Goldwater Care Clinton
Inspection history, citations, penalties and survey trends for this long-term care facility in Clinton, Illinois.
- Location
- 1 Park Lane West, Clinton, Illinois 61727
- CMS Provider Number
- 146076
- Inspections on file
- 57
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 52
Citation history
Health deficiencies cited at Goldwater Care Clinton during CMS and state inspections, most recent first.
The facility did not ensure required RN coverage for eight hours per day, as staffing records showed no RN on duty for two of the fourteen days reviewed while 105 residents resided in the facility. On those days, there was no RN present at any time, and the Administrator confirmed the lack of RN staffing during surveyor interview.
A cognitively intact resident reported that night-shift direct care staff frequently used personal cell phones while providing care, including texting, talking on calls via earbuds or speakerphone, and participating in video calls with the camera pointed at themselves. The resident also observed staff hiding in the dining room to use their phones while on duty, noting that such behavior did not occur during daytime shifts. A CNA stated that this resident is generally reliable and accurate in their reports. These practices conflicted with the facility’s Resident Rights policy, which guarantees residents’ privacy and confidentiality.
The facility failed to provide timely toileting assistance and respond promptly to call lights for three cognitively intact residents who required staff help with transfers to the toilet and toileting hygiene, including residents with MS, muscle wasting, overactive bladder, and a UTI. Residents reported that at night staff sometimes entered, turned off call lights, and did not return, that responses to call lights for toileting could take 30 minutes or longer, and in one case a resident reported waiting two hours after activating a call light at night. Residents stated these delays occurred frequently, including daily or often at night with agency staff, and reported toileting accidents while waiting. A CNA and an LPN stated these residents make reliable statements and do not make false allegations, while the facility’s call light policy requires staff to answer call lights in a timely manner.
A resident with dementia, reduced mobility, and type 2 DM was admitted without any documented advance directive, POLST, or physician order for life-sustaining treatment in the medical record. The MDS showed the resident was cognitively impaired. During interviews, the resident’s POA reported they had not selected or signed a POLST, and the Regional Nurse Consultant confirmed there were no life-sustaining treatment orders or POLST on file, indicating the facility failed to ensure the resident’s right to formulate and document advance directives.
A cognitively impaired resident with dementia, depression, diabetes, and a pacemaker was seated in a wheelchair in a common area when another resident exhibiting severe behavioral disturbances, including violence toward staff and flipping tables, attempted to strike staff and instead hit the resident in the back of the head. Multiple staff, including an LPN, CNAs, and a dietary manager, as well as the administrator and regional nurse consultant, confirmed that the aggressive resident made physical contact with the resident’s head while trying to hit staff. The resident’s family was informed and the resident was evaluated in a local ER, where documentation noted no visible injuries and baseline mental status. This incident occurred despite a facility abuse prevention policy that prohibits abuse and mistreatment and affirms residents’ rights to be free from abuse.
The facility failed to arrange necessary follow-up care for a hospice resident with terminal dementia and liver disease who had self-removed an abdominal drain. A nurse practitioner documented that the hospital would not reinsert the drain but would perform paracentesis if needed, and a hospice nurse confirmed the facility should have scheduled and transported the resident for this procedure. Nursing notes showed increasing abdominal girth/ascites and repeated family requests for paracentesis, yet there was no documentation that follow-up appointments were scheduled. In a separate incident, the facility did not complete required neurological assessments for a cognitively impaired resident who was struck in the back of the head by another resident exhibiting behavioral issues. Staff and a family member confirmed the head strike, and ER documentation noted the blow to the head, but the regional nurse consultant verified that no neuro checks were documented despite a policy requiring them after all head injuries and upon return from the hospital.
The facility failed to protect cognitively impaired residents from physical abuse by another resident with known aggressive behaviors. One resident with poor vision and wandering behavior sustained a bruising and a 5 cm by 3 cm skin tear to the right forearm after a physical altercation with an aggressive resident, as witnessed by an LPN and documented in behavior notes. Staff, including CNAs and an activity aide, described the aggressive resident as verbally and physically aggressive toward staff and sometimes attempting to become physical with other residents. Another cognitively impaired resident with care-planned verbal/physical aggression and hoarding/rummaging behaviors was also documented as having an altercation with the same aggressive resident. These incidents occurred despite the facility’s written abuse prevention policy prohibiting abuse and affirming residents’ right to be free from abuse.
The facility failed to report an alleged resident-to-resident altercation to the State Agency as required by its abuse reporting policy. One resident with dementia, depression, poor impulse control, and a history of verbal/physical aggression, and another resident with Alzheimer’s disease, mood disorder, vascular dementia, anxiety, hoarding/rummaging behavior, and verbal/physical aggression were involved in an alleged altercation documented by an LPN. The nurse’s note did not show notification to the abuse coordinator, and the Administrator later stated he did not report the incident because he was unaware of it, even though staff interviews confirmed ongoing aggressive behaviors and the facility’s policy required reporting all abuse allegations to public health authorities.
The facility failed to investigate an alleged physical altercation between two residents with severe cognitive impairment and documented histories of verbal/physical aggression and problematic behaviors. Nursing notes recorded that one resident had an alleged physical altercation with another, and an LPN documented the same incident without notifying the abuse coordinator. Despite a written abuse policy requiring that all incidents be documented and any allegation involving abuse be investigated, the Administrator later stated that no investigation occurred because the incident was not reported to administration.
Surveyors found that the facility failed to follow its fall prevention policy and resident care plans, resulting in multiple accidents and injuries. A resident with dementia and Parkinsonism, known to require close supervision, was left unsupervised in a dining room, stood up to sweep, and fell, sustaining a head laceration and clavicle fracture while on anticoagulant therapy. Another fully dependent resident was transferred to a shower chair with a mechanical lift, but staff left the sling under the resident and moved the chair; the sling straps caught in the wheels, the resident slid from the chair, and suffered a fractured tailbone. A third resident with severe cognitive impairment and high fall risk fell in a bathroom when a CNA turned away, striking a loose towel bar at head height and sustaining facial injuries; no post-fall risk assessment or care plan update was completed. Additional residents had care-planned fall interventions, such as floor mats, a concave mattress, non-skid strips, and task-based activities, that were not implemented or communicated to staff.
The facility failed to ensure accurate transcription and administration of medications for three residents. One resident with dementia and major depression had a psychiatric order to continue daily Quetiapine 50 mg plus PRN dosing, but the scheduled dose was erroneously discontinued in the MAR, resulting in 13 missed days of the antipsychotic and escalating agitation and aggressive behavior. Another resident with Parkinson’s disease received Carbidopa/Levodopa three times daily without regard to meals, despite the physician’s statement that dosing 30–60 minutes before meals is crucial for absorption and that improper timing was likely contributing to worsening Parkinsonian symptoms. A third cognitively intact resident did not receive any scheduled evening medications, including antihypertensives, anticoagulant, antiseizure, and other drugs, because an agency nurse left the full medication cup on a dresser and the doses were discovered untouched the next day.
The facility did not ensure required RN coverage for at least eight consecutive hours daily and lacked consistent full-time DON coverage. The administrator stated there was no stand-alone staffing policy and that the facility followed minimum staffing guidelines, with nurses working 12-hour shifts. Staffing records showed multiple days with no RN scheduled or available, and the former DON reported that an RN was not always present, especially on weekends, and that agency RNs were not consistently available to cover open shifts. At the time, 104 residents were documented as residing in the facility.
Failure to Document Annual CNA Performance Reviews and Required In-Service Training: The facility did not complete annual performance reviews for every CNA or provide documentation that CNAs completed the required 12 hours of annual in-service education. The Facility Assessment identified required training topics related to abuse, neglect, exploitation, reporting, dementia care, and resident abuse prevention, and the Administrator and Interim DON/Regional Nurse Consultant confirmed the missing documentation. The facility had 104 residents.
Missing food temperature documentation was identified in the main kitchen food log. The log lacked entries for breakfast and lunch meals on multiple days, and a Cook stated they did not know why the temperatures were not recorded. The DON/Dietary Manager confirmed the logs should have been completed when the food was cooked and was unsure who filled in the temperatures later.
The facility failed to ensure required members attended quarterly QAA meetings. Record review showed the Medical Director was not documented as present at an April meeting, and the Administrator believed he was likely absent. The Administrator also stated the Medical Director was not present for a later QAA meeting, though the information was reviewed with him afterward.
Infection prevention and control practices were not followed for a resident receiving oxygen therapy when an undated nasal cannula was observed in use with a portable O2 tank, and another undated cannula from an oxygen concentrator was draped over the siderail and touching the floor. The facility’s policy required cannulas to be changed weekly, stored in a labeled plastic bag when not in use, and switched to a room concentrator when possible. The facility also failed to accurately track infections, as active COVID cases were present but the infection summary reports for December and January documented zero COVID infections, which the DON said did not capture the facility’s COVID cases.
Failure to designate an Infection Preventionist. Interview and record review showed the facility did not currently have a certified Infection Preventionist. The Acting DON stated her certification had expired and she was working on completing the required tasks to obtain Infection Control Certification, and the undated Department Head list did not include any employee listed as Infection Control and Prevention. The facility's LTC application documented 104 residents.
Failure to Provide QAPI Training for Staff: The facility did not provide QAPI training for staff. The Facility Assessment Tool listed QAPI as a training topic, but the Administrator stated he could not provide documentation showing the training had been completed and said he was not aware that QAPI training was required for staff.
Failure to provide behavioral health training to all direct care staff. The facility’s census was 104 residents, and the Administrator and Acting DON verified they could not produce documentation showing that any behavioral health training had been conducted for staff during the prior 12 months.
Failure to honor resident shower preferences. Three cognitively intact residents who needed staff help with bathing reported they were assigned shower times without input, were offered showers at inconvenient late-night or very early-morning hours, or felt pressured to accept because refusal would be charted and they might not get another shower. CNA and scheduler interviews confirmed showers were sometimes pushed to evening or night shift when staffing was short, and refusals were sometimes documented when showers could not be completed.
An LPN administered Insulin Aspart to a resident using a multi-dose insulin pen that had been opened but not dated. The LPN confirmed the pen was previously opened without a date, and the facility policy required injectable medication to be dated when opened.
Failure to document offered flu and pneumococcal vaccinations for five residents. The medical records for five residents did not show that influenza or pneumococcal vaccines were offered, and the Acting DON could not produce the documentation. One resident had severe cognitive impairment, another was cognitively intact, and a family member and a resident stated they did not recall being informed or questioned about immunizations during admission.
Failure to document and offer COVID-19 vaccinations to five residents. Records for a resident with severe cognitive impairment and four other residents did not show that COVID-19 vaccine education, offer, administration, refusal, or medical contraindication was documented; the DON could not produce the required documentation. A family member of one resident did not recall being informed about immunizations, and a cognitively intact resident stated she did not recall being educated or questioned about COVID-19 immunizations at admission.
A resident’s record showed orders for an antipsychotic and two antidepressants, but no informed consents were present for any of the psychotropic medications. The Administrator confirmed there were no consents, despite the facility policy stating psychotropic meds shall not be given without informed consent from the resident or resident’s representative.
Failure to notify the physician and dietician of significant weight loss for a resident with dementia, severe cognitive impairment, and dependence for transfers. The resident lost 8.8 pounds, or 6.6%, and the record did not show a re-weigh or documentation that nursing notified the MD, RD, or family; the care plan also lacked a targeted intervention for the weight loss.
A resident with dementia, psychotic disturbance, bipolar disorder, depression, and anxiety received Olanzapine, Citalopram, and Trazodone, but the record lacked documentation of alternatives to psychotropics, behavioral interventions, AIMS monitoring for TD, and any GDR. The care plan noted use of antianxiety, antidepressant, and antipsychotic meds, but did not include alternatives or behavioral interventions, and the Administrator confirmed the missing documentation.
A resident’s MDS was inaccurately coded after a fall that resulted in a left arm fracture and hospital transfer. The quarterly assessment recorded no major injuries since the last assessment, even though the MDS Coordinator stated the fracture should have been counted as a major injury.
Failure to develop constipation care plans for two residents. One resident was admitted with constipation and had a provider note with bowel monitoring, PRN laxative/stool softener use, hydration, fiber, activity, and limiting narcotics, but no corresponding care plan was in place. Another resident had a PRN opioid order, yet the care plan still did not include constipation interventions, and the DON confirmed such a plan was expected.
Care Plan Did Not Reflect Significant Weight Loss. A resident’s care plan failed to include a major weight loss documented in the EMR, with the resident losing 60.4 pounds over the course of the stay. The care plan addressed a special diet, but the Care Plan Coordinator stated that the weight loss itself was not documented in the plan.
A resident had an unwitnessed fall and another fall involving a head injury with a right cheek laceration and ED transfer. Although neuro-check assessments were created and the facility’s policy required them after unwitnessed falls and head injuries, the checks were not completed as written in the medical record, as confirmed by the Interim DON/Regional Nurse Consultant.
Failure to update a dementia care plan for a resident with Alzheimer's dementia, DM2, repeated falls, and major depression. The resident became increasingly agitated, shouted profanities, isolated, refused care, and was heard cursing in his room; staff stated his dementia-related behaviors were escalating and had increased after he did not receive the correct dose of Seroquel. The ADON and Activity Director also reported he had stopped attending activities and had knocked his tray off the table, yet no updated dementia care plan was in place to address the behaviors.
Medication Not Administered as Ordered: An LPN was preparing a resident’s meds and found that calcium 600 mg and omeprazole 20 mg were not available in the cart or in stock. The LPN confirmed both meds were not given as ordered. The MAR documented the doses with a note to see the progress note, and the progress note stated the meds were unavailable.
A resident with an order for nectar-thick liquids had both thickened liquids and regular water at the bedside. The resident said she took morning meds with the regular water, and an LPN confirmed regular water should not have been there. A CNA also stated the resident could not get her own water and staff would have had to place it on the bedside table.
A resident admitted for post‑surgical pain control after a total knee replacement arrived with multiple ordered pain medications and specific transfer needs but was not greeted promptly, was left without access to a call light, was instructed by a CNA to ambulate independently despite requiring assist with a gait belt, and was not assessed or medicated for severe pain by an LPN because controlled substance prescriptions were not faxed to the pharmacy and the admission process was not completed, leading to uncontrolled pain until transfer to the ER. In a separate case, another resident with COPD and pneumonia had a chest X‑ray showing right lung base opacities consistent with possible pneumonia; although nursing staff contacted the physician and received orders for antibiotics and DuoNeb, the MAR shows the antibiotic was not administered until four days after the X‑ray results were reported, delaying treatment and prolonging symptoms.
The facility failed to adequately supervise cognitively impaired residents at high risk for falls and did not complete thorough fall assessments and investigations. One resident with dementia and severe cognitive impairment, who required staff assistance for transfers, sustained two unwitnessed falls in common areas while not under direct supervision, each time attempting to self-transfer from a wheelchair without brakes applied, resulting in significant head hematomas, pain, and emergency transfers. Another severely cognitively impaired, bed-bound resident experienced multiple falls from bed, including events involving rolling out of bed onto a floor mat and being found hanging from a side rail, without completion of fall risk assessments, thorough root-cause investigations, required 72-hour neuro checks, side-rail assessments, or documented safety checks, despite a written fall prevention policy.
A resident with chronic pain and recent total knee replacement was admitted for post‑surgical pain control with orders for multiple opioids and muscle relaxants, but staff failed to ensure these medications were available or administered upon admission. The resident reported severe pain soon after arrival and again later in the evening, yet an LPN did not provide pain medication or effective intervention, and subsequent call‑light requests brought no relief. Near midnight, another LPN assessed the resident and discovered that controlled substance prescriptions had never been faxed to the pharmacy, leaving no ordered pain meds in the building or emergency supply. The resident, in extreme uncontrolled pain and visibly distressed, requested transfer and was sent to the ED for treatment of uncontrolled pain.
The facility failed to ensure that an RN was on duty for at least eight consecutive hours each day, despite a census of over 100 residents and a facility assessment stating that daily RN coverage was needed to provide competent support and care. Review of staffing schedules over several weeks showed multiple days without the required RN coverage, and the DON confirmed that the facility did not consistently meet the eight-hour RN requirement and needed additional RNs to do so.
Multiple cognitively intact residents who were incontinent of bowel and/or bladder reported that staff, particularly agency CNAs on night shift, failed to respond to call lights and did not perform regular incontinence checks, leaving them in saturated briefs and soiled bed linens for hours. One resident described activating the call light several times overnight without assistance and remaining in urine-soaked bedding until morning, while day-shift CNAs reported repeatedly finding residents with wringing-wet briefs and linens showing multiple rings of dried and fresh urine and feces, indicating a lack of overnight rounds. Another resident with diarrhea and requiring a full-body mechanical lift was told by two CNAs that she could not get up and would not be changed, until a CNA who witnessed this cleaned her and reported the incident to an RN, who later acknowledged it was a dignity issue. Other residents stated that when agency staff worked nights, they were not checked, were left in their incontinence, and felt horrible and like a burden.
The facility failed to honor residents’ preferences for shower timing and did not consistently provide or document scheduled showers for multiple cognitively intact residents who required assistance with bathing. Several residents with conditions such as muscle wasting, gait abnormalities, multiple sclerosis, epilepsy, chronic pain, and morbid obesity reported not receiving the two showers per week they were told they would get, with some describing long gaps between showers and being offered showers at unacceptable hours, such as in the middle of the night. Shower sheets frequently lacked documentation that showers were offered, completed, or refused, and when refusals were noted, reasons and follow-up attempts were often missing. CNAs, including agency staff, reported that some residents rarely received showers because they took a long time to bathe, and the DON acknowledged ongoing issues with showers not being done or properly documented despite a policy requiring showers according to resident preference at least twice weekly.
The facility failed to ensure timely ordering, receipt, and administration of medications, including controlled substances for pain, resulting in multiple missed doses for three cognitively intact residents. One resident admitted after a total knee replacement did not receive any ordered pain medications overnight because controlled substance prescriptions were not faxed to the pharmacy upon admission, leaving no medications available in the emergency supply. Two other residents experienced repeated missed doses of antidepressants, anticonvulsants, hormone cream, antihypertensives, and additional antidepressants documented as out of stock or unavailable from the pharmacy. An LPN, the ADON, the DON, and the pharmacist all confirmed that orders were not consistently placed in advance, prescriptions were not transmitted as required, and there were ongoing problems with the medication distribution system and timely pharmacy delivery.
A resident with chronic pain, vertebral compression fractures, muscle wasting, and mobility abnormalities, and with intact cognition and documented moderate pain, had an order for Methocarbamol 750 mg PO three times daily for pain. Over several days, multiple scheduled doses were not administered, with the MAR and nursing notes repeatedly indicating the medication was on order, awaiting pharmacy, out of stock, or unavailable. The resident reported near-constant deep muscle pain and stated that the muscle relaxer was not consistently available or given as scheduled, despite also receiving hydrocodone. The DON later acknowledged that the resident had missed several doses of the ordered Methocarbamol and described this as a significant medication error.
Two residents were affected when the facility failed to implement droplet isolation precautions for a resident with active, symptomatic pneumonia. A chest X-ray confirmed pneumonia, and antibiotics were ordered and later administered, but no isolation orders or care plan entries for infection control were documented, and droplet precautions were never initiated during the illness and treatment period. The coughing resident was placed in a shared room with another resident who did not have pneumonia, and staff did not use gowns or masks, despite a facility policy allowing nursing leadership and the infection preventionist to initiate transmission-based precautions without a physician order.
A resident admitted for post-surgical pain control after a total knee replacement experienced severe, uncontrolled pain when ordered opioid and muscle relaxant medications were not available from the pharmacy or emergency supply. Over several hours, the resident repeatedly reported severe knee pain, became tearful and shaking, and requested transfer to the ER, yet the assigned LPN did not notify any physician about the pain escalation, the lack of ordered medications, or the resident’s request for hospital transfer, stating she was unsure who the physician was. Documentation lacked evidence of physician notification despite facility policy requiring notification for significant changes in condition and for transfers.
A resident with intact cognition reported that a CNA threw clothes at her and told her to dress herself and get into her wheelchair on her own, leaving her upset and feeling abused. The concern was documented on a grievance form and relayed by a housekeeping supervisor to the Administrator/Abuse Prevention Coordinator, who treated it as a customer service issue rather than an abuse allegation. The facility’s abuse policy requires that any abuse allegation be reported to the State Agency within specified time frames, but this allegation was not reported as required.
The facility did not have an RN on duty for at least eight consecutive hours on multiple days, as confirmed by administrative staff and assignment records, despite maintaining a census of 104 residents.
Three dependent residents with significant medical conditions did not receive all scheduled showers, and staff failed to document missed showers or refusals as required by facility policy. Interviews with the administrator and DON confirmed that showers should be provided and documented twice weekly, but records showed multiple missed or undocumented bathing opportunities.
A resident with dementia and a malignant breast neoplasm did not receive multiple ordered wound dressing treatments, and repeated refusals for wound care were not properly addressed or documented. The DON confirmed that staff did not follow required procedures for completing treatments and notifying the physician when treatments were missed or refused.
A resident with a history of aggression, psychiatric issues, and cognitive impairment physically contacted another resident's upper thigh while that resident was in their bed. Staff and administrative interviews confirmed ongoing aggressive behaviors by the resident, and the care plan documented these risks, but the facility did not prevent the incident.
A resident with cognitive impairment and high fall risk experienced a fall that was not promptly reported or investigated by facility staff. Confusion among the DON, ADON, and Administrator led to delayed recognition and documentation of the incident, contrary to facility policy requiring immediate reporting and investigation of accidents.
An audit identified 40 instances of inaccurate ADL documentation for five residents, including false charting of care such as baths not actually provided. The mis-documentation was confirmed through record review and staff interviews.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to provide the required eight hours of Registered Nurse (RN) staffing coverage per 24-hour period on two of fourteen days reviewed, affecting the entire census of 105 residents. Review of facility staffing schedules for April 14, 2026, through April 28, 2026, showed that no RN worked at any time in the facility on April 25, 2026, and April 26, 2026. During an interview on 4/29/2026 at 11:04 AM, the Administrator confirmed that the facility did not have an RN working eight hours per day on those two dates. The deficiency centers on the absence of any RN coverage on the identified days, as documented in the staffing schedules and acknowledged by the Administrator, despite the requirement to have an RN on duty for eight hours each day and to have an RN serving as the full-time Director of Nursing.
Failure to Protect Resident Privacy During Night-Shift Care
Penalty
Summary
The facility failed to maintain a resident’s right to privacy and confidentiality while being assisted by staff. One cognitively intact resident (R1), as documented in a resident assessment dated on an unspecified date, reported that direct care staff working the night shift frequently used their personal cell phones while in the room providing care. R1 stated that staff were often texting or on phone calls, sometimes using earbuds or speakerphone with the phone in their pocket, and at times on video calls with the camera pointed toward themselves rather than toward R1. R1 also reported that some staff hid in the dining room to use their phones while on duty, and that these issues did not occur during the daytime. During an interview, CNA V4 stated that R1 makes reliable and accurate statements. The facility’s Resident Rights policy dated 1/4/2019 states that residents have a right to privacy and confidentiality, which was not maintained for R1 during care interactions on the night shift. These findings were identified for one resident out of three reviewed for privacy in the sample of three residents.
Failure to Provide Timely Toileting Assistance and Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely toileting assistance and respond promptly to call lights for three cognitively intact residents who required staff help with toileting and transfers. One resident with multiple sclerosis, chronic respiratory failure, morbid obesity, chronic pain, overactive bladder, and depression was assessed and care planned as needing partial/moderate staff assistance for transfers to the toilet and toileting hygiene, with documented bladder incontinence. This resident reported that at night, when the call light was activated for help to use the bathroom, a CNA would sometimes enter the room, turn off the call light, and not return, requiring the resident to press the call light again. The resident stated this occurred weekly, that staff could take up to thirty minutes to respond to call lights, and that toileting accidents had occurred while waiting for help. A CNA stated this resident makes reliable and accurate statements. A second resident with muscle wasting and atrophy, generalized anxiety disorder, and depression was assessed and care planned as cognitively intact and needing partial/moderate assistance for transfers to the toilet and toileting hygiene, with bowel and bladder incontinence. This resident reported that staff sometimes took thirty minutes at night to answer call lights for toileting assistance and that this occurred daily. A third resident with overactive bladder and a urinary tract infection was assessed and care planned as cognitively intact, requiring substantial/maximal assistance for transfers to the toilet and partial/moderate assistance for toileting hygiene. This resident reported activating the call light at about 3:00 a.m. a couple of nights prior to use the restroom and waiting two hours for staff to arrive, stating that this often happens at night with agency staff and that staff sometimes shut off the call light and then do not return. An LPN reported that the second and third residents make reliable statements, do not have behaviors, and do not make false allegations. The facility’s call light policy states that staff will answer resident call lights in a timely manner.
Failure to Obtain and Document Advance Directives for a Cognitively Impaired Resident
Penalty
Summary
The facility failed to protect a resident’s rights regarding advance directives by not obtaining or documenting any form of life-sustaining treatment orders for one cognitively impaired resident. Record review on 4/15/2026 at 11:45 a.m. showed that the resident, admitted on 2/2/2026 with diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, reduced mobility, and type 2 diabetes mellitus without complications, had no advance directive, no POLST (Physician Ordered Life Sustaining Treatment) form, and no physician’s order for life-sustaining treatment in the medical record. The Minimum Data Set documented that the resident was cognitively impaired. In an interview at 11:50 a.m., the resident’s Power of Attorney stated they had not chosen or signed a POLST form for the resident, and at 12:30 p.m. the Regional Nurse Consultant confirmed there was no physician order for life-sustaining treatment or POLST form documented in the resident’s record. These findings demonstrate that the facility did not ensure the resident’s right to formulate an advance directive and have life-sustaining treatment preferences documented, as required, for one of one resident reviewed for advance directives in the sample of nine residents.
Failure to Protect Cognitively Impaired Resident From Peer Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from physical abuse by another resident. The resident, admitted with dementia with psychosis, depression, gastritis, basal cell carcinoma of the nose, type 2 diabetes mellitus, and sick sinus syndrome with a pacemaker, was documented as cognitively impaired on the Minimum Data Set. On the date of the incident, multiple staff and a family member reported that another resident was exhibiting behavioral disturbances in the common area, including being violent toward staff, flipping over tables, and attempting to leave (exit seeking). During these behaviors, the resident attempted to strike a staff member but instead struck the cognitively impaired resident in the back of the head while the resident was seated in a wheelchair. Interviews with an LPN, CNAs, the dietary manager, the administrator, and the regional nurse consultant consistently confirmed that the aggressive resident made physical contact with the resident’s head while trying to hit staff. The resident’s family member reported being informed of the incident and, despite being told there were no injuries, insisted the resident be sent to the local emergency room, where documentation noted the resident had been struck in the back of the head by another resident, was at her cognitive baseline, had no complaints, and had no visible injuries. The facility’s Abuse Prevention and Reporting policy affirms residents’ rights to be free from abuse and mistreatment and states the facility prohibits such conduct, yet the incident investigation documented that the aggressive resident, while experiencing behaviors, attempted to make contact with staff and instead made contact with the peer resident, resulting in the physical abuse event.
Failure to Arrange Needed Paracentesis and Omit Neuro Checks After Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to medical orders and resident preferences for a hospice resident with terminal dementia, liver mass, cirrhosis, and ascites. The resident had previously had an abdominal indwelling catheter drain, which the resident self-removed. A nurse practitioner documented that the local hospital declined to reinsert the drain because it was too soon, but indicated that paracentesis would be performed if needed. The hospice nurse confirmed that, if paracentesis was needed, the facility should have scheduled and transported the resident to a treatment center, and also confirmed that the resident’s family requested paracentesis on several occasions. Nursing progress notes documented increasing abdominal girth/ascites and repeated family questions about when the drain could be reinserted and when paracentesis would occur, but there is no documentation that follow-up medical appointments for paracentesis were scheduled. A second deficiency involves the facility’s failure to complete neurological assessments after a known head injury for a cognitively impaired resident with dementia with psychosis, depression, gastritis, basal cell carcinoma of the nose, type 2 diabetes, and sick sinus syndrome with a pacemaker. The resident was struck in the back of the head by another resident who was exhibiting behavioral issues and attempting to hit a staff member. Multiple staff, including an LPN, CNA, and dietary manager, confirmed that the resident was hit in the back of the head. The family member was informed of the incident, was told there were no injuries, and insisted the resident be sent to the ER, where documentation noted the resident had been struck in the back of the head, had no complaints, and no visible injury, with no fall or loss of consciousness. The facility’s neurological assessment policy requires neurological checks after all head injuries, upon physician order, with change in condition, and when nursing judgment deems necessary. The regional nurse consultant confirmed that the medical record did not contain completed neurological assessments following this known head injury and that neurological assessments should have been restarted and completed upon the resident’s return from the hospital.
Failure to Protect Cognitively Impaired Residents From Peer-to-Peer Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect cognitively impaired residents from physical abuse by another resident with known aggressive behaviors. One resident (R1), who is cognitively impaired with poor vision and a history of wandering into other residents’ rooms and beds, was documented in a behavior note dated 2/27/2025 as having an alleged physical altercation with another resident (R2), resulting in bruises and a skin tear to the right forearm measuring 5 cm by 3 cm. An LPN (V6) reported witnessing this physical altercation on the evening of 2/27/2026 and confirmed that R1 sustained a skin tear from the incident. R1’s family member (V7) stated they were notified of this altercation and the resulting skin tear. During observation on 3/21/2026, R1 was seen wandering independently around the dining room and had a healed wound on the right forearm, and staff interviews confirmed R1 is usually verbally, but not physically, aggressive. The same aggressive resident (R2), who has severely impaired cognition per the MDS and is care planned for potential physical aggression related to anger, dementia, depression, history of harm to others, and poor impulse control, was repeatedly described by staff as verbally and physically aggressive, particularly toward staff and sometimes toward other residents. A CNA (V4) and an activity aide (V5) reported that R2 can become aggressive when frustrated or overstimulated, with V5 noting that R2 sometimes attempts to get physical with other residents and that staff usually remove R2 before this occurs. R2’s nurse’s notes and behavior notes dated 2/25/2026 and 2/27/2026 document alleged physical altercations with other residents. Another cognitively impaired resident (R5), who has care plans for problematic behaviors including verbal/physical aggression and hoarding/rummaging related to dementia and mood disorders, was also documented in a nurse’s note dated 2/25/2026 as having an alleged altercation with R2. Despite the facility’s written Abuse Prevention and Reporting Policy affirming residents’ right to be free from abuse and prohibiting abuse, these documented altercations show that residents R1 and R5 were not protected from physical abuse by R2.
Failure to Report Alleged Resident-to-Resident Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of resident-to-resident abuse to the State Agency as required by its Abuse Prevention and Reporting Policy. The facility’s policy, revised 10/24/22, states that when an allegation of abuse has occurred, the resident’s representative and the Department of Public Health’s regional office shall be informed by telephone or fax, and Public Health shall be informed that an occurrence of potential abuse has been reported and is being investigated. A nurse’s note dated 2/25/2026 by an LPN documented that one resident (R5) had an alleged altercation with another resident (R2), but the note did not document any notification to the abuse coordinator. The Administrator later stated that he did not report the incident between these two residents because he was not aware of it and that staff should have reported it to him. The residents involved had known behavioral issues and cognitive impairments documented in their care plans and assessments. One resident (R2) had care plans initiated on 8/25/2025 and 3/2/2026 indicating problematic behavior characterized by ineffective coping, verbal and physical aggression related to cognitive impairment and physiological brain changes, and a potential to be physically aggressive related to anger, dementia, depression, history of harm to others, and poor impulse control. Staff interviews described this resident as verbally and sometimes physically aggressive, primarily toward staff, with attempts to become physical with other residents. The other resident (R5) had care plans initiated on 3/3/2026 documenting problematic behavior with verbal and physical aggression related to cognitive impairment, Alzheimer’s disease, mood disorder, vascular dementia, anxiety, and inability to differentiate others’ belongings, as well as hoarding and rummaging behaviors. A RN described this resident as usually angry and mostly verbally aggressive. Despite these documented behaviors and the alleged altercation between the two residents, the incident was not reported to the State Agency as required by facility policy.
Failure to Investigate Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to investigate an allegation of resident-to-resident physical abuse involving two residents with known histories of aggression and cognitive impairment. The facility’s Abuse Prevention and Reporting Policy, revised 10/24/22, states that all incidents will be documented whether or not abuse is alleged or suspected, and that any incident or allegation involving abuse will result in an investigation. Nursing notes dated 2/25/2026 document that one resident (R2) had an alleged physical altercation with another resident, and another note from the same date by an LPN documents that a second resident (R5) had an alleged altercation with R2. The nurse’s note for R5 does not document any notification to the abuse coordinator. R2’s care plans, initiated 8/25/2025 and 3/2/2026, identify a problematic manner of acting characterized by ineffective coping and verbal/physical aggression related to cognitive impairment and physiological brain changes, as well as a potential to be physically aggressive related to anger, dementia, depression, history of harm to others, and poor impulse control. R2’s MDS shows a BIMS score of 02, indicating severely impaired cognition. R5’s care plans, both initiated 3/3/2026, document problematic behavior characterized by ineffective coping, verbal/physical aggression, and inappropriate behavior such as hoarding and rummaging, related to cognitive impairment, onset of Alzheimer’s, mood disorder, vascular dementia, anxiety, and inability to differentiate between personal and others’ belongings. On interview, the Administrator stated that the incident on 2/25/2026 between R2 and R5 was not investigated because the Administrator was not aware of it and staff had not reported it, resulting in no investigation of the alleged abuse as required by policy.
Failure to Prevent Falls and Remove Hazards Leads to Multiple Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and fall prevention interventions for multiple residents, contrary to its Fall Prevention Program policy. The policy requires assessment of fall risk, implementation of appropriate interventions, adherence to professional standards and manufacturer recommendations, and completion of fall risk assessments after any fall. For one resident with moderate cognitive impairment, Parkinsonism, and dementia, the MDS documented an inability to safely ambulate ten feet and a care plan identifying a risk for falls with interventions including frequent checks and increased supervision during mealtimes. Despite this, the resident was left in the dining room without staff present, attempted to stand and sweep with a broom, lost balance, and fell, sustaining a head laceration and an acute distal clavicle fracture while on anticoagulant therapy. Staff interviews confirmed that this resident requires very close, often constant, supervision and that there should always be staff present in the dining room, but staff acknowledged that the resident was left unsupervised at the time of the fall. Another deficiency involved a resident with multiple sclerosis, demyelinating disease of the CNS, muscle wasting and atrophy, polyneuropathy, and abnormal posture, who was dependent on staff for all mobility and required substantial to maximal assistance with bathing. This resident was transferred to a shower chair using a mechanical lift by a CNA and an LPN, and the mechanical lift sling was left under the resident. The CNA then attempted to move the shower chair without removing the sling or securing the sling straps, which became caught in the wheels, causing the chair to stop abruptly and the resident to begin sliding forward. The CNA tried to hold the resident in the chair and called for help; the LPN and another CNA responded, but before they could use the lift to reposition the resident, the resident slid or was dropped to the floor and was later diagnosed with a new angulation at the sacrococcygeal junction consistent with a broken tailbone. Staff interviews confirmed that leaving the sling under the resident was common practice and that only one staff member typically assisted with the resident’s bath, despite the resident’s total dependence for ADLs. A further deficiency concerned a resident with dementia, syncope, difficulty walking, muscle wasting and atrophy, pain, cognitive communication deficit, depression, and anxiety, who had severely impaired cognition and required substantial to maximal assistance for transfers. This resident had a documented fall risk and a prior unwitnessed fall, and later experienced a fall in the bathroom when a CNA turned away after assisting from the toilet to a wheelchair. While the CNA turned to back the wheelchair out, the resident rose from the wheelchair, reached for a towel bar located above and to the right of the grab bar, and fell into it, causing a facial laceration, swelling, and a hematoma extending from the cheek to the neck, requiring emergency department evaluation, CT imaging, and adhesive skin closures. The fall investigation and staff interviews confirmed that the CNA had turned away from the resident, that the towel bar at head height remained in place and was loose and dislodged, and that the towel bar was recognized as a safety hazard. The resident’s care plan was not revised with a targeted intervention after this fall, and no post-fall risk assessment or 72-hour follow-up charting was documented, despite facility policy requiring a fall risk assessment after any fall and care plan updates addressing each fall. Additional deficiencies involved failures to implement existing fall-prevention care plan interventions for other residents. One resident’s fall prevention care plan required floor mats on each side of the bed when the resident was in bed, but observations on two occasions showed the resident in bed with no fall mat on one side and a mat leaning against the wall instead. Another resident, identified as high risk for falls, had care plan interventions for a concave mattress, non-skid strips by the bed, and provision of working tasks as activities. Observations showed the resident lying on a regular mattress without a concave mattress or non-skid strips in place, and later sitting in a television room without any working task activity. A CNA who regularly cared for this resident reported never seeing a concave mattress or non-skid strips in use, and the activity aide stated she was not familiar with the working task intervention and that such interventions were not always communicated to her. The administrator confirmed that the concave mattress and non-skid strips should have been implemented and that the working task intervention was unclear and not conveyed to activity staff.
Medication Transcription, Timing, and Administration Failures Affecting Three Residents
Penalty
Summary
The deficiency involves multiple failures in medication management, including inaccurate transcription of an antipsychotic order, improper timing of an antiparkinsonian medication in relation to meals, and failure to ensure medications were actually taken by a resident. One resident with diagnoses including Type II diabetes, Alzheimer’s dementia, repeated falls, and major depression had a psychiatric visit on 12/10/25, during which the psychiatric provider ordered continuation of Quetiapine 50 mg daily for agitation related to dementia and added Quetiapine 25 mg every 6 hours PRN. However, the resident’s Medication Administration Record and current physician order sheet show that the scheduled Quetiapine 50 mg dose was discontinued in error on 1/28/26, and no PRN doses were administered. As a result, the resident missed 13 consecutive days of the antipsychotic until the surveyor identified the error. During this period, staff and the psychiatric provider described escalating agitation, aggressive behavior, cursing, shouting, refusal of care, and isolation, and the psychiatric PA stated it was never the intention to stop the Quetiapine and that abrupt cessation likely contributed to the behavioral escalation. Another resident, with diagnoses including depressive disorder, history of right femur fracture with hip replacement, and Parkinson’s disease, was ordered Carbidopa/Levodopa (Sinemet) 25/100 mg three times daily for Parkinson’s disease with dyskinesia and fluctuations. The resident’s family reported being instructed that the medication should be given 30–60 minutes prior to food because high-protein foods interfere with absorption, but stated that in the facility it was sometimes given before, sometimes after, and sometimes with meals. The MAR documented the three-times-daily Sinemet order without specific meal-related instructions, and the primary physician confirmed that timing 30–60 minutes prior to meals is crucial for absorption and that incorrect timing could be causing increased Parkinson’s symptoms. The acting DON confirmed that this resident’s Sinemet had been administered without regard to meals, while nursing staff described a general practice of administering medications within one hour before or after scheduled times due to workload. A third resident, documented as cognitively intact, reported that on a Sunday evening an agency nurse left all of the resident’s evening medications in a cup on the dresser for the empty bed next to the resident, and the resident did not remember to take them. The next day, an activity assistant found the untouched medications, and the acting DON verified they were all of the resident’s 8:00 p.m. medications. The MAR showed that these evening medications included multiple critical drugs: Amlodipine and Lisinopril (antihypertensives), Atorvastatin (anticholesterol), Eliquis (anticoagulant), Keppra (antiseizure), Metoprolol (beta blocker), as well as Famotidine and Senna. The administrator confirmed that the resident did not receive any of the scheduled 8:00 p.m. medications that night because they had been left in the cup on the dresser by the agency nurse. The facility’s policy on entering and processing physician orders requires licensed nurses to confirm and complete instructions for new orders, but the documented events show failures in accurately maintaining and administering ordered medications for these residents.
Failure to Provide Required Daily RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide a registered nurse (RN) on duty for eight consecutive hours daily as required, affecting all 104 residents. The administrator reported that the facility does not have a stand-alone staffing policy and instead follows minimum nurse staffing guidelines, including RN coverage, and provided staffing sheets showing nurses work 12-hour shifts. Review of these staffing sheets showed that on multiple specific dates (1/3/26, 1/4/26, 1/17/26, 1/18/26, 1/31/26, and 2/1/26), there was no RN scheduled or available in the facility. The former DON stated that their last day of employment was 1/30/26 and confirmed that the facility did not always have an RN available, particularly on weekends, and that while agency nurses were used to cover open shifts, agency RNs were not always available to fill those shifts. The Long-Term Care Facility Application for Medicare and Medicaid dated 2/08/26 documented that 104 residents resided in the facility at the time of the survey, and the lack of RN coverage on the identified dates occurred despite this census.
Failure to Document Annual CNA Performance Reviews and Required In-Service Training
Penalty
Summary
The facility failed to complete a performance review of every nurse aide at least once every 12 months and failed to provide regular in-service education based on the outcome of those reviews. Review of the Facility Assessment dated 2/6/26 documented required abuse, neglect, and exploitation training, including education on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property; reporting of crimes under the Elder Justice Act; and care and management for persons with dementia and resident abuse prevention. The Facility Assessment also documented required in-service training for nurse aides, stating that in-service training must be sufficient to ensure continuing competence and be no less than 12 hours per year. On 2/11/26, the Administrator and Interim DON/Regional Nurse Consultant confirmed they were unable to provide documentation of annual CNA staff reviews and documentation that CNA staff completed 12 hours of continuing education. The facility application dated 2/8/26 documented that 104 residents resided in the facility.
Missing Food Temperature Log Documentation
Penalty
Summary
The facility failed to document food preparation temperatures on the main kitchen food temperature log. On 2/8/26 at 08:10 AM, review of the log showed missing temperature entries for breakfast and lunch meals on 2/5/26 and 2/6/26, and for breakfast on 2/8/26. The undated Food & Beverage Temperature Control policy states that food and beverage temperatures should be taken and logged when cooked and again prior to meal service, with documentation of cook and service holding temperatures. At 08:10 AM on 2/8/26, V39, Cook, stated they did not know why the temperatures were not logged. On 2/10/26 at 1:10 PM, V3, Dietary Manager, confirmed the temperature logs should have been completed at the time the food was cooked for consumption and stated they were unsure who or how the presented temperature logs now had temperatures filled in.
QAA Meetings Lacked Required Medical Director Attendance
Penalty
Summary
The facility failed to ensure required staff members attended Quarterly Quality Assurance meetings. The facility’s QAPI policy states the committee shall meet at least quarterly and includes members such as the Administrator, Medical Director, DON, and other department leaders. During record review and interview, sign-in sheets for the April 2025 Quarterly Quality Assurance meeting did not include the Medical Director’s signature, and the Administrator stated he was not working at the facility at that time and believed the Medical Director was most likely not present. The Administrator also provided QAA meeting minutes for December 16, 2025 and stated the Medical Director was not present for that meeting, although he reviewed the information with the Medical Director afterward. The Administrator confirmed that the Medical Director should be present at these meetings.
Infection Control and Infection Tracking Failures
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices related to oxygen administration for one resident, R73, who had diagnoses including malignant neoplasm of colon, vitamin deficiency, hyperlipidemia, excoriation disorder, and squamous blepharitis. R73’s MDS dated 01/25/2026 documented a BIMS score of 11, indicating moderate cognitive impairment. On 2/08/2026, R73 was observed sitting in a wheelchair with a nasal cannula attached to a portable oxygen tank hanging on the back of the wheelchair. The nasal cannula applied to R73’s nose was undated. Behind R73 was an oxygen concentrator with an undated nasal cannula attached, and the other end of that cannula was draped over R73’s siderail and touching the floor. The facility’s Oxygen and Respiratory Equipment Changing/Cleaning Policy dated 09/08/2016 states nasal cannulas are to be changed weekly and as needed, that residents using a portable oxygen tank will be switched to a room oxygen concentrator while in their room whenever possible, and that a plastic bag with a zip lock or drawstring will be provided to store the cannula when not in use and dated with the date the tubing was changed. On 02/10/2026, an LPN stated residents’ nasal cannulas should be stored in the provided plastic bag when not in use. The facility also failed to accurately document and analyze infections: although the facility had active COVID-19 cases beginning in December 2025 and a sign on the front door indicated active COVID-19 cases on 2/8/26, the infection summary reports for December 2025 and January 2026 documented zero COVID infections. The Acting DON stated those reports did not capture the facility’s COVID infections.
Failure to Designate an Infection Preventionist
Penalty
Summary
The facility failed to designate one or more individuals as infection preventionist for its infection prevention and control program. During interview and record review, the Acting DON stated that the facility did not currently have a certified Infection Preventionist and that her certification had expired while she was working on completing the required tasks to obtain Infection Control Certification. The undated Department Head list did not include any employee listed as Infection Control and Prevention. The facility's Long-Term Care Application for Medicare and Medicaid documented a total of 104 residents currently residing at the facility.
Failure to Provide QAPI Training for Staff
Penalty
Summary
The facility failed to provide Quality Assurance and Performance Improvement (QAPI) training for staff. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 2/08/26 documented a total census of 104 residents. The Facility Assessment Tool, which was undated, stated that the facility would provide staff with the necessary training, education, and competencies to deliver the level and types of care required for its resident population, and it included QAPI as a listed training topic. During an interview on 2/17/2026 at 10:32 a.m., the Administrator stated he could not provide documentation showing that QAPI training for staff had been completed and said he was not aware that QAPI training was required for staff.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide behavioral health training to all direct care staff. The facility's Long-Term Care Application for Medicare and Medicaid dated 2/8/26 documented a census of 104 residents. On 2/17/26 at 10:00 AM, the Administrator and Acting DON verified that they could not provide documentation showing that any behavioral health training had been conducted for staff during the 12 months before the survey.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to honor residents’ rights to make choices regarding the timing of their showers and did not promote resident self-determination through support of resident choice. The facility’s Bathing - Shower and Tub Bath Policy states that residents are to be offered a shower, tub bath, or bed/sponge bath according to their individual preferences for timing and frequency, at least twice per week, and additionally as requested or needed. Interviews and record review showed this did not occur for three residents reviewed for personal care choices. R11, who had intact cognition and required staff assistance with showers after right hip surgery, stated she was assigned to Tuesday and Friday evenings but had no input in the schedule and did not like showers after supper. She said staff sometimes came late in the evening and she felt she had to accept because refusing meant waiting until the next scheduled shower day. R23, who had intact cognition and required substantial to maximal assistance with showers due to multiple sclerosis, stated she accepted an early morning shower because if she declined it would be documented as refused and she would not receive a shower later that day. R45, who also had intact cognition and required partial to moderate assistance with showers due to chronic respiratory failure and multiple sclerosis, stated she often did not receive showers as scheduled and described showers being offered at 10:00 PM or 3:00 AM. Staff interviews confirmed showers were sometimes moved to evening or night shift when not completed, and that night shift sometimes documented showers as resident refusals.
Undated Multi-Dose Insulin Pen
Penalty
Summary
The facility failed to date a multi-dose insulin pen when it was opened for one resident, R56, who was reviewed for medication administration. On 2/09/2026 at 12:13 PM, V12, an LPN, administered 10 units of Insulin Aspart to R56 using a multi-dose insulin pen that had previously been opened and was not dated. During the observation, V12 confirmed that R56's multi-dose insulin pen had been opened without a date and stated that the opened insulin pen should be dated. The facility's Injectable Medication Administration policy, revised November 2021, documents a procedure to date injectable medication when opened.
Failure to Document Offered Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure influenza and pneumococcal vaccinations were offered and documented in the medical record for five of five residents reviewed for infection control: R15, R4, R2, R63, and R12. The medical records for these residents did not document that either vaccine was offered. The Acting DON stated on multiple occasions that she was unable to produce documentation regarding influenza and pneumococcal immunizations for these residents, and the facility’s policy dated 11/28/2012 states the resident’s medical record should include documentation regarding whether the resident received or did not receive the influenza immunization. R15’s record showed an admission date of 02/11/2025 and diagnoses including iron deficiency, lipoprotein deficiency, vascular dementia with anxiety, depression, restless legs syndrome, and chronic pain; the MDS documented a BIMS score of 6, indicating severe cognitive impairment. R63’s record showed an admission date of 05/02/2025 and diagnoses including hypothyroidism, GERD without esophagitis, major depressive disorder, overactive bladder, and calculus of kidney; the MDS documented a BIMS score of 13, indicating cognitive intactness. R15’s family member stated she did not recall being informed of immunizations during the admission process, and R63 stated she did not recall being educated or questioned about influenza or pneumococcal immunizations at admission.
Failure to Document and Offer COVID-19 Vaccinations
Penalty
Summary
The facility failed to ensure COVID-19 vaccinations were offered, educated on, and documented for five of five residents reviewed for infection control. The record for R15, who was admitted with diagnoses including iron deficiency, lipoprotein deficiency, vascular dementia with anxiety, depression, restless legs syndrome, and chronic pain, did not document that a pneumococcal vaccine, influenza vaccine, or COVID-19 immunization was offered or administered. R15’s MDS showed a BIMS score of 6, indicating severe cognitive impairment, and the resident’s family member stated she did not recall being informed of immunizations during the admission process. The records for R4, R2, R63, and R12 also did not document that a COVID-19 immunization was offered or administered. R63’s care plan listed diagnoses including hypothyroidism, GERD without esophagitis, major depressive disorder, overactive bladder, and calculus of kidney, and the MDS showed a BIMS score of 13, indicating cognitive intactness; R63 stated she did not recall being educated or questioned about COVID-19 immunizations at admission. The Acting DON stated she was unable to produce documentation regarding COVID-19 immunizations for R15, R4, R2, R63, and R12. The facility policy required documentation that the resident or representative was educated on the benefits and risks of the COVID-19 vaccine and documentation of each dose administered or the reason the vaccine was not received due to medical contraindication or refusal.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents for psychotropic medications for one resident, R17, who was reviewed for unnecessary medications. R17’s medical record included orders for Olanzapine 2.5 mg at bedtime, Citalopram Hydrobromide 10 mg daily, and Trazodone 100 mg at bedtime, but the record did not contain consents for these medications. During an interview on 2/10/2026 at 9:00 AM, the Administrator stated there were no consents for R17’s use of psychotropic medications. The facility’s psychotropic medication policy, revised 2/01/2018, states that psychotropic medication shall not be administered without the informed consent of the resident and/or resident’s representative.
Failure to Notify Physician and Dietician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and dietician of a significant weight loss for one resident reviewed for physician notification. The resident had diagnoses including dementia, syncope and collapse, difficulty walking, muscle wasting and atrophy, pain, cognitive communication deficit, depression, and anxiety. The resident’s assessment documented severely impaired cognition, substantial to maximal staff assistance needed for transfers, and no behaviors, delusions, or hallucinations. The resident’s weight record showed a weight of 137.0 pounds on 1/5/26 and 128.2 pounds on 2/1/26, a loss of 8.8 pounds or 6.6%. The facility’s Weights Policy stated that undesired or unanticipated weight loss of 5% in 30 days, 7.5% in three months, or 10% in six months shall be reported to the physician, Dietician and/or Dietary Manager as appropriate, and that a re-weight should be obtained as soon as possible after an unanticipated weight change is noted. Review of the resident’s record showed no documentation of physician, dietician, or dietary manager notification and no re-weigh despite the significant weight loss. The resident’s care plan also did not contain a targeted intervention related to the weight loss.
Failure to Document Alternatives, AIMS Monitoring, and GDR for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a resident’s right to be free from chemical restraints by not implementing alternatives to psychotropic medications, not monitoring for tardive dyskinesia, and not attempting a gradual dose reduction for one resident reviewed for unnecessary medications. The facility’s policy stated that psychotropic drugs should not be given unless necessary, that alternatives should be incorporated into the care plan with suitable goals and approaches, that residents on antipsychotic therapy should be monitored for tardive dyskinesia every six months using the AIMS, and that gradual dose reductions should be attempted at least twice yearly unless the physician documented a clinical rationale for declining a reduction. The resident’s record showed orders for Olanzapine 2.5 mg at bedtime, Citalopram 10 mg daily, and Trazodone 100 mg at bedtime, with diagnoses of dementia without behavioral disturbance, psychotic disturbance, bipolar disorder, depression, and anxiety. The record did not contain documentation of alternatives used instead of the psychotropic medications, behavioral interventions, an AIMS assessment, or a gradual dose reduction order. The care plan documented the use of antianxiety, antidepressant, and antipsychotic medications, but it did not include alternatives or behavioral interventions. The Administrator confirmed that the record lacked documentation of alternatives, AIMS monitoring, behavioral interventions, and gradual dose reductions.
Inaccurate MDS Coding for Major Injury After Fall
Penalty
Summary
The facility failed to accurately code a Minimum Data Set assessment for R17. R17’s medical record showed that after a fall on 10/9/2025, the resident was sent to the hospital and diagnosed with a left arm fracture. However, the Quarterly MDS assessment documented that R17 had fallen since the last assessment and recorded zero major injuries since the last assessment. During interview on 2/08/2026, the MDS Coordinator stated that the fall with fracture was a major injury and should have been captured on R17’s 11/15/25 quarterly MDS assessment.
Failure to Develop Constipation Care Plans
Penalty
Summary
The facility failed to develop care plans for constipation for two residents reviewed for care plans. One resident was admitted with a diagnosis of constipation, and a progress note by the nurse practitioner documented a plan to monitor bowel movements daily, give laxatives and/or stool softeners as needed, notify the provider if there was no bowel movement within three days, increase hydration, fiber intake, and physical activity, and limit narcotic use; however, the resident’s care plan did not include constipation interventions. The Interim DON stated there should be a care plan addressing constipation for this resident and confirmed none was present. Another resident had an order for Hydrocodone-Acetaminophen 5 mg-325 mg every four hours as needed for pain, but the care plan did not include constipation interventions. The Interim DON stated any resident taking an opioid is expected to have a care plan for constipation.
Care Plan Did Not Reflect Significant Weight Loss
Penalty
Summary
The facility failed to update R81’s comprehensive care plan to include a significant weight loss. R81 was admitted on 7/11/25, and the EMR documented weights from 7/13/25 through 2/9/26, showing a decrease from 175.0 pounds to 114.6 pounds, a loss of 60.4 pounds. The care plan dated 2/4/26 did not address the weight loss. During interview on 2/12/26 at 2:30 PM, the Care Plan Coordinator stated she did not realize the care plan did not document the weight loss and said the resident’s need for a special diet had been addressed, but nothing about weight loss was documented. The facility policy titled Comprehensive Care Plan states that the care plan is to direct the care team and incorporate the resident’s goals, preferences, and services to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.
Incomplete Neurological Checks After Falls
Penalty
Summary
The facility failed to complete neurological checks after an unwitnessed fall and after a fall with a head injury for one resident reviewed. The facility’s Fall Prevention Program required a fall risk assessment after any fall incident and documentation of the resident’s assessment, vital signs, treatment rendered, and follow-up, including at least 72 hours of documentation after the incident. The resident’s fall log documented an unwitnessed fall in the facility, and the facility also provided a fall investigation for another fall in which staff turned around as the resident stood from a wheelchair in the bathroom, reached for a towel bar, and fell into it, causing a laceration on the right cheek and transfer to the hospital emergency department by ambulance. The medical record showed that an LPN created a fall assessment for the documented fall, and neuro-check assessments were created after both the unwitnessed fall and the fall with head injury. However, review of those neurological checks showed they were not completed as required. The Interim DON/Regional Nurse Consultant confirmed that neuro-checks are to be completed as written in the medical record and are to be initiated after a fall involving the head or any unwitnessed fall, and confirmed that the resident’s neuro-check assessments for both falls were not completed at the time of review.
Failure to Update Dementia Care Plan for Escalating Behaviors
Penalty
Summary
The facility failed to implement resident-centered interventions for a resident with dementia, identified as R7, who had diagnoses of Type II Diabetes, Alzheimer's Dementia, Repeated Falls, and Major Depression. R7's care plan, updated 11/6/25, documented these diagnoses, and the MDS dated [DATE] documented that R7 had no behavioral symptoms. However, during observation on 2/8/26, R7 was in bed watching TV and became highly agitated when the surveyor introduced herself, shouting profanities, stating he was being held prisoner, and pounding on the bed rail while demanding to be taken out of the facility and to get his money back. Facility staff acknowledged that R7's behavior was escalating and that he had been seen by a contracted psyche provider. The Administrator and acting DON stated that R7 was suspicious of his POA, did not like women, and that his dementia-related behaviors were increasing. They also verified that cursing, isolating, shouting, and refusal of care had increased since R7 had not received the correct dose of Seroquel. The Activity Director stated that since the end of January, R7 had not attended activities, had been heard shouting and cursing in his room, and had knocked his tray off the table during a meal. The facility verified on 2/18/26 that an updated dementia care plan had not been put in place to address the escalating behaviors.
Medication Not Administered as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the physician for one resident, R111, during a medication administration review. On 2/09/2026 at 8:45 AM, an LPN was preparing R111’s medications and stated that Calcium 600 mg and Omeprazole 20 mg were not available in the medication cart or in stock at the facility. The LPN confirmed that both medications were not administered as ordered. R111’s MAR for February 2026 shows an order dated 1/13/26 for calcium 600 mg, one tablet by mouth daily, and an order dated 10/17/25 for omeprazole 20 mg, one capsule daily, with both medications documented as “see progress note” on 2/9/26 at 8:00 AM. R111’s progress note dated 2/9/26 at 8:50 AM documents that the Omeprazole and Calcium were unavailable. The facility’s Medication Administration policy dated November 2021 states that medications should be administered as ordered by the physician.
Regular Water Left at Bedside Despite Nectar-Thick Order
Penalty
Summary
The facility failed to ensure that liquids provided at the bedside were prepared in the form ordered to meet the resident’s individual needs. One resident had a physician’s order dated 12/23/25 for nectar thickened liquids, and the care plan revised 12/24/25 also documented the need for nectar thickened liquids. During observation on 2/08/2026 at 11:25 AM, a glass of thickened liquids and a glass of regular water were both sitting on the resident’s bedside table. The resident stated she took her morning medications with the regular water rather than the thickened liquids. Later that day, the regular water was still on the bedside table. An LPN confirmed the resident’s liquid order was nectar thick and that regular water should not have been at the bedside, and a CNA stated the resident could not get up on her own to get water and that staff would have had to place the regular water there.
Failure to Complete Admission Process, Manage Pain, and Act on Chest X‑Ray Results
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough admission process and to provide timely pain management for a newly admitted post‑surgical resident, as well as a separate failure to act promptly on chest X‑ray results for another resident. One resident was admitted after a left total knee arthroplasty with chronic pain, morbid obesity, and a history of motor vehicle injury, and arrived with orders for multiple pain medications including Hydrocodone, Hydromorphone (Dilaudid), Morphine, and Tizanidine. Hospital documentation indicated she required a gait belt and one‑person assist with a walker for transfers, was cognitively intact, and was being admitted for post‑surgical pain control, with controlled substance prescriptions sent in the discharge packet and Morphine next due at 9:00 p.m. Upon arrival at the facility in the early evening, the resident reported not being greeted or seen by staff for approximately two hours, not having access to a call light, and being placed in a room with a broken bed remote. When a CNA eventually responded to a call light activated by the roommate, the resident requested assistance to the bathroom. The CNA instructed her to ambulate independently with a walker, despite the resident’s report that she had not walked independently since surgery and was supposed to have staff walking beside her with a gait belt. The CNA watched her ambulate but did not assist with transfers or help her get her legs back into bed. The resident reported being in significant pain, having last received pain medication prior to leaving the hospital, and feeling unsteady and scared of falling. Later, an LPN entered the room, acknowledged knowing the resident was there but did not perform an assessment or evaluate the surgical knee. When the resident requested pain medication and repeatedly reported severe pain and that something did not feel right, the LPN stated she was unsure if any pain medication was available and left without returning with medication. The resident continued to lack ready access to a call light until she later found it on the floor and used it around midnight to again request help for uncontrolled pain. Around midnight, another LPN assessed the resident, who was in extreme pain, visibly upset, and shaking. This nurse discovered that the controlled substance prescriptions had not been faxed to the pharmacy upon admission and that the admission process, including a full admission assessment and required admission tasks, had not been completed. The prescriptions were not faxed until approximately 1:00 a.m., and the resident had not received any of her ordered pain medications since arrival. A nursing progress note documented that the prescribed pain medications were not delivered by the pharmacy, were not available through the emergency medication supply, and that the prescriptions required refaxing and a new access code. By 1:00 a.m., the resident was tearful, shaking, and stated she could not wait any longer for pain medication, requesting transfer to the emergency room, where she was treated for uncontrolled pain. The regional nurse later confirmed that staff should have greeted the resident upon arrival, ensured access to a call light, notified the pharmacy, faxed prescriptions within two hours, and completed admission assessments including pain, fall risk, transfer status, and care plan focus, and acknowledged that failure to address the resident’s pain caused undue stress and pain. In a separate incident, another resident with diagnoses including COPD with acute exacerbation and pneumonia underwent a chest X‑ray performed by a private company. The X‑ray report, received by the facility, documented opacities in the right lung base that could represent atelectasis or pneumonia. The facility’s infection control log later showed that this resident was diagnosed with pneumonia of an unknown organism and started on antibiotic therapy several days after the X‑ray. Nursing progress notes documented that nursing staff called the physician regarding the chest X‑ray results and the resident’s condition, describing the resident as extremely congested and coughing, and that the physician’s office returned the call with a new diagnosis of pneumonia and orders for a 10‑day course of antibiotics and DuoNeb treatments as needed. Despite the new orders, the medication administration record showed that the ordered antibiotic, Amoxicillin, was not actually administered until the evening of the same day the physician’s office returned the call, which was four days after the chest X‑ray results had been reported to the facility. The MAR also reflected the start of Ipratropium‑Albuterol nebulizer treatments as needed for cough, congestion, and shortness of breath beginning on the date the pneumonia diagnosis and orders were received. The DON/Infection Preventionist acknowledged that the delay in initiating antibiotic and respiratory treatment for the resident’s confirmed pneumonia resulted in prolonged infection and symptoms.
Failure to Supervise Cognitively Impaired Residents and Complete Thorough Fall Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and fall prevention for cognitively impaired residents, resulting in repeat traumatic falls and incomplete post-fall management. One resident with dementia, syncope, difficulty walking, muscle wasting, pain, and severe cognitive impairment was assessed as at risk for falls and required staff assistance for transfers. This resident experienced an unwitnessed fall in the memory care living room, where staff overheard a gasp and then found the resident on the floor with a head impact, head pain, a large hematoma, a knee skin tear, knee pain, and new back and neck pain, requiring emergency transfer and multiple CT scans. Prior to this fall, pain assessments had not been positive, but immediately afterward the resident reported high pain scores. The same resident, still identified as severely cognitively impaired and at risk for falls, later had another unwitnessed fall in the memory care dining room. Staff reported the resident repeatedly attempted to get up from a wheelchair and was redirected to sit, but at the time of the fall no staff were present because they were taking other residents to their rooms after supper. The resident attempted to self-transfer from the wheelchair, which rolled backward because the brakes were not applied, resulting in a fall to the floor, a large forehead hematoma, complaints of dizziness and pain, and another emergency transfer with multiple CT scans and new pain medication orders. The DON reported the resident lacked safety awareness and frequently attempted to self-transfer, and also reported not being aware of the presence of auto-locking brakes on the resident’s wheelchair prior to this fall, despite these behaviors having occurred for a long time. A second resident with severe cognitive impairment and total dependence for bed mobility experienced multiple falls with inadequate assessment, investigation, and monitoring. This resident had an unwitnessed fall after rolling out of bed onto a floor mat; the fall note documented confusion, a moderate pain score, and initiation of neurological checks, but the unwitnessed fall report did not identify environmental, physiological, or situational factors, and no fall risk assessment was completed before or after the fall. A subsequent fall was documented as witnessed, with the resident found partially out of bed and hanging from a side rail, but no CNA was identified and no witness statements were included, and required neurological assessments for 72 hours were only documented twice. There was no bedside side-rail assessment in the record, and after a third unwitnessed fall, safety checks were ordered but not documented as completed. The DON later confirmed deficiencies in fall investigations, assessments, neurological monitoring, care planning, and documentation, despite an existing fall prevention policy outlining required assessments, interventions, and documentation.
Failure to Manage Post‑Surgical Pain Due to Admission and Pharmacy Process Lapses
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate post‑surgical pain management for a resident admitted after a left total knee replacement. The resident had a history of chronic pain following a motor vehicle injury, morbid obesity, and left knee osteoarthritis, and had been taking Dilaudid chronically prior to surgery. Hospital discharge instructions included multiple pain medications (hydrocodone, hydromorphone/Dilaudid, morphine, and tizanidine) and directions to call the physician for severe uncontrolled pain. The hospital report indicated the resident was admitted specifically for post‑surgical pain control, was cognitively intact, required one‑person assist with a walker, and that controlled substance prescriptions were sent with the discharge packet, with morphine next due at 9:00 PM. Upon arrival at the facility in the early evening, the resident reported already experiencing significant pain. According to the resident, no nurse entered the room until approximately 9:00 PM, at which time an LPN was informed of the resident’s severe pain and request for pain medication. The LPN reportedly stated she was unsure whether any pain medication was available and, despite the resident’s repeated reports of severe pain and that something did not feel right, did not provide any intervention or return with medication. The resident stated that a subsequent call light at about 11:00 PM resulted in contact with an unidentified staff member, but again no intervention occurred, and no nurse assessed or addressed the pain during this period. Around midnight, the resident again used the call light, reporting that the pain and discomfort were no longer tolerable and expressing feelings of being disregarded and not cared for. Another LPN then assessed the resident’s pain and discovered that the controlled substance prescriptions had not been faxed to the pharmacy upon admission, so the ordered pain medications were not available in the facility or in the emergency medication supply. Nursing documentation noted that the prescriptions had to be re‑faxed and a new access code obtained, and confirmed that the resident had not received any prescribed pain medications since admission. During this time, the resident was described as in extreme pain, visibly distressed, tearful, and shaking, and ultimately requested transfer to the emergency department, where she was treated for uncontrolled pain.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours per day as required, affecting a census of 107 residents. Review of nursing staff schedules from 12/17/25 through 1/7/26 showed that on five days (12/20, 12/21, 12/26, 12/29, and 12/30/25) there was no RN coverage for at least eight consecutive hours. During an interview on 1/7/26 at 11:50 AM, the Director of Nurses (DON) confirmed that the facility did not have eight hours of RN coverage every day and acknowledged the need to hire more RNs to meet the requirement. The facility assessment dated [DATE] documented that an RN is needed every day to provide competent support and care for the resident population, and the Central Management Services 802 Matrix dated 12/23/25 confirmed the facility census of 107 residents. The deficiency centers on the facility’s failure to ensure daily RN coverage consistent with its own facility assessment and regulatory requirements, as evidenced by documented staffing schedules and the DON’s confirmation of inadequate RN staffing on the identified dates.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
The deficiency involves multiple cognitively intact residents being left wet or soiled for extended periods, particularly during night shifts staffed by agency CNAs, in violation of their right to dignified care. One resident with frequent bowel and bladder incontinence reported that on a specific overnight, she activated her call light multiple times requesting toileting assistance, observed two agency CNAs pass her room without responding, and ultimately fell asleep with the call light on. She awoke soaked in urine on several occasions, again turned on the call light, and no staff responded; she stated she lay in a wet incontinence brief and saturated bed linens the rest of the night and felt neglected and ashamed. Day-shift CNAs later found her with fully saturated linens requiring a full bed change and total bed bath, and she reported the incident to her nurse. Day-shift CNAs corroborated a pattern of residents not being checked or changed overnight when agency CNAs worked, describing repeatedly finding residents, including this resident, with incontinence briefs “wringing wet” and bed linens showing multiple rings of dried and fresh urine and feces, indicating they had not been changed during the night. One CNA stated she could not count how many times she had found this resident’s bed saturated in the morning and that the resident was not a heavy wetter, while another CNA described following night agency staff and finding residents’ beds totally saturated, with obvious evidence that residents had not been changed on two-hour rounds. A CNA and the DON both characterized these situations as dignity issues, and the DON stated residents are to be checked every two hours on all shifts and as needed. Additional residents with no cognitive impairment and bowel and bladder incontinence reported similar experiences of not being checked or changed overnight when agency staff were on duty. One resident stated she had laid in her own incontinence for hours and believed the problem was with agency staff. Another resident, who was always incontinent and required a full-body mechanical lift, was observed by a CNA asking two CNAs to be cleaned and gotten out of bed while she had diarrhea; the CNAs told her she could not get up and that they would not change her, stating she was not finished yet. The observing CNA reported this to an RN and then returned to clean the resident herself, finding her sheets soiled and her brief full, while the resident repeatedly thanked her and said she could not stand lying in her own feces any longer. The RN later acknowledged that if CNAs told the resident she could not get up and had to remain soiled, it was not appropriate and was a dignity issue. Another resident stated that when agency staff worked nights, nobody checked on them, and that lying in urine all night made them feel horrible and like a burden.
Failure to Honor Shower Preferences and Provide Scheduled Showers
Penalty
Summary
The deficiency involves the facility’s repeated failure to honor residents’ shower time preferences and to consistently provide scheduled showers to dependent residents, despite facility policy requiring bathing according to resident preference at least twice weekly. Multiple residents with intact cognition and no documented refusal behaviors did not receive showers as scheduled, and staff did not consistently document whether showers were offered, completed, or refused. The Director of Nursing confirmed that all residents are to receive two showers per week, that CNAs are to sign off when showers are given, and that refusals must be documented with reasons and multiple attempts; however, the records and interviews showed this was not occurring. One resident with muscle wasting, atrophy, and coordination problems, and a BIMS score indicating no cognitive impairment, was care planned as needing partial to moderate assistance with bathing and to be kept clean and dry. This resident was scheduled for showers on the night shift but requested showers on the day shift. Despite this documented preference, the resident continued to be scheduled and bathed on the night shift, with multiple weeks showing no shower sheets at all and several dates where showers were either not given, not documented as offered, or documented as declined at night without any change to the schedule. The resident and a family member both reported that showers were not being provided as supposed, and a CNA stated that this resident was among those who rarely received showers because they took a long time to complete. Another resident with epilepsy, muscle wasting, gait abnormalities, and generalized edema, and a BIMS score indicating no cognitive impairment, was scheduled for day-shift showers. On multiple documented shower dates, there was no indication that the shower was offered, done, or refused. The resident reported receiving showers but not consistently twice a week, stating that agency staff said they did not have time and that the resident often had to request showers to receive them. A third resident with primary progressive multiple sclerosis, gait abnormalities, and muscle wasting, also cognitively intact, was scheduled for showers but had gaps of a week or more with no shower documentation. This resident reported not receiving showers routinely twice a week and described being offered showers at approximately 3:00 a.m., which the resident refused as unacceptable given a known preference to sleep until mid-morning; the resident stated they generally liked showers and did not usually refuse. A fourth resident with vertebral compression fractures, restless leg syndrome, chronic pain, muscle wasting, and gait abnormalities, and a BIMS score indicating no cognitive impairment, had long periods with no shower sheets to show that showers were scheduled or provided. When showers were scheduled, documentation was often incomplete, with some entries lacking any indication of whether the shower was offered, done, or refused, and one entry noting a refusal due to pain without further documented offers. During observation, this resident was in bed with greasy, uncombed shoulder-length hair and stated needing a shower, reporting that a shower had not been offered the prior week because staff were too busy. A fifth resident with visual disturbance, cognitive communication deficit, morbid obesity, multiple pain diagnoses, muscle wasting, and difficulty walking, also cognitively intact, had multiple shower dates with no documentation of whether showers were offered, done, or refused. This resident reported receiving the first shower in two weeks the previous night, stated never refusing showers, and indicated typically receiving only one shower per week despite being told two were scheduled. Staff interviews corroborated the pattern of missed and undocumented showers. A CNA reported that three specific residents rarely received showers because they took a long time to bathe, and that the CNA tried to make up missed showers when working. Another agency CNA who frequently worked nights stated that other night staff reported resident refusals for care and showers, but that this CNA personally did not have issues with residents refusing care and was able to provide care when answering call lights, regardless of assignment. Overall, the documentation gaps, resident statements, and staff interviews demonstrate that residents’ preferences for shower timing were not honored and that scheduled showers were repeatedly not provided or properly documented, contrary to facility policy and stated expectations.
Repeated Medication Unavailability and Delayed Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely ordering, receipt, and administration of prescribed medications, including controlled substances for pain management, for multiple residents. One resident was admitted after a left total knee replacement with hospital discharge orders for several pain medications, including hydrocodone, hydromorphone (Dilaudid), morphine, and tizanidine, for chronic pain, morbid obesity, and osteoarthritis status post total knee arthroplasty. Hospital documentation indicated that controlled substance prescriptions were sent with the discharge packet and that the next morphine dose was due at 9:00 PM, with the last Dilaudid dose given at 4:00 PM prior to transfer. Nursing documentation showed that by 1:10 AM the following day, the resident’s prescribed pain medications had not been delivered by the pharmacy and were not available in the emergency supply. The LPN caring for the resident reported that the resident complained of severe left knee pain multiple times between 11:00 PM and 1:00 AM and confirmed the resident had not received any pain medication since admission. The LPN stated the pharmacy informed her they had not received the faxed controlled substance prescriptions, and she did not fax them until approximately 1:00 AM, after discovering they had only been sent with the admission packet, contrary to the facility’s admission checklist requiring orders to be faxed within two hours of arrival. Additional deficiencies were identified for another resident whose MAR documented multiple missed doses of medications due to unavailability from the pharmacy. These included missed doses of Wellbutrin XL for depression and morbid obesity, oxcarbazepine for multiple sclerosis, and estradiol cream for postmenopausal atrophic vaginitis on various dates. Each missed dose was documented as “unavailable” or “medication not available,” with corresponding administration notes confirming the lack of medication. This resident reported having a “big problem” with medications and stated that the facility was “always out of something,” indicating repeated interruptions in medication availability. A third resident, cognitively intact and documented as experiencing occasional moderate pain that frequently interfered with activities and sleep, also had missed doses of medications due to pharmacy unavailability. The MAR and administration notes showed that labetalol for atherosclerotic heart disease and duloxetine for depression were not administered because they were out of stock or there was “no medication.” The Assistant DON acknowledged that medications were not always ordered in advance as required and that delays from both nursing and pharmacy had resulted in missed doses. The pharmacist stated the pharmacy expects three to five days’ notice before medications run out, typically fills prescriptions within two days, and can provide same-day delivery for urgent needs. The DON confirmed that two residents’ medications were out of stock and acknowledged ongoing issues with timely medication delivery and ordering practices, despite facility policies requiring an effective medication distribution system and timely faxing of new admission orders to the pharmacy.
Failure to Provide Ordered Muscle Relaxant Resulting in Significant Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a prescribed muscle relaxant for pain, Methocarbamol 750 mg three times daily, was not administered for multiple scheduled doses. The resident had diagnoses including wedge compression fracture of T9–T10 vertebra with routine healing, restless leg syndrome, chronic pain syndrome, muscle wasting and atrophy, and gait and mobility abnormalities. The resident’s MDS documented intact cognition (BIMS 15/15) and occasional, moderate pain that frequently interfered with activities and sleep. The December MAR showed repeated use of chart code 9 (Other/See Progress Notes) for the Methocarbamol doses scheduled at 6:00 a.m., 1:00 p.m., and 8:00 p.m. on multiple consecutive days, indicating the medication was not given as ordered. Progress and administration notes documented that from 12/24 through 12/27, the Methocarbamol was repeatedly noted as “on order,” “awaiting pharmacy,” “out of medication,” or “medication unavailable,” resulting in missed doses over several days. During interview, the resident reported hurting almost constantly “deep down in the muscle,” stated that the muscle relaxer was not available or not given when scheduled, and reported that even with hydrocodone, they still experienced pain, noting that the combination of medications significantly affected their comfort. The DON acknowledged unawareness of the issue until review with the surveyor, stated there had been problems with the pharmacy sending medications, and confirmed on review of the MAR that the resident had missed several Methocarbamol doses in December, characterizing this as significant and more than a single delayed dose.
Failure to Implement Droplet Isolation for Resident With Pneumonia
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control measures, specifically droplet isolation precautions, for a resident with active, symptomatic pneumonia and the resulting exposure of a roommate. One resident (R4) had a history of pneumonia treated in the hospital prior to admission and later developed congestion and an active cough while in the facility. A chest X-ray completed by a private company showed opacities in the right lung base, interpreted as possibly due to atelectasis or pneumonia, and the results were reported to the facility on 11/13/25. The facility’s Infection Control Log documented that on 11/17/25, R4 had a diagnosis of pneumonia of unknown organism and was started on antibiotic therapy, and the Medication Administration Record showed amoxicillin ordered for pneumonia for 10 days. Despite the confirmed pneumonia diagnosis and active cough, R4’s Physician Order Sheet for the relevant period did not document any order for infection control precautions, and the care plan from admission through discharge did not document that R4 was being treated for pneumonia or that isolation precautions were initiated or implemented. The MAR documented that the antibiotic was not actually administered until the evening of 11/17/25, four days after the X-ray results were reported, and continued through the morning of 11/27/25. During this time, droplet isolation precautions were never implemented from the date the X-ray confirmed pneumonia through the end of treatment, resulting in approximately 14 days of potential exposure while R4 had an active cough and was receiving treatment for pneumonia. Another resident (R3), who had no cognitive impairment per a recent MDS, reported that R4 was brought into their room as a new roommate while R4 was actively coughing all the time and had pneumonia, which staff knew about. R3 stated that no one wore gowns or masks, that R4 coughed constantly, and that R3, who spent a lot of time in bed, had to pull the curtain when in the room because they did not want to get sick. The facility’s infection precaution policy stated that transmission-based precautions, including droplet precautions, are to be used for residents known or suspected to be infected with microorganisms transmitted by droplets from coughing, and that isolation precautions may be instituted by nursing leadership or the infection preventionist without a physician’s order. The DON and Infection Control Preventionist acknowledged that R4 had an active cough with confirmed pneumonia, that droplet isolation should have been implemented immediately, and that R4 should not have been placed in the same room with R3, who did not have pneumonia.
Failure to Notify Physician of Resident’s Severe Uncontrolled Pain and Medication Unavailability
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of a significant change in condition, specifically severe, uncontrolled post-surgical pain, and the unavailability of ordered pain medications. The resident had recently undergone a left total knee replacement and was admitted for post-surgical pain control with multiple prescribed pain medications, including Hydrocodone, Hydromorphone (Dilaudid), Morphine, and Tizanidine. Hospital discharge instructions directed staff to call the physician for any severe, uncontrolled pain. Upon admission, the resident was cognitively intact, required one-person assist with a walker, and had chronic pain, morbid obesity, and left knee osteoarthritis status post total knee arthroplasty. The hospital report indicated that controlled substance prescriptions were sent with the discharge packet and that the resident had last received Dilaudid at 4:00 p.m. prior to transfer. According to nursing documentation, by 1:10 a.m. the resident’s prescribed pain medications had not been delivered by the pharmacy and were not available in the facility’s emergency medication supply. At approximately 1:00 a.m., the resident was tearful, shaking, and stated she could not wait any longer for pain medication, requesting transfer to the emergency room. The progress note did not document any physician notification. The LPN caring for the resident overnight confirmed that the resident complained of severe left knee pain multiple times between 11:00 p.m. and 1:00 a.m., had not received any pain medication since admission, and that the LPN did not notify a physician about the severe pain, the lack of available ordered pain medications, or the resident’s request to go to the emergency room because she was unsure who the resident’s physician was. The Regional Nurse confirmed that nursing staff should have notified the physician when the resident’s pain became severe, when ordered pain medications were unavailable, and when the resident was transferred to the hospital. The facility’s policy required physician notification for significant changes in condition and when a decision is made to transfer a resident from the facility.
Failure to Recognize and Report Resident’s Abuse Allegation to State Agency
Penalty
Summary
The facility failed to recognize and report an allegation of abuse to the State Agency after a resident complained about the conduct of a CNA. The grievance tracking log for November 2025 shows that the resident filed a grievance on 11/06/25, but the log contains no additional information about the nature of the grievance. A Grievance Concern/Compliment Form dated the same day documents that the Housekeeper/Laundry Supervisor received the report and recorded that the resident stated a CNA, described as a heavier-set girl of a specified race, threw clothes at the resident and told the resident to get dressed and into the wheelchair independently. The resident’s MDS showed a Brief Interview of Mental Status score of 13/15, indicating no cognitive impairment. Despite this, the Administrator/Abuse Prevention Coordinator did not report the grievance to the Illinois Department of Public Health, stating he considered it a customer service issue rather than abuse at the time. In an interview, the resident recounted that the CNA tossed clothes to her, told her to dress herself, and that she then had to get into her wheelchair on her own. The resident reported feeling upset and described the CNA as rude and in a hurry, and stated that no one deserves to be rushed or treated rudely. The Housekeeper Supervisor later stated that the resident appeared anxious and somewhat agitated, with a facial expression suggesting she was holding back tears, and that the resident reported the CNA had thrown her clothes and told her to dress and get into her wheelchair by herself. The Housekeeper Supervisor also stated that this concern was reported immediately to the Administrator/Abuse Prevention Coordinator and that the resident stated she felt abused. The facility’s Abuse Prevention and Reporting policy, revised 10/24/22, requires that any allegation of abuse be reported to the Illinois Department of Public Health immediately, but no later than two hours after the allegation, or within 24 hours for incidents not involving abuse and not resulting in serious bodily injury. The Administrator acknowledged that the resident’s grievance should have been reported as an abuse allegation in accordance with this policy.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours per day, as required. Review of Nursing Hall Assignment Sheets from 8/27/25 through 9/15/25 revealed that on nine separate days, there was no RN coverage for the required duration. This was confirmed by the facility administrator, who acknowledged the absence of RN staffing on those days. The facility maintained an average daily census of 104 residents during this period, as documented in the Bed Management sheet.
Failure to Provide and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide multiple scheduled showers for dependent residents, as required by its own policy, which states that residents should be offered a shower, tub bath, or bed/sponge bath at least two times per week or according to their preference. Documentation in the electronic medical records for three residents revealed missed showers without any record of showers, baths, or refusals for several scheduled dates. Specifically, one resident with diagnoses including dementia, Parkinson's disease, and a pressure ulcer was scheduled for showers twice weekly but only received five showers over a 30-day period, with no documentation for other scheduled dates. Another resident with chronic kidney disease, muscle atrophy, sepsis, gangrene, and diabetes was also scheduled for twice-weekly showers but only received three showers and had two refusals documented, with no other entries for the remaining dates. A third resident with dementia, delusional disorder, and depression received only two showers and had two refusals documented, with no other records for the rest of the scheduled showers. Interviews with the facility's administrator and director of nursing confirmed that the expectation is for residents to receive two showers per week and for staff to document all showers given or refused in the electronic medical record. Both leaders acknowledged that staff are required to document when a shower is given or refused, and if a shower is refused, the nurse should be notified to reapproach the resident and address any barriers. The lack of documentation and missed showers for these dependent residents represents a failure to follow facility policy and ensure proper hygiene and dignity for residents unable to perform activities of daily living independently.
Failure to Complete and Address Repeated Refusals of Wound Care Treatments
Penalty
Summary
The facility failed to complete multiple wound dressing treatments and did not address a resident's repeated refusals for wound care as required by physician orders. According to the facility's policy, dressing changes should be performed in accordance with physician orders and documented in the Treatment Administration Record (TAR), with staff initialing the electronic TAR after each administration. For one resident diagnosed with dementia, delusional disorder, depression, need for assistance with personal care, and malignant neoplasm of the right breast, there was a physician order for daily wound treatment to the right breast. The resident's care plan also specified that staff were to perform treatments per physician order for a cancer ulcer under the right breast. Record review revealed that, over a period of several months, there were multiple instances where wound treatments were not completed and several occasions where the resident refused treatment. Specifically, the TARs documented missed and refused treatments across July, August, and September, with a pattern of both non-completion and repeated refusals. The Director of Nurses confirmed that staff are expected to complete wound care as ordered and to notify the physician and document in the electronic medical record if treatments are not completed or if there are repeated refusals.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. One resident, who had a documented history of physical and verbal aggression, psychiatric and cognitive impairments, and was not cognitively intact, made physical contact with another resident's upper thigh while the second resident was lying in the first resident's bed. Staff interviews confirmed that the aggressive resident frequently attempted to grab or reach for other residents and had previously been physical with others. The care plan for the aggressive resident noted ongoing issues with ineffective coping and aggression related to cognitive impairment. Despite these known behaviors and risks, the facility did not prevent the incident of physical abuse, as documented in the facility's abuse report and confirmed by staff and administrative interviews.
Failure to Investigate and Report Resident Fall
Penalty
Summary
The facility failed to conduct a fall investigation, develop a root cause, and implement relevant fall interventions for one resident who was at high risk for falls. The resident had multiple diagnoses, including cellulitis of the right lower limb, chronic pain, lack of coordination, and required assistance with personal care. The resident was documented as not cognitively intact and required supervision or touching assistance with walking. The care plan identified impaired cognitive function and high fall risk, with interventions to cue, reorient, and supervise as needed. Despite these risk factors, the facility did not report the resident's fall in a timely manner, and the incident was only recognized after a coroner's request from the hospital following the resident's death. Interviews revealed confusion and lack of communication among facility staff regarding the reporting and investigation of the fall. The Administrator stated that the fall was not reported until after the coroner's inquest, and the DON and ADON each believed the other was responsible for reporting and follow-up. The facility's policy required that all incidents or accidents be reported, assessed, and investigated by nursing staff and reviewed by the Administrator and DON, but this process was not followed in this case. The failure to promptly report, investigate, and address the fall resulted in a lack of timely interventions for the resident.
Failure to Accurately Document and Maintain Resident Records
Penalty
Summary
The facility failed to accurately document and maintain resident records in accordance with accepted professional standards for five residents. An audit of documentation revealed a total of 40 instances of mis-documentation related to Activities of Daily Living (ADL) over a 30-day period, with individual residents experiencing between two and sixteen occurrences each. The mis-documentation included false charting, such as documenting that baths were provided when they were not actually given. These findings were supported by a review of the facility's Employee Disciplinary Form and interviews with facility staff.
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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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