Carlton At The Lake, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 725 West Montrose Avenue, Chicago, Illinois 60613
- CMS Provider Number
- 145679
- Inspections on file
- 33
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Carlton At The Lake, The during CMS and state inspections, most recent first.
Surveyors found that multiple nurses on several floors did not complete their morning medication passes within the facility’s required one-hour before/after window, resulting in numerous medications showing as late on the eMAR. RNs and LPNs reported starting medication administration early in their shifts but still had outstanding medications several hours later, and some acknowledged giving medications without promptly documenting them. Audit reports confirmed that multiple residents across several floors received medications late, and facility policy requires that medications be administered on time and signed on the MAR immediately after administration.
A resident with intact cognition but significant left-sided weakness and multiple care needs was observed seated in a mechanical chair while the call light was placed on the bed out of reach. The resident reported being unable to reach the call light due to weakness from a prior stroke and stated they sometimes had to shout for help or rely on a cell phone because the call light was not always accessible. A CNA and an RN both acknowledged that the resident could not reach the call light as placed and that call lights should be within residents’ reach so they can obtain assistance, and the DON confirmed that facility policy requires call lights to be placed within reach of residents able to use them at all times.
A resident with intact cognition and multiple medical conditions reported that the facility’s showers were dirty and contained soiled incontinence briefs. Surveyors later observed strong, pervasive feces and urine odors in shower rooms on multiple floors, with one shower room’s odor so strong it could not be entered and a yellowish-brown substance resembling mixed feces and urine smeared on a shower entry wall. The Environmental Services Director acknowledged the odors and substance, and the Assistant Administrator confirmed that showers are expected to be clean and odor-free, despite a policy requiring regular cleaning and disinfection of public and high-touch areas.
A resident with type 2 DM, severe cognitive impairment, and multiple comorbidities did not receive care in accordance with physician orders and facility policy. An A1c lab ordered with instructions to re-attempt using a different technician after an initial refusal was only documented as refused once, with no record of a subsequent attempt. Blood glucose monitoring parameters for when to notify the provider were not documented, and an RN reported not knowing these parameters and being unable to locate documented blood glucose values. Blood glucose checks were recorded with times that did not match the ordered administration times, despite policy requiring that all treatments and the MAR accurately reflect physician orders.
A resident with multiple medical conditions and intact cognition repeatedly did not receive requested scrambled eggs at breakfast or expected double portions, despite dietary notes documenting these preferences. CNAs and LPNs reported that the resident’s meals were often incorrect and required frequent calls to the kitchen for corrections. Review of records showed only a regular diet order without double portions and no documented Food Preference Interview, indicating that the resident’s stated dietary preferences were not consistently incorporated into formal diet orders.
A resident with psychiatric disorders reported ongoing threats, theft, and intimidation by their roommate, including threats of physical harm and taking of a debit card. Despite these allegations being communicated to several staff members, the incident was not reported to the abuse coordinator or administration as required by facility policy, resulting in a failure to follow mandated abuse reporting procedures.
A resident with multiple psychiatric and neurological diagnoses reported a sexual assault to the ADON after returning from a community pass. Although the facility's policy required reporting abuse allegations to the state agency within two hours, the Administrator delayed notification until the next day due to conflicting accounts and lack of initial disclosure to hospital staff. The delay in reporting exceeded the facility's stated policy and regulatory requirements.
A resident with multiple psychiatric and neurological diagnoses was allowed to leave the facility on a supervised community pass but did not return as scheduled. Staff did not contact police after the required grace period, failed to complete an elopement risk assessment upon admission, and delayed initiating a care plan for community pass privileges, all in violation of facility policy.
Two residents experienced ongoing bed bug infestations after being relocated due to an initial finding of bed bugs in their shared room. Despite treatment by a pest control company and laundering of belongings, bed bugs were observed again during a survey, and there was no documentation of follow-up inspections or checks of the new rooms as required by facility policy.
A resident with a history of hypotension and mobility issues experienced a fall resulting in injuries after the facility failed to incorporate the resident's medical diagnosis and medication regimen into the fall prevention care plan. The care plan did not address the need for Midodrine when blood pressure was low, and fall risk assessments were not consistently performed or used to guide interventions. Staff interviews revealed confusion over responsibilities and a lack of coordination in updating care plans and assessments.
A resident with a history of hypotension and mobility issues was not given physician-ordered Midodrine when their systolic blood pressure fell below the prescribed threshold. The medication was not documented as administered on the MAR, and the DON confirmed it was not given. This omission led to the resident experiencing low blood pressure and a fall, resulting in lacerations.
A resident with multiple health conditions, including diabetes mellitus, did not receive prescribed Lantus insulin for ten days due to a delay in following a physician's order. The resident's cognitive impairment and high fasting blood sugars necessitated the medication, but the order was not entered until several days after the clinic visit. The facility's policy requires timely execution of physician orders, which was not followed in this instance.
A facility failed to document medication administration for a resident with multiple health conditions, including diabetes and impaired cognition. The resident's MAR lacked a nurse's signature for a scheduled dose of Trulicity, indicating the medication may not have been administered. The ADON confirmed that missing initials suggest non-administration, and the facility's policy requires documentation after medication is given.
The facility failed to revise care plans with preventive interventions for two residents, resulting in injuries of unknown origin. A resident with dementia sustained a hand fracture, believed to be from bumping a bedside table, but the care plan lacked preventive measures. Another resident with hemiplegia was found with a leg fracture, suspected from bumping a bed rail, yet the care plan did not include interventions to prevent further harm.
The facility failed to follow procedures for administering and documenting enteral feedings for two residents, leading to discrepancies in feeding schedules and intake monitoring. One resident's feeding bottle was found full despite orders for continuous infusion, and another's bottle was not replaced as per schedule. The LPN admitted to not clearing the pump, and the facility did not document enteral intake, contributing to the deficiencies.
The facility failed to remove and discard expired medications in one of two medication carts reviewed. A surveyor found an opened bottle of Docusate Sodium 100mg with an expiration date of December 2022 in the Team 1 medication cart. The RN responsible for the cart admitted that expired medications should not be stored and should be discarded. This oversight has the potential to affect 20 residents whose medications are stored in the Team 1 medication cart on the second floor.
The facility failed to convey funds to a resident's family after the resident's death. The Business Office Manager was unaware of the facility's policies, leading to delays and miscommunication. The Administrator acknowledged that the funds should go to the individual overseeing the resident's estate, as per the facility's policy.
A facility failed to provide timely incontinence care for a dependent resident who reported being left in soiled briefs for extended periods. Despite the care plan and facility policies requiring checks every two hours, the resident was found soiled and had not been changed since the start of the CNA's shift.
Untimely Medication Administration and Delayed eMAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to administer prescribed medications in a timely manner according to physician orders and to document administration promptly on the electronic medication administration record (eMAR). On the date of survey, multiple nurses on different floors reported starting their shifts around 7:00–7:30 AM and beginning medication passes between 7:30–8:00 AM, yet by approximately 10:11–10:39 AM several had not completed their medication passes. When the surveyor reviewed the eMARs with these nurses, multiple residents’ medication entries appeared in red, which the nurses stated indicated that the medications were late. Some nurses also stated that they had administered certain medications but had not yet documented them on the eMAR. One nurse assigned to the third floor stated she had completed her medication pass and acknowledged that medications not given on time are considered medication errors and that all medications should be given on time according to physician orders. The Director of Nursing stated that the facility’s time frame for medication administration is one hour before and one hour after the scheduled time. Facility medication administration audit reports for the same date documented that multiple residents on the second, third, fourth, and fifth floors received their medications late. The facility census documented 34 residents on the second floor, 57 on the fourth floor, and 54 on the fifth floor, indicating that the issue had the potential to affect 145 residents. Facility policy titled “Medication Pass,” dated 07/02/2025, states in part that after medication is administered to each resident, staff must sign the MAR to indicate it was given. The observations, staff interviews, and audit reports collectively show that medications were not consistently administered within the prescribed time frame and were not consistently documented immediately after administration, resulting in untimely medication administration for multiple residents.
Failure to Keep Call Light Within Reach of Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its call light policy by not ensuring a cognitively intact resident with left-sided weakness could access the call light. The resident had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, major depressive disorder, and dysphagia following cerebral infarction. An MDS dated February 16, 2026 documented a BIMS score of 15/15, indicating intact cognition, and Section GG showed the resident required varying levels of assistance with eating, oral hygiene, personal hygiene, toileting, dressing, footwear, and bathing. On observation at 12:26 PM, the resident was seated in a mechanical chair on the right side of the bed, while the call light was placed on the bed out of the resident’s reach. The resident stated they could not reach the call light due to left-sided weakness from a stroke, demonstrated an inability to reach it with the left hand, and reported needing to shout for help and keeping a cell phone nearby because the call light was sometimes placed too far away. At 12:49 PM, a CNA and the surveyor again observed the call light on the bed out of the resident’s reach. The CNA confirmed the resident had left-sided weakness and could not stretch far enough to reach the call light where it was placed, and stated the call light needed to be closer so the resident could call staff when help was needed, otherwise the resident’s needs would not be met and the resident could fall or choke. At 1:00 PM, an RN stated that call lights should be within residents’ reach so they can access staff for help and that if not accessible, a resident might fall out of bed trying to get help or be in an emergency and unable to reach staff. At 3:45 PM, the DON stated call lights should be placed close enough for residents to reach to call for assistance and that if the call light is far from a resident, the resident will not be able to call for assistance. The facility’s call light policy dated June 30, 2025 documented that call lights must be placed within reach of residents who are able to use them at all times, which was not followed in this case.
Failure to Maintain Clean and Odor-Free Shower Rooms
Penalty
Summary
The facility failed to maintain clean, odor-free shower rooms, resulting in a deficient environment for residents. One cognitively intact resident with multiple medical conditions, including hemiplegia, major depressive disorder, dysphagia, severe protein-calorie malnutrition, and hypertension, reported that the showers were dirty and contained soiled incontinence briefs, particularly on the floor where the resident previously lived. The resident’s BIMS score of 15 indicated little to no cognitive impairment, supporting the reliability of the report about the condition of the showers. On the day of surveyor observations, multiple shower rooms on several floors had strong, pervasive feces and urine odors. On the 4th floor, both shower rooms had such strong odors that one shower room in the East wing could not be entered by the surveyor. Similar strong odors were present in the 2nd floor shower rooms. On the 5th floor, in addition to strong feces and urine odors, there was a yellowish-brown substance approximately 7 by 10 inches smeared on the entry wall of a shower, appearing like mixed feces and urine. The Environmental Services Director acknowledged the substance and agreed the odors were unpleasantly strong and unacceptable. The Assistant Administrator stated that showers are expected to look and smell clean and free of debris, and the facility’s Public Areas Daily Cleaning Workflow policy states that public areas and high-touch areas are to be regularly cleaned, disinfected, and well-maintained to promote a hygienic environment.
Failure to Follow Physician Orders for Diabetic Monitoring and A1c Lab
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and its own policy regarding diabetes management and lab monitoring for one resident. The resident had multiple diagnoses including type 2 diabetes mellitus with hyperglycemia, metabolic encephalopathy, bipolar disorder, schizoaffective disorder, chronic embolism and thrombosis of the femoral vein, and difficulty in walking, and was documented as having severe cognitive impairment with a BIMS score of 3/15. A physician order dated 2/19/2026 directed that an A1c lab be completed on 2/20/2026, with instructions that if the resident refused, a different technician should attempt the draw in the morning. Progress notes show the resident refused the A1c at 1:02 AM on 2/20/2026, but there is no documentation that the A1c was offered again by a different technician as ordered. The DON stated that if it is not documented, it is not done. The facility also failed to document blood glucose monitoring parameters for when to notify the physician, despite the DON stating that the physician gives such parameters and that nurses should carry out orders as written. The RN caring for the resident reported that the resident is diabetic and that blood sugars are taken two times a shift, but she could not locate the blood glucose levels she documented and did not know the parameters for when to notify the physician. Blood glucose records from 2/20/2026 to 2/27/2026 show levels ranging from 122 mg/dL to 230 mg/dL, and on 2/28/2026, blood glucose checks ordered for 8:00 AM and 11:00 AM were documented as taken at 2:03 PM, which did not align with the physician’s ordered times. These actions and omissions conflict with the facility’s policy requiring that all treatments and plans of care be in accordance with physician orders and that orders in the POS be accurately reflected in the MAR.
Failure to Consistently Honor Resident Dietary Preferences and Portions
Penalty
Summary
The facility failed to consistently honor a resident’s documented dietary preferences and needs, specifically regarding double portions and scrambled eggs at breakfast. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, muscle wasting and atrophy, dysphagia (oropharyngeal phase), benign prostatic hyperplasia, hypertension, and depression, and was documented as cognitively intact with a BIMS score of 14. The resident reported ongoing complaints about receiving the wrong food orders. The dietician stated that on one occasion the resident did not receive scrambled eggs with breakfast because the meal ticket had not been updated after the resident requested scrambled eggs every breakfast the previous day. The dietician also noted that the scrambled eggs were a preference and that the resident was to receive double portions with meals. Multiple CNAs and LPNs reported that the resident’s food orders were frequently incorrect, including not receiving scrambled eggs with breakfast and not receiving double portions as expected, requiring calls to the kitchen for corrections. One CNA reported that the resident complained that morning about not getting double the portion of eggs. Nursing staff confirmed that the resident was prescribed double portion meals and often complained about not receiving them, and one LPN stated that most of the time the resident’s meals were wrong. Review of the resident’s diet order showed only a regular diet with no specification for double portions, and although the dietician’s notes documented the preference for scrambled eggs at breakfast, there was no corresponding diet order for double portions or documentation of the required Food Preference Interview in the electronic medical record.
Failure to Report Alleged Abuse and Threats Between Roommates
Penalty
Summary
The facility failed to follow its 'Abuse and Neglect' policy by not reporting an allegation of abuse involving a resident with schizophrenia, delusional disorders, major depressive disorder, and anxiety disorder. This resident alleged that their roommate, who also had significant psychiatric diagnoses and behavioral issues, had threatened to hit them, requested money, and took their debit card. The resident reported these threats and theft to staff, stating that the threats had persisted for several days. Despite these allegations, the staff did not report the incident to the abuse coordinator or the appropriate authorities as required by facility policy. Multiple staff members were aware of the situation, with some reporting the behavior to other staff but not escalating it to the designated abuse coordinator or administrator. Interviews revealed confusion and lack of communication among staff regarding the reporting process. The nurse who was informed of the threats relayed the information to the social worker, who in turn did not report it to the abuse coordinator. The social worker and restorative nurse both stated they were not made aware of any abuse allegations, and the director of nursing and assistant administrator confirmed they were not informed until the surveyor brought it to their attention. The facility's policy clearly states that all allegations or suspicions of abuse must be reported immediately to the administrator or their designee, which did not occur in this case.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to follow its abuse policy and procedure by not reporting an allegation of sexual abuse to the State Agency within the required two-hour timeframe. A resident with diagnoses including major depressive disorder, epilepsy, bipolar disorder, anxiety disorder, and dissociative and conversion disorder, who was cognitively intact, reported being sexually assaulted while out on pass with a family member. The resident communicated the assault to the Assistant Director of Nursing via text message, who then informed the Administrator. Despite the facility's policy requiring immediate reporting of abuse allegations to the Illinois Department of Public Health (IDPH) within two hours, the Administrator delayed the report until the following day, citing conflicting stories and lack of disclosure to hospital staff upon the resident's return. The initial report to IDPH was made more than 20 hours after the resident returned to the facility and disclosed the assault. Documentation shows that the resident described the assault, underwent a nursing assessment, and a police report was eventually filed. The facility's own policy clearly states that all allegations of abuse must be reported to IDPH immediately, not exceeding two hours after the initial allegation is received, but this protocol was not followed in this case.
Failure to Follow Elopement Policy and Timely Care Planning for Community Pass Privileges
Penalty
Summary
The facility failed to follow its policies and procedures to ensure the safety and supervision of a resident who was on a supervised community pass. Specifically, the facility did not contact the police to assist in locating the resident when he did not return at the indicated time, as required by their elopement policy. Staff attempted to reach the resident and his family by phone but did not escalate the situation to law enforcement after the two-hour grace period had elapsed. Multiple staff members were unclear about the policy for contacting the police, and communication was limited to internal notifications and calls to emergency contacts. Additionally, the facility did not complete a risk for elopement assessment for the resident upon admission, as mandated by their own elopement policy. The assessment was only completed several days after admission, leaving a gap in identifying and addressing potential elopement risks. The resident had a history of major depressive disorder, epilepsy, bipolar disorder, anxiety disorder, and dissociative and conversion disorder, and was considered cognitively intact but required supervision with activities of daily living. Furthermore, the facility did not initiate a person-centered care plan to address the resident's community pass privilege in a timely manner. Although a physician's order for outside pass privileges was obtained, the corresponding care plan was not started until several days later, beyond the expected timeframe. This delay in care planning meant that the interdisciplinary team did not have timely guidance to address the resident's needs and potential risks associated with community outings.
Failure to Maintain Effective Pest Control Program for Bed Bugs
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of bed bugs in the rooms of two residents. Approximately three weeks prior to the survey, bed bugs were found in the room shared by these residents, prompting their temporary relocation. One resident reported the discovery of bed bugs, while the other was unaware of the reason for the move. During the survey, a bed bug was observed crawling on one resident's bed, and multiple dried blood spots were noted on the bed sheets. Upon further inspection, multiple bed bugs were found under the mattress. The maintenance staff confirmed the presence of bed bugs and acknowledged that the pest control company had previously treated the room with chemicals, and that belongings were bagged and laundered. However, there was no documentation of follow-up inspections or confirmation that the new rooms to which the residents were moved were inspected for bed bugs. Record review showed that the facility's pest control service had documented the initial bed bug finding and treatment, but there was no evidence of subsequent inspections or monitoring to ensure eradication. The facility's own policies require inspection of the affected room, adjacent rooms, and the new room to which residents are relocated, as well as the use of non-chemical control measures when practical. These steps were not documented as completed. The lack of follow-up and failure to inspect new rooms upon relocation contributed to the ongoing presence of bed bugs, affecting the residents involved and potentially the entire facility population.
Failure to Address Hypotension and Medication Needs in Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident's medical diagnosis and medication regimen were incorporated into preventive interventions to avoid falls and accidents. Specifically, the care plan and fall interventions did not address the resident's diagnosis of hypotension or the prescribed medication, Midodrine, which was to be administered when the resident's systolic blood pressure dropped below 95 mm/Hg. Documentation showed that there were days when the resident's blood pressure was below this threshold, but the medication was not administered as ordered. The care plan prior to the fall only included teaching on positioning and instructions for assistance, with no reference to the resident's hypotension or related interventions. The resident, who had a history of hypotension, abnormal gait, lack of coordination, and muscle wasting, experienced a fall resulting in a forehead laceration requiring sutures and a laceration to the left arm. At the time of the fall, the resident's blood pressure was recorded at 85/63 mm/Hg, which was significantly lower than their baseline. The fall occurred when the resident attempted to pick something up from the floor after getting up from bed. Staff interviews revealed that the fall care plan and assessments did not consistently consider the resident's medical conditions or medication regimen, and there was confusion among staff regarding responsibility for fall assessments and care plan updates. Further, the facility's policy required fall risk assessments upon admission, readmission, quarterly, significant change, and annually, with interventions to be reevaluated and revised as necessary. However, the Falls Coordinator stated that quarterly assessments were not performed and that interventions were only added after a fall occurred. There was also a lack of communication and coordination between the restorative nurses and the Falls Coordinator regarding fall assessments and care planning. The failure to address the resident's hypotensive state and medication needs in the care plan and to utilize fall assessments contributed to the resident's fall and subsequent injuries.
Failure to Administer Prescribed Medication for Hypotension Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to administer a physician-prescribed medication, Midodrine 10 mg, to a resident with a diagnosis of hypotension and other mobility-related conditions. The resident was prescribed Midodrine to be given when systolic blood pressure dropped below 95 mm/Hg. Review of the resident's blood pressure logs showed multiple instances of systolic blood pressure below this threshold, but the medication administration record (MAR) did not document that Midodrine was given on those occasions. The Director of Nursing confirmed that if the medication was not documented as administered on the MAR, it was not given, and stated that the expectation is to follow the physician's order for as-needed medication. As a result of this failure, the resident experienced an episode of hypotension with a blood pressure reading of 85/63 mm/Hg and subsequently fell, sustaining lacerations to the forehead and left arm. The facility's medication pass policy requires adherence to physician orders and proper documentation on the MAR after medication administration. The failure to administer the prescribed medication as ordered directly contributed to the resident's hypotensive episode and fall.
Failure to Administer Insulin in a Timely Manner
Penalty
Summary
The facility failed to follow a physician's order for a resident in a timely manner, resulting in the resident not receiving prescribed medication for a period of ten days. The resident, who has a severely impaired cognitive status as indicated by a BIMS score of 03, was diagnosed with multiple conditions including diabetes mellitus, vitamin D deficiency, and other metabolic disorders. On 10/22/2024, a clinic record indicated the need to restart Lantus insulin due to high fasting blood sugars. However, the order for Lantus was not entered until 11/01/2024, and the medication was not administered until after this date. The Assistant Director of Nursing (ADON) stated that the nurse responsible for receiving the resident from a hospital or clinic appointment should review any new medication orders before the end of their shift and verify them with the resident's physician or nurse practitioner. The delay of eight to nine days in contacting the physician to verify the medication order was deemed unacceptable. The facility's policy on physician orders requires that they be carried out within a reasonable time, which was not adhered to in this case.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to appropriately document in the Electronic Medication Record (eMAR) for a resident, identified as R3, who was reviewed for improper nursing care. R3's medical history includes multiple diagnoses such as heart failure, type 2 diabetes mellitus with hyperglycemia, and schizoaffective disorder, among others. The resident's Brief Interview for Mental Status (BIMS) score indicated severely impaired cognition. During a review of R3's Medication Administration Record (MAR) and Physician Order Statement (POS), it was found that there was a missing nurse's signature for a scheduled dose of Trulicity, a medication for diabetes, on a specific date in October 2024. The Assistant Director of Nursing (ADON) confirmed that the assigned nurse is responsible for administering medications and documenting them in the MAR. The ADON stated that missing initials on the MAR suggest the medication was not administered, and there are codes available to indicate reasons for non-administration. The facility's policy requires nurses to sign the MAR after administering medication, and the job descriptions for Registered Nurses (RN) and Licensed Practical Nurses (LPN) emphasize the importance of completing medical records in accordance with nursing policies. The failure to document the administration of medication as per the facility's policy led to the identified deficiency.
Failure to Revise Care Plans with Preventive Interventions
Penalty
Summary
The facility failed to revise comprehensive care plans with preventive interventions for two residents, leading to injuries of unknown origin. Resident R3, diagnosed with dementia, sustained a non-displaced fracture of the right-hand proximal third phalanx, believed to be caused by bumping his hand on a bedside table. Despite the incident, R3's care plan only included monitoring and follow-up actions without preventive measures to avoid further injury. The Care Plan Coordinator acknowledged the absence of preventive interventions, such as assisting the resident or repositioning the bedside table, which were not included in R3's care plan. Similarly, Resident R4, who has hemiplegia/hemiparesis affecting the right side and is non-verbal, was found with a tibial fibula fracture on the right leg. The injury was suspected to have occurred when R4 attempted to move his paralyzed leg using his left leg, causing it to bump against the lower side rail of the bed. R4's care plan lacked interventions to prevent further harm, such as padding the lower side rails, despite the presence of padded upper side rails. The facility's care plan policy mandates the development of person-centered plans within seven days of assessment, but the plans for R3 and R4 did not include necessary preventive measures.
Failure to Administer and Document Enteral Feedings Properly
Penalty
Summary
The facility failed to adhere to its policy procedures regarding the administration and documentation of enteral feedings, leading to deficiencies in the care of two residents. Resident 1, who has anoxic brain damage, tracheostomy status, gastrostomy status, and is dependent on a ventilator, was observed with discrepancies in the administration of their enteral feeding. Despite orders for Jevity 1.5 to be infused at 60ml/hr and a 250ml water flush every 6 hours, the feeding bottle was found full, and the pump indicated an incorrect infused amount. The Licensed Practical Nurse (LPN) admitted to not clearing the pump, which is necessary for accurate monitoring of intake, and there was a lack of documentation on the resident's enteral intake. Similarly, Resident 4, who also has gastrostomy status and is ventilator-dependent, was found with an enteral feeding bottle that should have been empty based on the prescribed infusion rate. The LPN confirmed that the bottle had been hanging since the morning, indicating a failure to follow the prescribed feeding schedule. The Assistant Director of Nursing acknowledged that the facility does not document enteral intake, despite the policy requiring nurses to follow orders for feeding type, rate, and duration. This lack of documentation and adherence to feeding schedules contributed to the identified deficiencies.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to remove and discard expired medications that had been open in one of two medication carts reviewed for medication labeling and storage. During an observation on the second floor, a surveyor found an opened bottle of Docusate Sodium 100mg with an expiration date of December 2022 in the Team 1 medication cart. The Registered Nurse responsible for the cart admitted that expired medications should not be stored and should be discarded. The nurse also mentioned that the night shift usually checks for expired medications, but he last checked the cart two to three weeks ago. This oversight has the potential to affect 20 residents whose medications are stored in the Team 1 medication cart on the second floor. A resident reported that a female nurse informed her she was receiving expired medications, although the resident could not identify or describe the nurse. The resident's Minimum Data Set indicated she was cognitively intact. Her physician order sheet included an order for Docusate Sodium 100mg to be taken as needed for constipation. The facility's policy on medication storage, labeling, and disposal states that house stock medications should be labeled with the name, strength, instructions, and expiration date, and should be discarded based on the manufacturer's expiration guidelines.
Failure to Convey Resident Funds After Death
Penalty
Summary
The facility failed to convey funds to a resident's family after the resident's death. The family member of the deceased resident (R4) reported that the Business Office Manager (V6) explained the trust funds would be used for funeral expenses and any remaining balance would be sent back to the state. Despite the family providing a small estate affidavit and invoices for the funeral expenses, V6 insisted that the funds should go to the funeral home directly. The family member expressed frustration and confusion over the process, as the Administrator acknowledged that the funds should go to the individual overseeing the resident's estate, according to the facility's policy. The review of R4's trust fund showed a balance of $7980.88. The facility's policy states that upon a resident's death, the facility must convey the resident's funds and a final accounting of those funds within 30 days to the individual or probate jurisdiction administering the resident's estate. The Business Office Manager admitted to not being aware of the facility's policies concerning the trust fund, leading to a delay and miscommunication in handling the deceased resident's funds. This deficiency affected one of three residents reviewed for resident funds in a total sample of five residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a dependent resident, identified as R5, who reported that no one had come to her room to change her incontinence briefs on the morning of 04/13/2024. R5 stated that she was currently soiled and often had to remain in soiled briefs for extended periods, indicating this was an ongoing issue. A Certified Nursing Assistant (CNA), identified as V4, confirmed that she had not yet changed R5's incontinence briefs since starting her shift at 7 AM and was observed checking and finding R5's briefs soiled with urine at 9:38 AM. V4 then proceeded to change the briefs. R5's medical records indicate she is cognitively intact with a BIMS score of 14/15 and is always incontinent of bowel and bladder, requiring complete assistance with ADL care. R5's care plan includes specific instructions for incontinence care, such as checking for incontinence at least every two hours and ensuring soiled areas are washed, rinsed, and dried. The facility's policies on incontinence and perineal care, as well as ADL care, also mandate regular checks and appropriate care based on comprehensive assessments and care plans. Despite these guidelines, the facility did not adhere to the required care protocols, resulting in R5 remaining in soiled briefs for an extended period on the day of the observation.
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A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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