fully interview all relevant staff (such as the CNA who discovered the resident behind the closed door in the morning), and did not reconcile the resident’s consistent statements that the nurse hurt her with the physical findings. This failure to follow policy and to investigate all injuries and allegations of abuse led to the cited deficiency. The surveyors’ findings show that while the facility substantiated involuntary seclusion based on the nurse pushing the resident into her room and shutting the door, it did not extend the investigation to encompass the full scope of potential abuse, including the large chest bruise and the resident’s ongoing verbal reports. Staff, including CNAs, nurses, the former DON, and Social Services, consistently reported that the resident was pointing to her chest and finger and saying the nurse hurt her, and several staff explicitly stated that the resident could not have caused the chest bruise herself. Despite this, the facility’s documentation and investigative efforts remained incomplete, and no evidence was produced to show that the chest bruise or the resident’s abuse allegations were thoroughly investigated as required by facility policy.
Failure to Maintain Sufficient Nursing Staff for Resident Needs
Penalty
Summary
The facility failed to maintain sufficient nursing staff to meet the needs of all residents, as evidenced by interviews, record reviews, and direct observations. Three residents with significant care needs reported long wait times for call light responses, particularly during the night shift when staffing was lowest. One resident, with diagnoses including Multiple Sclerosis and a history of falls, described having to yell for help after falling out of bed when her call light was not answered. Another resident with mobility limitations stated that night shifts often lacked enough staff to provide timely assistance with medications and personal care. A third resident, who required assistance with activities of daily living, reported delays in call light responses and sometimes had to seek out staff herself. Staff interviews corroborated these resident accounts, with multiple CNAs stating that the facility was frequently understaffed, especially at night. CNAs reported that with only one or two staff members on duty for 47 residents, it was impossible to provide timely care, complete necessary documentation, or perform all required tasks such as repositioning, changing, and showering residents. Staff also noted that mechanical lifts could not be used safely without adequate personnel, and that some residents were left wet or not transferred as needed due to insufficient staffing. The administrator acknowledged the staffing challenges, citing a recent COVID outbreak and reliance on agency nurses, but confirmed that the facility often operated below its own assessed staffing needs. Review of staffing schedules and payroll records confirmed that on multiple occasions, only one CNA was present in the facility during overnight hours, despite the facility's own assessment indicating a need for at least 10 CNAs over a 24-hour period. The administrator admitted that she was not always notified of these staffing shortages and that the facility's budget allowed for only two CNAs on the night shift, which was not sufficient to meet resident needs. The deficiency was further substantiated by the facility assessment tool, which documented the high level of assistance required by the majority of residents for activities of daily living.
Failure to Implement Infection Control and COVID-19 Isolation Protocols
Penalty
Summary
Staff failed to consistently don the required Personal Protective Equipment (PPE) when caring for residents with confirmed COVID-19, and contaminated PPE was not always discarded as required after use. Observations included staff exiting rooms of COVID-positive residents wearing only surgical masks or not changing N95 masks and other PPE between resident encounters, despite signage and facility policy requiring full PPE including N95 respirators, gowns, gloves, and eye protection. Some staff members reported not receiving recent or any infection control or COVID-specific training, and there was confusion among staff regarding the COVID status of residents and the need to follow posted isolation precautions. COVID-positive residents were not consistently separated from COVID-negative residents. Instances were observed where COVID-positive residents shared rooms with COVID-negative roommates, and COVID-positive residents were allowed to eat in the dining room and move about the facility without masks, in direct contact with other residents. Staff interviews revealed uncertainty about cohorting practices, with some staff and leadership stating they were told not to move residents to avoid spreading the virus, despite facility policy and infection control guidelines recommending isolation and cohorting of positive cases. Additionally, the facility failed to monitor and document vital signs for COVID-positive residents every shift as required by policy. Electronic health records for several COVID-positive residents did not include evidence of vital sign checks each shift following diagnosis. Staff interviews confirmed that vital sign monitoring lists were not consistently created or followed, and there was a lack of clarity and adherence to the policy regarding the frequency and documentation of vital sign assessments for symptomatic and COVID-positive residents.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual as the Infection Preventionist (IP) responsible for the infection prevention and control program. During interviews, the DON stated that the Resident Care Coordinator was handling infection control duties but had not completed the required certification. The Administrator, who holds an Infection Control Preventionist Certification, indicated that they were not involved in the infection control program due to their current administrative role. The Resident Care Coordinator confirmed she had not received infection control or COVID-19 training at the facility, had not passed the certification test, and was unfamiliar with the facility's infection control and COVID-19 policies. Facility documentation, including the Facility Assessment Tool and the Infection Prevention and Control Program policy, indicated that a certified and trained Infection Control Preventionist should be in place to oversee infection tracking, decision-making, and staff education. However, the individual performing most infection control tasks lacked the necessary certification and training, and there was no evidence of staff education being provided. At the time of the survey, 44 residents were living in the facility.
Failure to Assess, Document, and Safely Install Bed Rails Resulting in Resident Death
Penalty
Summary
The facility failed to implement appropriate alternatives and conduct adequate assessments prior to the installation of bed rails for multiple residents, resulting in a fatal incident for one resident. Specifically, the facility did not attempt different approaches before using bed rails, did not adequately assess or monitor residents for risk of injury or entrapment, and did not ensure that bed rails were installed and maintained according to manufacturer’s recommendations. Additionally, the facility failed to obtain physician orders for the use of bed rails for six residents reviewed, and did not document informed consent or proper care planning related to bed rail use. One resident, who had diagnoses including Parkinson’s Disease, dementia, morbid obesity, and hydrocephalus, was admitted with severe cognitive impairment and required significant assistance with activities of daily living. The resident’s care plans did not address the use of side rails, and documentation regarding alternatives attempted prior to bed rail use was incomplete or inconsistent. The bed rail assessments were not fully completed, and there was no evidence of interdisciplinary team review or staff signatures. The resident was found deceased in a sitting position on the floor with the head and neck trapped between the mattress and bed rail, with the coroner determining the cause of death as positional asphyxiation. Observations revealed that the bed rail was loose and the gap between the mattress and rail exceeded safe limits, expanding further when weight was applied. Interviews with facility staff revealed a lack of knowledge and training regarding bed rail assessments, installation, and maintenance. Maintenance staff installed bed rails without reference to manufacturer specifications or gap measurements, and there was no routine checking of bed rails after installation. Staff were unclear about who was responsible for assessments, consents, and documentation, and there was no incident report completed following the resident’s death. The facility used old beds and side rails from other facilities without proper documentation or manuals, and there was no system in place to track when bed rails were installed or to ensure that care plans and physician orders were updated accordingly.
Failure to Seek Emergency Care for Resident with Critically High Blood Sugar
Penalty
Summary
A deficiency occurred when the facility failed to seek emergency care for a resident with Type 2 Diabetes Mellitus who was experiencing blood sugar levels too high to be measured by the facility's glucose monitoring device. The resident, who had a complex medical history including cerebral palsy, quadriplegia, chronic kidney disease, and a history of diabetic ketoacidosis (DKA), exhibited a significant change in condition with persistently elevated blood glucose readings that exceeded the glucometer's measurable range. Despite repeated 'HI' readings on the glucometer, which indicated blood glucose levels above 600 mg/dL, and observable changes in the resident's behavior and responsiveness, emergency medical intervention was not initiated in a timely manner. Throughout the day, certified nurse assistants (CNAs) reported to the agency LPN that the resident was not acting normally and recommended hospital transfer, but the LPN chose to administer insulin and wait for a physician's response instead. The LPN was unfamiliar with the facility's policies, the glucometer's limits, and had not received training on change in condition or emergency protocols. The DON was consulted and advised the LPN to use her judgment or wait for physician orders, but did not direct immediate transfer. Communication with the on-call physician was attempted, but there was no documented response or follow-up, and the facility's communication system was not effectively utilized. The resident's condition continued to deteriorate, with ongoing 'HI' blood sugar readings and increasing unresponsiveness. Later, the oncoming agency RN also observed the resident's critical state, continued to attempt to reach the physician, and administered additional insulin per verbal orders, but did not document the physician's name or the new orders properly. The resident's blood sugar eventually decreased to 488 mg/dL, but his condition worsened, culminating in respiratory distress, unresponsiveness, and ultimately death. Documentation and communication lapses were evident, including incomplete MAR entries and lack of proper notification or escalation. The cause of death was listed as probable diabetic ketoacidosis.
Removal Plan
- Facility administrator was in-serviced by Regional Reimbursement Consultant on ensuring that glucometer values out of normal range are communicated to the attending physician or authorized designee in a timely, efficient and effective manner.
- Facility administrator was in-serviced by Regional Reimbursement Consultant on ensuring that licensed nursing personnel will inform the physician or authorized designee with any change in condition of the resident in an effective, timely and efficient manner.
- Facility administrator was in-serviced by Regional Reimbursement Consultant on medications being administered in accordance with the good nursing principles and practices and only by persons legally authorized to do so and only after they have been properly oriented to the facility's medication distribution system.
- Facility's administrator in-serviced by Regional Reimbursement Consultant on using nursing judgement to seek emergency treatment when appropriate.
- Facility Administrator initiated in-servicing for nursing staff on using nursing judgement to seek emergency treatment when appropriate.
- Facility Administrator initiated in-servicing for all nursing staff on ensuring glucometer values out of normal range are communicated to the attending physician or authorized designee in a timely, efficient and effective manner to be completed before the start of their next shift.
- Facility Administrator initiated in-servicing for all nursing staff on medications being administered in accordance with the good nursing principles and practices and only by legally authorized to do so and only after they have been properly oriented to the facility's medication distribution system, to be completed before the start of their next shift.
- Facility policy for physician notification has been reviewed by Regional Director of Operations and has been found to be in compliance.
- Facility completed an audit of all diabetic residents to ensure that their blood sugars are within therapeutic range and a weekly audit will be performed by the DON or designee weekly for four weeks.
- Quality Assurance and Performance Improvement (QAPI) plan has been revised to include that the facility will ensure residents experiencing an acute critical situation receive timely emergency care and lacks a process for physician notification and receiving orders in an acute situation. QAPI revisions will be discussed at the next QAPI meeting.
- Monitoring will be ongoing in the morning Quality Assurance (QA) meeting by the QA team (Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Minimum Data Set (MDS)), the QA team will review the 24-hour report and follow up on any changes in condition to ensure that proper care was received and proper procedures were followed.
Failure to Provide Safe Peritoneal Dialysis Care by Qualified Staff
Penalty
Summary
The facility failed to provide safe and appropriate peritoneal dialysis care for a resident who required such services, resulting in a serious adverse event. The resident, who had a history of sepsis, peritonitis, and dependence on dialysis, was admitted with moderate cognitive impairment and had recently been discharged from the hospital. On the day of the incident, the resident's peritoneal dialysis (PD) cycler was malfunctioning, and staff were unable to resolve the issue. Communication between the facility staff and the dialysis company led to instructions for a manual fill of dialysate fluid, with a specific order for 1.5 liters to be administered manually. Despite the order, the nursing staff involved were not properly trained in manual peritoneal dialysis procedures. The Director of Nursing (DON) was unfamiliar with manual fills and relied on a Registered Nurse (RN) and an LPN, neither of whom had received adequate training for the procedure. Miscommunication and lack of clarity regarding the correct volume to be infused resulted in the entire 2.5-liter bag of dialysate being administered, rather than the ordered 1.5 liters. The staff did not verify the order or ensure proper documentation in the resident's medical record, and there was confusion about who was responsible for the procedure and the amount to be infused. As a result of the over-infusion, the resident developed severe shortness of breath, hypotension, and hypoxemia, requiring emergency transfer to the hospital. Upon arrival, the resident was found to be in acute respiratory distress with significant abdominal distention and was subsequently intubated and placed on mechanical ventilation. Hospital records confirmed that over 3.9 liters of fluid were drained from the resident's abdomen, and the event was attributed to excessive dialysate instillation at the facility. The lack of proper training, failure to follow physician orders, and inadequate communication and documentation directly led to this Immediate Jeopardy event.
Removal Plan
- The contract for dialysis was terminated with the facility.
- Facility Administrator and Director of Nursing reviewed all the residents at the time of the event and no other residents were receiving PD services at the time of the event and no other residents have received PD services since this event.
- Facility Administrator and Director of Nursing were in-serviced by dialysis company on manual fill PD.
- Both nurses involved in the event were suspended pending investigation and terminated.
- Facility policy for dialysis was reviewed by Regional Director of Operations and found to be in compliance.
- QA meeting was held with dialysis company and policies and procedures were reviewed.
- Administrator or designee will review PD patients weekly times 4 weeks.
Failure to Implement New Fall Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement new fall interventions for a resident identified as high risk for falls. The resident had multiple diagnoses, including dementia, legal blindness, history of falls, and was dependent on staff for all care, including transfers and mobility. The resident's care plan noted a risk for falls due to cognitive impairment and unawareness of safety needs, but after an unwitnessed fall from bed, there was no evidence that new or additional fall prevention interventions were put in place. The resident previously had a side rail and the bed positioned against the wall, but the side rail was removed at the request of the family, and no alternative interventions such as alarms, lowering the bed, or fall mats were implemented. Staff interviews confirmed that the resident was totally dependent, rarely moved independently, and required two staff for transfers. Both CNAs involved in the resident's care on the day of the fall stated that after the side rail was removed, no other interventions were added, and they were unaware of any new fall prevention measures. The resident was found on the floor by a roommate, with significant bruising and swelling to the head and face. The incident was unwitnessed, and the resident was unable to describe how the fall occurred. Documentation indicated that the resident was placed on a scoop mattress after the fall, but this was the only intervention noted. Following the fall, the resident exhibited a decline in condition, including decreased responsiveness and abnormal vital signs, which led to eventual transfer to the hospital. Imaging revealed new hyper density in the posterior right globe and soft tissue swelling/hematoma. The facility's fall prevention policy required individualized assessment and implementation of appropriate interventions, but the record review and staff interviews indicated that this was not done after the resident's fall, resulting in a failure to provide adequate supervision and prevent further accidents.
Physician Review and Signature Deficiency on Resident Care Orders
Penalty
Summary
The facility failed to ensure that the physician reviewed residents' plans of care and signed and dated orders as required. Interviews with staff, including the Registered Nurse/Resident Care Coordinator and the Administrator, confirmed that the Medical Director did not review or sign physician orders or progress notes; instead, these tasks were performed solely by the Nurse Practitioner. Review of both electronic and paper medical records for multiple residents over several months showed that all physician orders were signed by the Nurse Practitioner, with no signatures or progress notes from the Medical Director or other physicians. Further, the Medical Director stated that he did not see patients and only attended quarterly meetings, attributing the lack of direct involvement to poor reimbursement. The facility's Medical Director Agreement specified that the physician was responsible for reviewing residents' overall condition and care, documenting progress notes, and signing all orders, but these requirements were not being met. The deficiency had the potential to affect all 50 residents in the facility.
Failure to Ensure Required Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter, as required. Interviews with the Administrator and Registered Nurse/Resident Care Coordinator revealed that the Medical Director only visited the facility for quarterly Quality Assurance meetings and did not make regular rounds to see residents. Instead, a Nurse Practitioner was reported to make rounds every other Thursday, with telehealth visits occurring on alternate weeks for residents needing to be seen. Multiple residents confirmed that they had never seen a physician during their stay, with some stating they had only seen the Nurse Practitioner infrequently or not at all. Review of medical records for several residents over a three-month period showed no progress notes signed by the Medical Director. The Medical Director confirmed that he did not see patients in the facility and relied on Nurse Practitioners to conduct resident visits, citing poor reimbursement as a reason for this practice. The Medical Director Agreement indicated that physician services, including the required frequency of visits, were part of his responsibilities. At the time of the survey, the facility census documented 50 residents, all of whom were potentially affected by the lack of required physician visits.
Failure to Ensure 24-Hour Physician Availability for Emergencies
Penalty
Summary
The facility failed to ensure that the medical director or an on-call physician was available 24 hours a day for emergencies, as required by their agreement. On a specific date, a resident was reported by CNAs to be acting abnormally and appeared unwell. The LPN checked the resident's blood sugar, which registered as 'HIGH' on the glucometer. The LPN attempted to contact the on-call physician but was only able to leave a message. While waiting for a return call, the LPN consulted the DON, who advised waiting for the physician's response before taking further action. The LPN stated she was unfamiliar with the facility's electronic communication system and had not received training on it, relying instead on a phone number written at the nurse's station. A registered nurse who worked the same shift confirmed that the resident continued to have high blood sugar readings and that multiple messages were left for the on-call physician before eventually receiving a callback with orders for insulin. The medical director later stated that his phone had been accidentally silenced, preventing him from being reached for several days, and confirmed he did not receive any calls during the incident in question. The facility's medical director agreement specifically requires 24-hour physician availability for emergencies, but this was not met during the event, potentially affecting all residents in the facility.
Insufficient Nursing Staff Resulting in Missed Showers and Delayed ADL Assistance
Penalty
Summary
The facility failed to provide a sufficient level of nursing staff to meet the daily needs of all residents, specifically in providing timely assistance with activities of daily living (ADLs) such as scheduled showers. Interviews with CNAs and the facility administrator revealed that the facility often operated with only 2 CNAs and 2 nurses on day shift several times a week, despite a staffing plan that called for 4 CNAs and 2 nurses. Staff reported that with only 2 CNAs, they were unable to complete scheduled showers and other necessary ADL tasks, and even with 3 CNAs, all tasks could not be completed. The administrator confirmed that the facility was frequently short-staffed and unable to cover all positions, even when using agency staff. The day shift CNA schedule for February documented multiple days with only 2 CNAs scheduled, and the facility assessment tool indicated a 1:11 staff-to-resident ratio for direct care staff on days and evenings, with a census of 50 residents. Multiple residents, all cognitively intact per their BIMS scores, reported going extended periods without showers due to insufficient staffing. One resident stated she had to go 7 to 9 days without a shower during a particularly short-staffed period. Review of ADL documentation for several residents showed infrequent bathing, with some residents receiving only a few showers over a month-long period. Residents also reported that staff were unable to assist them with showers and that there were not enough staff to meet their needs. These findings demonstrate that the facility did not provide adequate nursing staff to ensure timely assistance with ADLs for all residents.
Failure to Provide Meals According to Planned Menus and Inadequate Menu Substitution Documentation
Penalty
Summary
The facility failed to provide meals in accordance with the planned menus, as observed during multiple meal services. On several occasions, the food served did not match the posted menus due to missing ingredients, such as chicken cordon bleu casserole being replaced with plain chicken breast, and orange sherbet being substituted with mandarin oranges. Staff interviews revealed that substitutions were made frequently, at least once a week, because of inadequate ingredient availability. The recipe binder was disorganized, making it difficult for staff to locate recipes, and there was confusion regarding food orders, with the Dietary Manager admitting to ordering ingredients for the wrong week. Additionally, rolls that were supposed to be served were omitted despite being available in the freezer. Further review showed that menu substitutions were not properly documented or approved by the Registered Dietitian, as required by facility policy. The Menu Substitution Log was largely blank, and when substitutions were made, they were not consistently recorded or justified. For example, planned meals such as Italian sausage with potato salad and peppers were replaced with mashed potatoes and California vegetable blend due to missing ingredients, and snickerdoodle blondie bars were omitted because of a lack of eggs. Another meal of chicken tenders and potato wedges was replaced with biscuits and gravy because there were not enough chicken tenders available. Resident interviews indicated dissatisfaction with the quality, variety, and temperature of the food. Several residents, all cognitively intact, reported that meals were repetitive, lacked variety, and sometimes consisted of leftovers. One resident with severe protein calorie malnutrition stated that the food was bad and sometimes cold, while another with muscle wasting and diabetes noted the lack of options and poor quality of the always available menu. A resident on a mechanical soft diet reported being served mashed potatoes daily. The facility's policy required menus to be followed as written, with substitutions documented and approved, but these procedures were not followed, affecting all 50 residents.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to provide food at palatable temperatures, affecting all 50 residents. During a kitchen tour, it was observed that the steam table was not functioning properly: the center compartment was missing a pan, and the right compartment had an ill-fitting pan. Staff interviews revealed that the steam table had been broken for several months, with makeshift repairs attempted but not resolving the issue. Dietary staff reported that food was kept on the stove as long as possible, but once it cooled, there was no way to reheat it effectively due to the broken equipment. The administrator was aware of the issue but stated that the facility lacked funds to repair the steam table. A test tray delivered to a resident's room was found to have food at 110.6°F, below the facility's policy preference of 120°F or greater for palatability, and the food was described as cold and mushy. Multiple residents, both cognitively intact and moderately impaired, reported that their food was consistently cold upon delivery to their rooms. Staff confirmed the poor quality and temperature of the food, and the ombudsman had previously discussed resident complaints with the administrator. The facility's own policy required periodic temperature checks to ensure hot foods on room trays were served at palatable temperatures, which was not being met.
Multiple Failures in Reporting, Emergency Response, Staff Training, and Oversight
Penalty
Summary
The facility failed to investigate and report a resident death to the Department, did not seek emergency services for a resident experiencing a significant change in condition, failed to implement new fall interventions after a resident fall, did not obtain or document orders for a resident receiving peritoneal dialysis, and did not provide adequate staff training or maintain effective communication with the medical director. In one instance, a resident with multiple comorbidities was found unresponsive and in a compromised position between the bed and bed rail, with no interventions in place for his known behavior of throwing his legs out of bed. The administrator did not report the death, believing it was not related to a fall or injury, and demonstrated a lack of knowledge regarding regulatory requirements and the use of side rails. Another resident with a history of diabetes and DKA experienced a critical change in condition when his blood sugar was too high to read on the glucometer. The LPN administered insulin and attempted to contact the on-call physician but received no immediate response. The DON advised waiting for the physician's return call rather than sending the resident to the ER. The resident's condition deteriorated, and CPR was initiated only after he became unresponsive. Staff reported a lack of training on change of condition protocols, blood glucose monitoring, and emergency procedures, and there was confusion about who was authorized to call 911. Additional deficiencies included the lack of new fall interventions after the removal of side rails for a resident with a history of falls, the absence of written orders for peritoneal dialysis, and insufficient training for staff on PD procedures. The facility also failed to provide routine and required training to staff, including effective communication, QAPI, compliance and ethics, and behavioral health care. The administrator lacked training on her duties and was unclear about her licensure status. The medical director was not regularly present, did not review care plans, and was sometimes unreachable, further compromising oversight and communication.
Failure to Provide Ongoing Effective Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to provide ongoing training in effective communication for direct care staff, as required by its own facility assessment. Review of in-service training records conducted by the Administrator showed no documentation that effective communication training had been completed. Additionally, the Regional Director of Operations confirmed that such training had not been conducted with facility staff. At the time of the survey, the facility census documented 50 residents who could potentially be affected by this lack of training. No specific residents or their medical histories were mentioned in the report, and the deficiency was identified through interviews and record reviews.
Lack of Ongoing QAPI Training for All Staff
Penalty
Summary
The facility failed to provide ongoing training in Quality Assurance and Performance Improvement (QAPI) for all staff. Review of in-service records conducted by the Administrator showed no documentation that QAPI training had been completed. During an interview, the Regional Director of Operations confirmed that QAPI training was not conducted with facility staff. At the time of the deficiency, there were 50 residents residing in the facility according to the census report. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Lack of Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to provide ongoing training in Compliance and Ethics for all staff. Review of in-service records conducted by the Administrator showed no documentation that such training had taken place. During an interview, the Regional Director of Operations confirmed that Compliance and Ethics training was not completed with facility staff. At the time of the survey, there were 50 residents residing in the facility, as documented in the census report.
Failure to Complete Annual CNA In-Service Training and Competencies
Penalty
Summary
The facility failed to conduct the required annual in-service training and competency assessments for Certified Nursing Assistants (CNAs), as documented in the facility's own assessment, which specifies the need for annual education and competency checks. Review of in-service records provided by the Administrator showed no documentation that these trainings or competencies were completed. This was confirmed by the Regional Director of Operations, who stated that the annual CNA in-services and competencies, due in September 2024, were not completed. At the time of the survey, the facility census indicated 50 residents who could be affected by this deficiency.
Lack of Behavioral Health Training for Staff
Penalty
Summary
The facility failed to provide ongoing behavioral health training for all staff as required by regulatory standards and as determined by the facility assessment. Review of in-service records conducted by the Administrator showed no documentation of training related to meeting residents' behavioral health care needs. During an interview, the Regional Director of Operations confirmed that behavioral health care training had not been completed with facility staff. At the time of the survey, the facility census documented 50 residents residing in the facility.
Failure to Provide Timely ADL Assistance Due to Staffing and Equipment Shortages
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically showering and toileting, for four residents who were dependent on staff for these needs. Documentation and interviews revealed that residents with diagnoses such as congestive heart failure, diabetes, muscle wasting, and severe malnutrition, who were cognitively intact and required varying levels of assistance, experienced significant delays or missed care. For example, one resident reported waiting up to two hours for toileting assistance and going 7 to 9 days without a shower due to staff shortages and issues with equipment, such as a dead mechanical lift battery. Multiple residents confirmed that there were frequent and prolonged periods without showers, and ADL documentation supported these claims, showing infrequent bathing over a one-month period. Staff interviews corroborated these findings, with CNAs and the facility administrator acknowledging that staffing levels were often insufficient to meet residents' scheduled care needs. Staff reported that with only two CNAs and two nurses on shift, it was not possible to provide timely ADL care or complete scheduled showers, and even with three CNAs, all necessary tasks could not be completed. The facility was also limited by having only one mechanical lift battery, which, when depleted, caused further delays in resident care. Meeting minutes from the resident council and additional staff interviews further confirmed ongoing issues with staffing and equipment, leading to delays and missed care for residents dependent on staff for ADLs. The administrator admitted that the facility was unable to consistently cover all required positions, even when using agency staff, and was not always certain that missed showers were made up by subsequent shifts.
Failure to Notify Physician of Missed Medications and Change in Condition
Penalty
Summary
The facility failed to notify the physician regarding the unavailability and non-administration of intravenous (IV) antibiotics for a resident admitted with multiple serious diagnoses, including peritoneal abscess, sepsis, and severe malnutrition. Documentation showed that the resident missed several doses of Vancomycin and Unasyn due to pharmacy issues and a transition to electronic records, but there was no evidence that the physician or nurse practitioner was informed of these missed doses. The Director of Nursing acknowledged uncertainty about whether the physician was notified and attributed the missed doses to a lack of communication with the pharmacy during the electronic records transition. Another deficiency involved the facility's failure to notify the physician of a significant change in condition for a resident with complex medical needs, including diabetes with ketoacidosis, quadriplegia, and chronic kidney disease. The resident experienced extremely high blood glucose levels, with the glucometer reading "HI," and received insulin as per orders. The LPN on duty attempted to contact the on-call physician but only left a message and did not receive a return call. The LPN also reported a lack of training on change of condition protocols and the facility's electronic communication system. The resident's condition deteriorated throughout the shift, and subsequent staff also failed to effectively communicate the ongoing critical condition to the physician. Facility policies required physician notification when vital medications are not administered or when there is a significant change in a resident's condition. However, documentation and interviews confirmed that these notifications did not occur as required. Staff also reported insufficient training on relevant protocols and communication systems, contributing to the failure to notify the physician in a timely and effective manner.
Failure to Timely Obtain and Administer IV Antibiotics
Penalty
Summary
The facility failed to obtain and administer intravenous (IV) medications as ordered by the physician for one resident. The resident, who was admitted with diagnoses including peritoneal abscess, anal abscess, sepsis, colostomy, hypertension, severe protein-calorie malnutrition, and anemia, had physician orders for IV Vancomycin and Unasyn to treat an abdominal abscess. Upon admission, the resident missed several doses of these IV antibiotics because the pharmacy did not receive the orders electronically, and the medications were not available in the facility. Documentation shows that a total of five doses of Vancomycin and seven doses of Unasyn were missed over several days. Progress notes indicate that the facility was transitioning to electronic records and failed to send a required phone or fax order to the pharmacy, resulting in the delay of medication delivery. The resident confirmed missing multiple doses of IV medication during the initial days after admission and reported that the pharmacy did not send the medications on time. The DON acknowledged the missed doses and attributed the issue to the facility's switch to electronic records and lack of awareness about the need for a phone or fax order for IV medications. The facility's policy requires immediate notification to the pharmacy for interim or emergency medication orders, but this procedure was not followed, leading to the resident not receiving prescribed IV antibiotics as ordered.
Failure to Administer Prescribed IV Antibiotics and Insulin Orders
Penalty
Summary
The facility failed to ensure that physician's orders for intravenous (IV) medications and insulin were followed for two residents. One resident, admitted with diagnoses including peritoneal abscess, sepsis, and severe malnutrition, had orders for IV Vancomycin and Unasyn to treat an abdominal abscess. Upon review, it was found that several doses of both antibiotics were missed in the initial days after admission due to the pharmacy not receiving the orders and the medications not being available in the facility. The Director of Nursing confirmed that the transition to electronic records contributed to the delay, as the necessary phone order was not faxed to the pharmacy. Documentation showed a total of five missed doses of Vancomycin and seven missed doses of Unasyn, with progress notes indicating medication unavailability as the reason for omission. There was no documentation that the physician was notified about the missed doses, as required by facility policy. Another resident with multiple chronic conditions, including diabetes mellitus, was admitted without a sliding scale insulin order due to missing discharge instructions from the hospital. Although the resident and his endocrinologist communicated the need for sliding scale insulin to the nursing staff, the order was not entered until the day of discharge. During the resident's stay, blood glucose readings were consistently high, and there was no documentation of sliding scale insulin administration prior to the order being entered. Nursing staff acknowledged that the sliding scale order was not completed as intended, and the Director of Nursing was unaware of the need for the order until it was finally entered. Facility policy requires that medications be administered as prescribed and that any withheld or unavailable doses, especially of vital medications, be documented and reported to the physician. In both cases, the facility did not follow these protocols, resulting in significant medication errors for the residents involved.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess, treat, and implement interventions to prevent pressure ulcers for two residents, R33 and R18, leading to significant health issues. R33, who was at high risk for skin breakdown due to conditions such as Parkinsonism, diabetes, and dementia, developed a Stage 3 pressure ulcer on his right ischium. Despite having a care plan that included the use of an air mattress and pressure reduction cushion, observations revealed that R33 was not provided with these essential items. He was frequently seen in a wheelchair without a pressure reduction cushion and on a mattress that was not an air mattress, contrary to the treatment orders. This lack of adherence to the care plan and physician orders contributed to the development and persistence of R33's pressure ulcer. R18, another resident with severe cognitive impairment and multiple health issues including diabetes and end-stage renal disease, experienced a worsening of an unstageable pressure ulcer on the left heel. The care plan for R18 included a high-protein supplement to aid in wound healing, but the facility failed to provide this supplement for an extended period due to supply issues. The dietary department had been out of the protein supplement, and the physician was not notified of this lapse, nor was an alternative supplement requested. This failure to provide necessary nutritional support likely contributed to the deterioration of R18's pressure ulcer. The facility's policies on skin condition assessment and pressure ulcer prevention were not effectively implemented, as evidenced by the lack of appropriate interventions for both residents. The facility's failure to follow through with prescribed treatments and nutritional support, as well as the lack of communication regarding the unavailability of essential supplies, directly led to the deficiencies observed in the care of R33 and R18.
Failure to Provide RN Coverage for 8 Hours Daily
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours per day, seven days a week, which has the potential to affect all 48 residents living in the facility. The Long-Term Care Facility Application for Medicare and Medicaid documented 48 residents residing in the facility. A review of the nursing schedules revealed that there were multiple days from April 6, 2024, to November 17, 2024, where no RN was on shift for the required 8 hours. Interviews with the Director of Nursing (DON), a Registered Nurse (RN), and the Administrator confirmed the facility's ongoing struggle to maintain daily RN coverage. The facility's Personnel Policy and Procedure, dated September 2024, states that the facility operates in compliance with applicable laws and professional standards, which was not adhered to in this case.
Failure to Follow Planned Menu and Recipe
Penalty
Summary
The facility failed to prepare food according to the planned menu and recipe, which has the potential to affect all 48 residents living in the facility. On December 12, 2024, a family member expressed concerns about the poor quality of food, stating that it was difficult for residents to eat. The cook admitted to not having the required chicken or ham for the Chicken Cordon Bleu Casserole and used frozen luncheon-style ham and chunk chicken instead. The cook was unsure of the amount of protein added, as the packaging labels with nutritional information were discarded. The recipe called for specific amounts of ingredients, but the cook used what was available without measuring, leading to uncertainty about the nutritional content of the meal. On December 13, 2024, another cook had to substitute the planned sweet and sour pork with a pork fritter and brown gravy due to the unavailability of the correct ingredients. This cook mentioned that substitutions were often necessary because the correct ingredients were not available. The facility's failure to follow the planned menu and recipe, as well as the lack of proper ingredient management, resulted in a deficiency in meeting the nutritional needs of the residents.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which could potentially affect all 48 residents. During an initial tour, several issues were observed, including a propped open back door without a screen and a kitchen window with a damaged screen, both of which could allow pests to enter. The refrigerator in the store room contained a dried brown spill under a bottle of Worcestershire sauce with an inadequate lid, expired milk, and undated, unlabeled cups with a milky liquid. Additionally, there were dried pink puddles and yellow splatters inside the refrigerator, and the temperature logs were incomplete for November 2024. A bulk sugar bag was improperly stored, not secured in an airtight container. Further inspection revealed a cooler with cloudy water and food items floating in it, which had not been used since a cook started working on November 26, 2024. The administrator acknowledged that the stationary refrigerator had been out of service since November 28, 2024, and a portable cooler was used during this time. The administrator also noted the importance of keeping the kitchen door closed to prevent pest entry and expressed expectations for the refrigerators to be clean and sanitary. The facility's food storage policy from 2020 outlines guidelines for proper food labeling, storage, and disposal, which were not adhered to in this instance.
Failure to Hold Quarterly QAPI Meetings
Penalty
Summary
The facility failed to hold quarterly Quality Assurance and Performance Improvement (QAPI) meetings, which is a requirement to ensure quality care for all residents. The administrator, who began her role in July 2024, was unable to provide documentation of QAPI meetings for January 2024 and April 2024. During the survey, no meeting minutes or attendance sheets were found, and the facility could not provide evidence that these meetings were scheduled or occurred. The facility's QAPI Plan, revised in October 2022, mandates that the committee meet at least quarterly, with minutes and attendance records maintained in the administrator's office. This deficiency has the potential to affect all 48 residents residing in the facility.
Failure to Notify Resident's Representative of Hospital Transfers
Penalty
Summary
The facility failed to notify the resident's representative in writing about hospital transfers for a resident who was reviewed for hospitalizations. The resident, who is [AGE] years old, was initially admitted to the facility on 08/27/2021. According to the nurse's notes, the resident was sent to the local emergency department on 09/11/2024 due to an episode of choking and was later admitted to the local hospital on 11/11/2024 with a diagnosis of preseptal cellulitis. On 12/13/2024, the facility administrator acknowledged the absence of bed hold or discharge notices for the resident's hospital transfers on the specified dates and was unsure why the resident's representative was not notified, despite the facility's typical practice of sending such notifications.
Failure to Notify Resident's Representative of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident's representative in writing of the bed hold policy during transfers to a hospital. This deficiency was identified for a resident who was initially admitted to the facility on August 27, 2021. The resident, aged [AGE], was transferred to a local emergency department on September 11, 2024, due to an episode of choking and was later admitted to a hospital on November 11, 2024, with a diagnosis of preseptal cellulitis. During an interview on December 13, 2024, the facility's administrator acknowledged the absence of bed hold notifications for the specified dates and expressed uncertainty about why the resident's representative was not informed. The facility's policy, revised on September 16, 2017, mandates that the bed hold policy be provided to the resident or their representative at the time of transfer, which was not adhered to in this case.
Inaccurate MDS Coding Due to PASRR Miscommunication
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident, identified as R21, who was part of a sample of 24 residents reviewed for assessment accuracy. R21's admission record indicated multiple diagnoses, including schizophrenia, depression, unspecified dementia, essential hypertension, anxiety disorder, and hyperlipidemia. The Preadmission Screening and Resident Review (PASRR) Level I and Level II outcomes documented that R21 was referred for a Level II onsite review and was determined to be excluded from PASRR due to a primary neurocognitive disorder with no loss of consciousness. However, the MDS assessment dated 11/15/2024 incorrectly marked the PASRR question as 'No,' indicating that R21 was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite having an active diagnosis of schizophrenia. The Licensed Practical Nurse (LPN) responsible for completing the MDS for R21 stated that she was unaware of R21's Level II PASRR status at the time of the assessment. The LPN had only been in the role for a few weeks and was not informed that R21 had a Level II PASRR. The Director of Nursing (DON) expressed that it is her expectation for MDS assessments to be coded accurately. This oversight in communication and documentation led to the inaccurate coding of the MDS assessment for R21, highlighting a deficiency in the facility's assessment process.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide necessary toileting assistance to a resident, identified as R33, who was dependent on staff for activities of daily living, including toileting. R33, who has diagnoses of Parkinsonism, Diabetes Mellitus Type 2, and Dementia, was observed in a wheelchair for extended periods on two consecutive days without receiving appropriate peri care or repositioning. On the second day, R33 reported that he had not been to the bathroom since 5 AM, and it was noted that he remained in his wheelchair without being checked or changed until the afternoon. During the afternoon of the second day, R33 was finally transferred to bed, and peri care was provided. It was observed that R33's adult brief was saturated with foul-smelling urine, indicating a lack of timely incontinence care. The CNAs involved, V5 and V6, admitted to not checking or changing R33 due to being pulled to work in other areas or starting their shifts later in the day. The facility's policy, as stated by the Administrator, requires residents to be checked every two hours for toileting or peri care, which was not adhered to in this case.
Failure to Implement Restorative Program for Resident with Limited Mobility
Penalty
Summary
The facility failed to implement appropriate treatment and services for a resident with limited range of motion (ROM) to maintain or improve their mobility. The resident, identified as R33, has a medical history that includes Parkinsonism, Diabetes Mellitus Type 2, and Dementia, and is dependent on staff for various activities of daily living. The resident's care plan, revised on 7/11/24, aimed to prevent complications related to immobility, such as contractures and skin breakdown. However, observations and staff interviews revealed that the facility did not have an active restorative program, and residents, including R33, were not receiving daily ROM exercises as required. On multiple occasions, R33 was observed in a state that indicated neglect of care. The resident was seen sitting in a wheelchair with soiled clothing and a cluttered room, and reported not being repositioned or toileted for extended periods. Staff members acknowledged the absence of a restorative program for two years, which contributed to the resident's stiffness and lack of mobility exercises. The facility's Restorative Nursing Program policy, last revised in 2019, outlines the need for individualized programs to maintain or regain residents' independence, but this was not being implemented for R33, leading to the deficiency noted in the report.
Failure in Communication and Dietary Provision for Dialysis Resident
Penalty
Summary
The facility failed to maintain effective communication and collaboration with an offsite dialysis center for a resident with end-stage renal disease (ESRD) who requires dialysis. The resident, who is cognitively intact, reported that she no longer has a permanent dialysis access site in her arm and only has a catheter in her chest, which is managed by the dialysis center to prevent infection. The resident also mentioned that she was prescribed a medication by her nephrologist at the dialysis center about a month ago, but had not received it. The Director of Nursing (DON) was unaware of the current order for the phosphorous binder, which had been discontinued previously, and acknowledged the poor communication between the facility and the dialysis center. The dialysis center's registered nurse confirmed multiple attempts to communicate the new order for the phosphorous binder to the facility, including phone calls and a fax, but no follow-up was conducted by the facility to ensure the order was received and implemented. Additionally, the resident's dietary needs were not met, as she did not receive the prescribed double protein portions with her meals, despite it being listed on her meal card. Observations confirmed that the resident received only single portions of protein at meals, and the only snacks she received were those she kept in her room.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to implement a gradual dose reduction (GDR) for a resident who was receiving lorazepam 0.5 mg twice daily. The resident, who was admitted to the facility with multiple diagnoses including major depressive disorder and generalized anxiety disorder, had been on lorazepam since October 2023. A company consultant recommended a GDR to reduce the dosage to 0.5 mg at bedtime, which was accepted by the nurse practitioner. However, the resident's power of attorney (POA) opposed the reduction, and the registered nurse (RN) documented this opposition without notifying the physician that the medication was not reduced. The facility's policy requires that residents on psychotropic drugs receive GDRs and behavioral interventions unless clinically contraindicated, with attempts encouraged at least twice yearly. Despite this policy, the RN stated that the facility does not reduce medication if the family opposes it. The resident's behavior tracking record showed no behaviors that would contraindicate a GDR, yet the reduction was not pursued due to the POA's wishes. This inaction led to the deficiency as the facility did not adhere to its policy or notify the physician of the POA's decision.
Medication Error: Eliquis Administered Despite Discontinuation Order
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of Eliquis, an anticoagulant medication. The resident, who was admitted to the facility with multiple diagnoses including chronic obstructive pulmonary disease, major depressive disorder, unspecified dementia, and chronic diastolic heart failure, returned from the hospital with orders to discontinue Eliquis due to a positive occult blood test and anemia. Despite this, the medication was administered from the beginning of November until the error was discovered on November 8th. The error was identified by a registered nurse who was preparing the resident's medication and noticed the discontinuation order. The Assistant Director of Nursing, responsible for verifying medication administration records, admitted to missing the discontinuation order. The Director of Nursing was informed of the error but did not complete a medication error report. The facility's policy requires medications to be administered according to prescriber's written orders, which was not adhered to in this case.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control protocols for two residents, R197 and R33, as observed during a survey. R197, a resident with multiple medical conditions including pressure ulcers and a suprapubic catheter, was not placed under enhanced barrier precautions despite having open wounds and an indwelling catheter. During a wound care session, a registered nurse and a certified nurse aide entered R197's room without donning personal protective equipment (PPE) and proceeded to perform wound care without following the enhanced barrier precautions. The facility's policy required the use of PPE during high-contact activities for residents with chronic wounds or indwelling devices, but this was not followed, leading to a deficiency in infection control practices. For R33, a resident with parkinsonism, diabetes, dementia, and hypertension, the facility failed to maintain proper infection control during a suctioning procedure. When R33 began coughing and required suctioning, the registered nurse found the suction machine without necessary components and had to leave the room to retrieve them. Upon returning, the nurse inadvertently contaminated the yankeur by hitting it against the wall but continued to use it for oral suctioning. The Director of Nursing later stated that the expectation was to discard and replace contaminated equipment, but the facility lacked a specific policy on suctioning procedures, contributing to the deficiency.
Insufficient Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to provide a sufficient number of dietary staff to ensure meals were served at the designated meal times, affecting all 29 residents. Observations revealed that breakfast service began late at 7:25 am, with only two dietary workers, including the Dietary Manager, present in the kitchen. Several residents were still without trays at 7:35 am, and some were served on Styrofoam plates and bowls. Lunch service also started late at 11:50 am, with only two dietary workers, and trays were still being served at 12:30 pm. On another occasion, lunch trays were served at 11:42 am with three dietary workers present. Interviews with residents and staff confirmed the issue of meals being served late. Residents reported that breakfast and other meals were often delayed. The Dietary Manager stated difficulties in retaining staff, as many do not pass background checks, and mentioned using Styrofoam bowls due to limited staff. CNAs also reported frequent delays in meal service due to inadequate kitchen staffing. The Director of Nursing acknowledged the issue, noting that the facility had been cited for it before, and part of their plan of correction involved her assisting with breakfast service, although the kitchen was often not ready. The dietary schedule for July showed only four employees, including the manager, working in the kitchen.
Meal Service Delays Due to Staffing Issues
Penalty
Summary
The facility failed to serve meals at designated meal times, affecting all 29 residents. Observations revealed that breakfast service began late at 7:25 am, with some residents still without trays at 7:35 am. Lunch service also started late, with trays being served inconsistently, causing some residents to finish their meals while others were still waiting. The use of Styrofoam plates and bowls was noted, attributed to insufficient kitchen staff. Interviews with residents and staff confirmed that meals were frequently late, with breakfast being consistently delayed. The Dietary Manager acknowledged the use of Styrofoam due to limited staff, and the Director of Nursing admitted that meals were not served on time, a recurring issue for which the facility had been previously cited. Staff members, including CNAs, reported that meal delays were often due to inadequate kitchen staffing. Residents expressed dissatisfaction with the timeliness of meal service, with some stating that meals were never timely, especially when served in their rooms.
Facility Fails to Serve Meals on Time Due to Staffing Shortages
Penalty
Summary
The facility failed to serve meals according to their designated schedule, which has the potential to affect all 27 residents living there. The Meal Time Policy, dated June 2006, specifies that breakfast should begin at 7:00 am, lunch at 11:30 am, and supper at 5:00 pm. However, observations on 5/28/24 revealed that lunch service did not start until 11:55 am, 25 minutes past the scheduled time. Interviews with the Dietary Manager confirmed that meals are usually late, and the kitchen is understaffed, needing three additional cross-trained staff members. Family members and residents reported that meals are consistently served late. A family member of a resident stated that lunch is typically served between 12:15 pm and 12:30 pm, making it difficult to plan visits. Residents also confirmed that meals are late due to insufficient kitchen staff. On 5/29/24, breakfast was reported to be 30 minutes late because only one staff member was working in the kitchen. The Director of Nurses confirmed that all 27 residents rely on meals from the facility kitchen.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving three residents, R4, R6, and R9. R4 reported an incident where R9 allegedly shoved his chair into her, causing a small discoloration on her forearm. Despite R4's report, the administrator, V1, did not initiate an investigation, dismissing the incident as unwarranted and attributing R4's behavior to being problematic. R6 reported an incident involving a CNA, V9, who allegedly screamed and cursed at her over a snack request. Although an investigation was initiated, it was incomplete as it did not include interviews with all involved staff, particularly V8, who was also accused of being mean to R6. V1 admitted to not suspending or investigating any staff other than V9. Additionally, the facility's abuse investigation included anonymous staff interviews that reported staff denying residents showers and leaving them in bed for meals. However, V1 did not investigate these anonymous reports further, believing they did not warrant an investigation. The facility's Abuse Prevention Program policy mandates thorough investigations of all reports, including anonymous ones, to prevent mistreatment, neglect, or abuse. The failure to investigate these allegations thoroughly and in accordance with the facility's policy constitutes a deficiency in handling abuse allegations.
Failure to Follow Physician's Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer treatment according to physician's orders for a resident with multiple medical conditions, including Diabetes Type 2, Anxiety Disorder, Depression, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and Hypertension. The resident had two Stage 2 pressure injuries upon admission. The physician's orders required specific wound care treatments to be administered every 12 hours and as needed. However, the Treatment Administration Record (TAR) indicated that these treatments were only performed once daily over a period of several days. This discrepancy was due to an error made by the Director of Nurses when transcribing the orders from the Physician's Order Sheet (POS) to the TAR, resulting in inadequate care for the resident's pressure ulcers.
Failure to Monitor Resident's Food Intake
Penalty
Summary
The facility failed to adequately monitor the food intake of a resident with a history of weight loss. The resident, who had been diagnosed with several conditions including Diabetes Type 2, Anxiety Disorder, Depression, Hypertension, Chronic Obstructive Pulmonary Disease, and Chronic Kidney Disease, experienced significant weight loss from February to May 2024. The resident's care plan identified a risk of weight loss due to a preference for not eating at times and occasionally ordering food independently. However, the facility's documentation of the resident's meal intake was incomplete for several days in May 2024. The deficiency was attributed to a lack of proper documentation procedures and staff assignment. The Dietary Manager, responsible for placing meal intake sheets in the binder, delayed this task due to staffing issues, resulting in missing documentation for the first two days of May. Additionally, CNAs were not specifically assigned to document meal intakes, leading to further gaps in records. The Director of Nurses confirmed that all meal intakes should be documented, as per the facility's policy, but this was not consistently done, contributing to the oversight in monitoring the resident's nutritional intake.
Failure to Provide 8 Hours of Daily RN Coverage
Penalty
Summary
The facility failed to provide 8 hours of daily Registered Nurse (RN) coverage, which has the potential to affect all 27 residents residing in the facility. On 5/15/24 at 11:00am, the Administrator acknowledged the shortage of RNs and admitted there were times when the facility did not meet the required 8 hours of RN coverage. The Director of Nurses also confirmed the ongoing efforts to recruit more RNs. A review of the nursing staff schedules for March, April, and May 2024 revealed specific dates (3/2/24, 3/30/24, 4/6/24, 5/4/24, and 5/12/24) when the facility did not have the required RN coverage. The Midnight Census Report Form dated 5/14/24 documented that 27 residents were residing in the facility, with one resident in the hospital.
Failure to Ensure Regular Physician Visits
Penalty
Summary
The facility failed to ensure that the physician visited and examined residents at least once every 30 days for the first 90 days after admission or at least once every 60 days thereafter. This deficiency was observed in three residents (R1, R2, and R3) out of a sample of seven. R1, who has multiple diagnoses including congestive heart failure and diabetes, was only seen by the physician on two occasions, with the last visit documented almost a year ago. R1 reported seeing the Nurse Practitioner (NP) regularly but not the physician. Similarly, R2, who has conditions such as cellulitis and chronic kidney disease, had no documentation of being seen by the physician since the previous Medical Director left. R2 also confirmed seeing the NP but not the physician. R3, with diagnoses including Parkinson's disease and bipolar disorder, also had no documentation of recent physician visits and reported seeing the NP regularly instead of the physician. Interviews with the facility staff, including the Administrator, Director of Nurses (DON), and the Licensed Practical Nurse (LPN), confirmed that the physician had not been visiting the facility regularly. The Medical Director admitted to not visiting the facility for a long time due to non-payment issues. The NP, who visits the facility about every other week, confirmed that she works under a different physician and has limited interaction with the Medical Director. The facility's Medical Director Agreement explicitly requires the physician to visit residents and review their medical conditions as needed, which was not being adhered to.
Latest citations in Illinois
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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