Integrity Hc Of Anna
Inspection history, citations, penalties and survey trends for this long-term care facility in Anna, Illinois.
- Location
- 315 South Brady Mill Road, Anna, Illinois 62906
- CMS Provider Number
- 146006
- Inspections on file
- 25
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 60 (2 serious)
Citation history
Health deficiencies cited at Integrity Hc Of Anna during CMS and state inspections, most recent first.
A resident with a known lung lesion and multiple comorbidities developed abdominal pain and later severe left shoulder pain; imaging showed a lung mass invading the rib and multiple suspected metastases, including a lytic humeral mass with pathologic fracture. The physician ordered oncology, pulmonology, orthopedic, and interventional radiology (IR) referrals, but staff failed to ensure that oncology and pulmonology referrals were successfully transmitted and acted upon, did not provide required CT images to IR for a lung biopsy order, and allowed an orthopedic appointment for the pathologic humeral fracture to be missed due to short staffing without rescheduling or informing the POA. The ADON acknowledged forgetting to follow up on the pulmonology referral and IR requirements, and the facility had no policy on following physician orders. During this time, the resident experienced ongoing pain, falls, and functional decline while expressing a desire for cancer treatment, and neither the resident nor POA refused treatment after the new CT findings, leading surveyors to cite a failure to provide timely follow‑up and treatment of known suspicious masses that had metastasized.
Two cognitively impaired residents with documented elopement and wandering risks repeatedly exited the facility without staff knowledge due to ineffective supervision, nonfunctioning or unmaintained wander guard and door alarm systems, and care plan interventions that were either not implemented or were altered after the fact. In one event, a resident with dementia left alone and was returned by police; in a later event, the same resident pushed her severely cognitively impaired roommate in a wheelchair along busy streets until a family member discovered them. Staff interviews revealed that nurses and CNAs were unaware the residents had left, the physician and a resident’s legal representative were not notified as required by policy, and elopement‑related education and communication to staff were lacking, leading surveyors to cite the facility for failing to prevent accidents and provide adequate supervision.
The facility failed to provide sufficient nursing staff to meet residents’ needs, resulting in delayed follow‑up on specialist referrals and missed medical appointments for a resident with complex conditions and suspected cancer, as well as long, painful, and untrimmed toenails for several residents, including those with diabetes. Multiple residents reported that fresh water was not passed daily despite care plans calling for encouragement of hydration, and family members described having to bring water themselves. Residents also experienced prolonged waits for responses to call lights and incontinence care, with one CNA reporting being the only aide on a hallway while training a new aide. A resident with Parkinson’s disease and dementia was observed unshaven, with a family member stating only one staff member could shave and that the resident had to wait until she had time. Nursing and CNA staff reported that there were not enough CNAs to properly care for residents, and leadership confirmed there were no policies for staffing levels or call‑light response.
Surveyors found that the facility did not hold QAA/QAPI meetings on a quarterly basis and did not include the medical director as a participant. Review of meeting sign-in sheets and minutes showed that the medical director did not attend documented meetings, and the Administrator acknowledged that no QAPI meeting was held for one quarter and that the medical director had never attended these meetings. The Administrator also reported there was no written policy governing quarterly quality assurance meetings, despite an expectation that they occur quarterly with medical director involvement, affecting all residents in the facility.
The facility did not maintain an effective training program for new and existing staff, as confirmed by record review and interviews with the Administrator and a regional clinical leader. Available in-service records showed training only on QAPI, infection control, resident rights, and abuse, with no documented training on communication, behavioral health, compliance and ethics, or required annual nurse aide education. The Administrator acknowledged that staff had not been trained on these topics, that CNAs had not received their required annual training hours, and that there was no facility policy governing staff training. This deficiency had the potential to affect all 67 residents in the facility.
Multiple dependent residents with diabetes and other chronic conditions did not receive timely toenail care or shaving assistance. Several residents with diabetic foot care needs were observed with long, thick, or curling toenails despite care plans and orders allowing podiatry involvement, and nursing staff acknowledged the nails needed trimming but cited lack of on-site podiatry, discomfort with trimming thick nails, unclear routines, and staffing issues. Other residents who depended on staff for personal hygiene were repeatedly observed with facial hair and dirty-appearing hair, and reported not being shaved or showered as expected, while staff described that only certain personnel performed shaving, there was no specific shaving policy, and RNs were responsible for diabetic toenail care per facility policy.
The facility failed to consistently pass water and maintain hydration for multiple residents with conditions such as COPD, diabetes, chronic kidney disease, dehydration, UTIs, muscle wasting, and skin integrity concerns, despite care plan interventions to encourage good nutrition and hydration. Several cognitively intact or moderately impaired residents were repeatedly observed without water in their rooms and reported that water was not passed daily, that they often only received water when they asked, and that available water was sometimes old and warm. Family members described having to bring in cups and fresh ice water because residents were not getting drinks during the day. Staff, including a helping hand, an RN, and the administrator, acknowledged that water was supposed to be passed several times per day but often was not due to CNA staffing shortages, and the administrator stated there was no facility policy on hydration and water passing.
Two residents with moderate cognitive impairment and significant care needs experienced delayed and inadequate responses to call lights. One resident, identified as a fall risk and care planned to receive prompt assistance, waited about 20 minutes for staff to respond to an activated call light, with the ADON citing CNA call-ins and staffing issues. Another resident, dependent for toileting and incontinent, had an activated call light ignored by an Activities Director who did not inquire about needs, leaving the light on while the resident remained soiled until other staff arrived later to provide care. Leadership confirmed there was no call light policy, and the administrator stated that any staff could answer call lights and that she would hope they are answered within 15 minutes.
Two residents with severe cognitive impairment and documented wandering or fall risk eloped from the facility, leaving the building and going up the street without staff knowledge until they were found and returned without injury. Facility documentation in Risk Management reports and late-entry progress notes described the incidents and residents’ confusion but did not include any notification to the attending physicians or resident representatives. A family member with POA reported learning of the elopement only later during a care plan meeting, and the RN responsible for the unit acknowledged that the physician was not notified, despite a facility elopement policy requiring physician and legal representative notification and documentation after such events.
A resident with bilateral hearing loss and highly impaired hearing documented on MDS assessments did not have communication needs or hearing loss addressed in the care plan, despite the Communication Care Area being triggered. Progress notes by nursing staff described the resident as deaf, relying on lip‑reading and occasional text‑to‑speech communication, and also noted difficulty understanding the severity of a cancer diagnosis. During observation, a CNA spoke to the resident from outside his visual field, leading the resident to state he could not hear or understand what was being said, while the CNA believed the resident could hear in one ear. The MDS coordinator later acknowledged missing the communication trigger and was unsure how the resident’s communication needs were conveyed to staff.
A resident with multiple cardiac conditions, COPD, and limited mobility, who used a wheelchair for ambulation, fell to the floor of a facility van when the driver braked suddenly to avoid an animal. The resident reported striking the dashboard and having the wheelchair land on top of him, and later imaging confirmed rib and clavicle fractures. The van driver (a CNA) stated that the wheelchair and seat belt had been properly secured using four clamps and a seat belt, while another CNA reported that the resident later said he had not been buckled in properly. Facility documentation initially cited a seat belt malfunction as the root cause, and the facility’s Drive Safe Program assigns responsibility to the driver to ensure all passengers are securely seated and using seat belts.
Multiple residents experienced unclean bathroom conditions when commodes and surrounding areas were left with feces or dried stains, and requests for cleaning were not promptly addressed. One resident and a roommate reported being unable to use their shared commode due to its dirty condition and being told by a staff member that cleaning it was not her job, with housekeeping only cleaning it the next morning. Other residents were observed with feces on toilet risers and dried red/brown substances on commode fixtures and walls. CNAs reported that bathrooms are sometimes "horrible" and that housekeeping does not always clean proactively, while the housekeeping supervisor reported no complaints despite a written environmental services quality control policy.
The facility failed to consistently honor resident diet orders and food preferences, including during use of an emergency menu while the kitchen was under renovation. A resident with multiple comorbidities and a moderate cognitive deficit, ordered an NCS diet and documented to prefer Cheerios, was served Fruit Loops instead of a non‑sugar cereal. A resident with diabetes reported repeated peanut butter and jelly sandwiches over several days due to reliance on a shelf‑stable emergency menu with limited variety. Despite resident council feedback that some did not want corned beef, the facility served corned beef hash, leading several cognitively intact residents to refuse the meal, describe lunch as awful, and substitute other foods or personal supplies. The Dietary Manager and Social Services Director acknowledged awareness of these expressed preferences, and facility policy required assessment and communication of individual food preferences.
Surveyors found that hot foods were not maintained at safe temperatures during a noon meal service. A resident with diabetes, morbid obesity, heart failure, and CKD, who was cognitively intact and on a NAS diet with fluid restriction and protein supplements, reported that her corned beef hash was served cold. Dietary staff, serving from roasting pans due to a kitchen remodel, checked food temperatures with a calibrated thermometer and recorded the corned beef hash at 110°F and green beans at 130°F, both below the FDA Food Code requirement of at least 135°F for hot holding TCS foods. The facility could not provide a policy on food temperatures.
A cognitively intact resident with COPD and morbid obesity, using a bariatric bed, repeatedly lacked properly fitting linens for her specialty mattress. Surveyors observed the bed with only a partially tucked flat sheet or a fitted sheet that had come off a mattress corner, and the resident reported that the facility had very few sheets that actually fit her bed and that incorrect or half sheets would not stay in place. CNAs acknowledged there were not enough bariatric-size sheets and that only certain marked sheets fit, while others did not work well. The Housekeeping/Laundry Supervisor confirmed a limited number of correctly sized sheets, noted that previously purchased sheets were the wrong size, and was unsure how many bariatric beds were in use or whether there were enough appropriate linens. The Administrator could not explain the lack of proper sheets, the resident’s care plan did not address linen or mattress needs, and the facility had no supply policy available.
A resident with multiple chronic conditions and moderate cognitive impairment had physician orders and a care plan for an NCS diet with super cereal at breakfast, fortified foods TID, and health shakes TID. During survey observation, the resident’s breakfast tray did not include the ordered fortified super cereal, despite the meal card specifying one serving. The Dietary Manager confirmed that the super cereal (oatmeal) should have been served, and facility policy requires use of a tray identification system to ensure residents receive therapeutic diets and supplements as ordered.
A resident with Parkinson’s disease, COPD, heart disease, adult failure to thrive, anxiety, and a moderate cognitive deficit had a physician order and care plan for an NCS diet with mechanical soft (dental soft) texture and thin liquids, along with fortified foods and health shakes. Despite a meal card specifying dental soft texture and a facility policy requiring adherence to therapeutic diet orders, the resident was served peanut butter cookies at breakfast that were not pre-softened. The resident reported being told by staff to dunk the cookies in milk and demonstrated difficulty eating them, stating they were not soft enough. The dietitian and dietary manager acknowledged that cookies for residents on mechanical soft diets were supposed to be softened before serving, but this was not done in this case.
A resident with diabetes, a chronic right plantar foot ulcer, and multiple comorbidities required extensive ADL assistance and was care planned as non‑weight‑bearing on the right lower extremity with twice‑daily wound treatments. A wound physician repeatedly documented an electronically signed order for a pressure‑relieving boot, but this order was never entered into the medical record, and no boot order appeared on the care plan, physician orders, or treatment records. Staff, including a CNA, PTA, RN, and the wound nurse, reported never or rarely seeing any boot in use, while a family member stated she had brought a specialized boot from home that was not used. The regional clinical director acknowledged the wound physician’s documentation should have been processed as an order, resulting in the resident not receiving the ordered pressure‑relieving boot to offload pressure from the diabetic foot ulcer.
A resident with severe cognitive impairment, total dependence for ADLs, incontinence, and a documented Stage IV pressure ulcer to the buttocks was care planned and assessed as high risk for skin breakdown, with facility policy requiring special support surfaces such as an air loss mattress. Although the wound log listed an air loss mattress as preventative equipment, surveyors twice observed only a standard mattress in use over an extended period following a room change, and staff could not explain why the air mattress had not been moved. Serial wound measurements by the wound physician and an LPN showed a deep, persistent Stage IV ulcer, and the wound physician, regional clinical director, and medical director all stated that an air loss mattress was expected and that lack of such a surface could contribute to wound deterioration, demonstrating the facility’s failure to implement appropriate pressure ulcer prevention and treatment interventions.
Several residents with significant medical needs were not provided with appropriate incontinence briefs, especially at night, leading to embarrassment and discomfort. Staff and resident interviews confirmed frequent shortages of the correct sizes, and facility documentation showed ongoing grievances about the lack of supplies. The facility did not have a specific policy for incontinence care, and staff were instructed not to use briefs at night unless requested by alert residents, without consulting families of those unable to express preferences.
A resident with severe cognitive and physical impairments, including Alzheimer's disease and contractures, experienced multiple falls resulting in facial lacerations requiring sutures. Despite a care plan outlining specific fall prevention interventions such as reclining the wheelchair and prompt repositioning after meals, staff did not consistently implement these measures. Staff interviews revealed uncertainty and inconsistent application of safety protocols, contributing to repeated falls and injuries.
Multiple residents with complex medical needs experienced delays in care, such as long waits for call light responses and infrequent showers, due to insufficient nursing staff. Staff interviews confirmed frequent short-staffing, especially on day shifts, making it difficult to complete all required care. Facility records showed that staffing levels often fell below what was needed for the resident census, and there was no policy or consistent tracking of staffing changes.
Several residents experienced repeated shortages of bed linens and hygiene supplies, leading staff to use towels, bath blankets, or cut-up materials as substitutes. Large holes in room walls, covered with duct tape, were observed and confirmed by maintenance staff, with some residents reporting the damage existed before their admission. Residents with various medical and cognitive conditions expressed discomfort and dissatisfaction with these conditions, while staff acknowledged ongoing issues with laundry and maintenance.
Several residents who were dependent on staff for bathing did not consistently receive scheduled showers, as confirmed by missing documentation and interviews with residents, family, and CNAs. The lack of a facility policy on bathing and frequent staffing shortages contributed to the failure to provide this essential care.
A resident experienced significant weight loss over nine months due to the facility's failure to implement and document nutritional interventions. Despite being at high risk for malnutrition, the resident's care plan was not effectively followed, and there was a lack of communication and documentation regarding dietary recommendations. The facility did not maintain records of supplement administration, and the resident's weight was not consistently monitored, contributing to ongoing weight loss.
The facility failed to transmit assessments for two residents within the required timeframe. A resident with cognitive communication deficit, dementia, anxiety, and weakness had their MDS completed but not transmitted on time. Another resident with cognitive communication deficit, depression, Parkinson's, and diabetes also had their MDS completed but not transmitted timely. The MDS Coordinator was unaware of the transmission process until consulting a supervisor, leading to late submission.
The facility failed to conduct Level II PASRR evaluations for three residents with mental disorders, including unspecified psychosis and PTSD. The Business Office Manager and Administrator did not refer these residents for evaluations, citing misunderstandings about the diagnoses and the absence of a PASRR policy.
The facility failed to ensure sufficient staff were available to meet resident needs, particularly during the night shift. A resident who had returned from dialysis had to wait a long time to be laid down due to insufficient staffing. Multiple residents and staff members expressed concerns about the staffing levels, particularly during the night shift.
The facility failed to immediately report abuse allegations involving an LPN being verbally and physically abusive to residents. CNAs were unaware of the reporting protocol and the Administrator did not provide the public health contact number.
A resident with multiple health conditions had to wait several hours to be laid down after returning from dialysis due to staffing shortages. The facility had only one nurse and one laundry staff member on duty for several hours, leading to a delay in providing necessary assistance.
The facility failed to identify, assess, and treat pressure ulcers for two residents, leading to the development and worsening of pressure ulcers. One resident developed a stage III pressure ulcer on the left buttock due to inconsistent skin checks and lack of treatment, while another resident developed a stage II pressure ulcer on the left buttock due to inadequate care and documentation.
A facility failed to implement necessary interventions for a resident with self-injurious behaviors and did not obtain required behavioral health services. Despite staff observations and reports, appropriate measures were not taken, leading to the resident developing cellulitis from a self-inflicted wound. The facility did not follow the primary physician's recommendation to use mittens, and instead used ineffective alternatives like socks and non-latex gloves.
The facility failed to complete baseline care plans for four residents within 48 hours of their admission. The care plans were undated, unsigned, and missing critical information such as active diagnoses, initial admission goals, and medication reconciliation. The residents had severe conditions, including sepsis, acute respiratory failure, Alzheimer's disease, and sleep apnea.
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in managing their medical conditions and behavioral issues. Delays in care plan initiation, incomplete documentation, and poor communication contributed to inadequate care.
The facility failed to properly assess and monitor the use of physical restraints for three residents. Socks were used as makeshift restraints for one resident without proper assessment. Two other residents used lap buddies and tray tables without proper assessments or physician's orders, and were observed using these restraints outside of mealtimes, contrary to facility policy.
The facility failed to ensure accurate MDS coding for three residents, leading to deficiencies in their assessments. One resident's cognitive status and medication use were inaccurately documented, another resident's mobility device use was misreported, and a third resident's urinary continence was incorrectly coded. The MDS coordinator admitted to not completing the assessments accurately and timely due to workload and inexperience.
A resident with a history of self-injurious behavior was admitted with multiple skin impairments. The facility failed to maintain consistent skin monitoring records and did not adequately address the resident's self-inflicted scratches. Despite recommendations from the primary physician, the facility did not have mittens available and used soft socks instead, which the resident could remove. The lack of timely and appropriate treatment led to the resident developing cellulitis and other complications, resulting in transfer to a higher level of care hospital.
Failure to Complete and Coordinate Cancer‑Related Referrals and Follow‑Up Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely follow‑up and treatment of known suspicious masses and related conditions for one resident, resulting in the resident not receiving care to support the highest practicable level of functioning. The resident was admitted with a known lung lesion and multiple comorbidities including COPD, type 2 diabetes, muscle weakness, unsteadiness, and fatigue, and had a BIMS score indicating moderate cognitive impairment. In January, after complaints of abdominal discomfort, the NP ordered extensive labs and a CT of the abdomen/pelvis. The CT on 1/28 showed a nodular opacity in the right lower lobe invading the right seventh rib, suspicious for primary lung neoplasm, with suspected metastatic lesions in the liver, adrenals, and T11 vertebra, and recommended tissue sampling and pulmonary consultation. On 1/29, the resident complained of new left shoulder pain, and imaging on 1/30 revealed a lytic humeral mass. The physician ordered an oncology referral on 1/30, and documentation shows that the referral and supporting documents were faxed that day. Despite these findings and orders, there were significant lapses in follow‑through on referrals and appointments. A progress note on 2/4 documents that oncology reported not having received the referral, prompting the former DON to obtain a direct fax number and resend the information to both medical and radiation oncology. After that, no one called to check on the oncology referral again until 2/23, when an LPN contacted oncology and learned they had only just received the fax sent the previous evening. Oncology later documented multiple contacts to the facility and the physician’s office requesting an urgent pulmonology referral for lung biopsy/work‑up, noting on 3/30 that the PCP had not placed the requested pulmonology order and that the oncology referral would be closed due to lack of biopsy‑proven malignancy. The ADON stated she faxed a pulmonology referral on 3/6, but later found the fax confirmation showed an error and acknowledged that nothing further was done with that referral and that she forgot to follow up. There were also failures to ensure the resident attended and received timely evaluation for a pathologic humeral fracture and to complete the interventional radiology (IR) biopsy process. After falls in February, imaging on 2/23 showed a large lucency of the proximal left humerus suspicious for metastatic disease with a pathologic fracture, and a pathologic rib fracture. An orthopedic appointment was scheduled for 3/2 related to the humerus, but the ADON reported the resident did not attend because the facility was short‑staffed and there was no one to transport him; the appointment was not rescheduled, and the POA stated she was never informed of that appointment or the no‑show. For the IR biopsy, IR staff reported that an initial fax on 3/11 contained only the resident’s name and “IR/pulmonary biopsy” without a diagnosis and was not a valid order; a subsequent order entered on 3/17 still lacked the required CT images. IR staff stated they notified the physician’s office that CT images were needed, but only reports were sent and no images were provided, so the biopsy was denied and not scheduled. The ADON acknowledged that, while short‑staffed and working the floor, she passed some referral responsibilities to the administrator and DON, forgot about the pulmonology referral, and did not follow up with IR regarding what was needed. Throughout this period, progress notes document the resident’s ongoing and increasing pain, repeated falls, weakness, and expressed desire for cancer treatment, while neither the resident nor his POA refused treatment after the new CT findings. The facility also lacked a policy related to following physician orders, as confirmed by the Regional Director of Clinical Services. The surveyors determined that these failures—specifically, not ensuring timely and effective completion of oncology, pulmonology, orthopedic, and IR biopsy referrals and not ensuring attendance at a scheduled orthopedic appointment—resulted in the resident not receiving timely follow‑up and treatment of known suspicious masses that had metastasized. This pattern of inaction and incomplete coordination of care, despite clear diagnostic findings and physician orders, led to the cited deficiency and was determined to constitute Immediate Jeopardy beginning on 1/30/26, when the facility failed to follow through with referrals to outside providers.
Failure to Prevent and Respond to Repeated Elopements of Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and effective elopement-prevention interventions for cognitively impaired residents. One resident with dementia and a BIMS score of 7, indicating severely impaired cognition, had documented daily wandering behavior and was repeatedly assessed as being at risk for elopement. Despite this, the resident was able to leave the building on two separate occasions without staff knowledge. In the first incident, the resident exited the facility, was later found in town by a pastor, taken to a police station, and then returned to the facility by law enforcement. Facility documentation shows that the resident stated she “just walked out the front door” to go for a walk and that she had removed her wander guard bracelet and placed it in her pocket. Staff, including the LPN on duty, reported they did not know the resident was gone until the police brought her back, and the administrator later confirmed uncertainty about why the wander guard did not alarm. Following the first elopement, the resident’s care plan documented that she was at risk for elopement, that she wore a wander guard she could remove, and that the device had been found in her purse on prior occasions. Interventions such as 15‑minute checks, moving the resident closer to the dining room for better observation, and adding a second wander guard to her purse were documented, but interviews and records revealed inconsistencies. The DON later stated that the intervention to move the resident closer to the dining room had been entered in the care plan but never actually implemented, and that she deleted and then intended to re‑enter and resolve it correctly. On the day of the second elopement, the resident had been moved to a different room with a roommate rather than closer to the dining room, contrary to the written care plan. The administrator also documented a late entry describing the second elopement and attributing the root cause to confusion and the resident thinking she was in the community. In the second incident, the same resident left the facility again, this time pushing her cognitively impaired roommate, who had a BIMS score of 4, in a wheelchair. Both residents traveled approximately 0.5 miles along busy streets without sidewalks before being seen by a family member, who reported that the resident pushing the wheelchair was limping, complained of foot and knee pain, and appeared exhausted. The family member called the administrator, who acknowledged that staff were unaware the residents were gone. A cognitively intact resident reported seeing the eloping resident push her roommate toward a line of smokers waiting to go outside but did not hear any alarm. The activities aide responsible for supervising the smokers stated she did not see either resident in the smoking line or exiting with the group and reported she had not been informed who was at elopement risk and had never reviewed the elopement book. The facility’s elopement and supervision systems were further undermined by problems with the wander guard and door alarm systems and by documentation practices. The administrator and maintenance director acknowledged that the wander guard system was only installed on the front door, that there was no regular maintenance or testing of that system, and that the maintenance director did not know how it worked. When the surveyor observed testing of the front door, the door alarm sounded when opened without a code, but there was no separate alarm when a wander guard was carried through, and when the code was entered, no alarm sounded at all. Subsequent testing of multiple residents wearing wander guards showed that none of the devices triggered an alarm when residents were walked through the door. The administrator also stated that the front door alarm installed later was hard‑wired with the wander guard system so that turning off the door alarm disabled the wander guard function. Additionally, the administrator initially stated she did not know if door checks were being done, then later produced door alarm check logs with her initials for daily checks, and then admitted that managers on duty had actually done the checks and she had just signed them. Care planning and notification requirements were not consistently followed. The physician was notified after the first elopement but was not notified after the second elopement involving both residents, and the physician later confirmed he had not been informed and stated he should have been. The facility’s elopement policy required notifying the attending physician and the resident’s legal representative and documenting these notifications, but one resident’s power of attorney reported he was not informed of the elopement until a care plan meeting many days later. The DON also acknowledged that she added elopement‑related care plan interventions for the second resident only after the surveyor requested the care plan and then back‑dated those interventions to the date of the incident. CNAs reported they had not been educated on specific elopement‑related interventions for either resident, including monitoring for makeup use or issues related to the resident’s purse, despite these being listed as care plan interventions. These combined failures in supervision, implementation of care‑planned interventions, functioning of elopement‑prevention systems, and required notifications led to the cited deficiency and the determination of Immediate Jeopardy.
Insufficient Nursing Staff Leading to Delayed Care, Missed Appointments, and Unmet Basic Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs in a timely manner, resulting in delays and omissions in care and services. One resident with COPD, diabetes, muscle weakness, hypertension, atherosclerotic heart disease, abnormal lung imaging, and moderate cognitive impairment reported constant pain in his back, chest, and left arm/shoulder and stated he had been told he had spreading cancer. His record showed an oncology referral ordered after abnormal CT and x‑ray results, followed by additional urgent referrals to pulmonology and interventional radiology for a biopsy. The Assistant DON explained that the initial oncology referral was faxed and re‑faxed, but there were long gaps without follow‑up, and when oncology requested pulmonology and biopsy, she faxed those referrals but then, due to short staffing and working daily as a CNA, passed the oncology and interventional radiology information to the Administrator and DON and forgot to follow up on the pulmonology referral and with the interventional radiology coordinator. She also stated that an orthopedic appointment for the resident’s arm fracture was missed because there was no staff available to transport him, the appointment was not rescheduled, and as of the interview the resident had no scheduled appointments with oncology, pulmonology, orthopedics, and had not had a biopsy. The facility also failed to provide basic foot and nail care in a timely manner. One resident with diabetes, Alzheimer’s disease, muscle weakness, and severe cognitive impairment had thick toenails that needed trimming; the LPN stated she did not feel comfortable trimming them and that the resident needed a podiatry referral. Another resident with diabetes, hemiplegia after stroke, and muscle weakness had long toenails and reported painful toes and a need for trimming. A further resident’s toenails were observed to be long and wrapping around the ends of his toes and underneath them; the LPN acknowledged they needed trimming and stated she did not know why this had not been done, adding that the facility no longer had a podiatrist coming in. The ADON stated that nurses are responsible for trimming toenails for diabetic residents, but that it always ended up being her and she had not had time to do it because of short staffing. Hydration needs were not consistently met, with multiple residents reporting that water was not passed regularly. One resident with COPD, emphysema, chronic kidney disease, and intact cognition repeatedly did not have water in her room, stated that water was not passed every day, and said she usually only received water when she asked, questioning what happened to residents who could not ask. Another resident with dehydration, muscle wasting, and moderate cognitive impairment, whose care plan included encouraging hydration to promote skin health, stated she did not get water passed every day and that her daughter began bringing her water because she was not receiving drinks during the day; a family member confirmed this. A further resident with muscle wasting, weakness, and fatigue, care‑planned for potential skin impairment with an intervention to encourage hydration, was repeatedly observed without a water cup and reported that water was only occasionally brought to her. The facility’s “Helping Hand” staff member stated that water was supposed to be passed once in the morning and once in the afternoon, but that many days it had not been passed by the time she arrived because there were not enough CNAs, and that the DON often directed her to pass water because CNAs had not had time. The facility did not respond promptly to call lights, and residents experienced delays in receiving incontinence care and assistance. One resident with hemiplegia after stroke, morbid obesity, weakness, and moderately impaired cognition had an activated call light; the Activities Director entered the room without asking if anything was needed and left with the call light still on. The resident told the surveyor she needed to be cleaned after incontinence. After additional delay, another staff member entered, asked what was needed, and then went to get help; CNAs arrived to provide care, with one CNA stating she was the only aide on the hallway and was training a new aide on her first day. Another resident with chronic kidney disease, anxiety disorder, essential tremors, and moderate cognitive impairment, care‑planned as a fall risk needing prompt response to all requests for assistance, had an activated call light while she waited for an adult brief after incontinence. The call light remained on for over 20 minutes before the ADON responded; the resident stated she always had a long wait and usually waited at least 20 minutes. The ADON stated she responded as quickly as she could but that more CNAs had called in and she was working the floor. Additional care needs were not met due to staffing shortages. One resident with Parkinson’s disease, dementia, muscle weakness, and severely impaired cognition, care‑planned for ADL self‑care deficits, was observed with facial hair and stated staff had not shaved him and that he did not like having facial hair. His roommate, who was also a family member, stated that only one staff member at the facility could shave residents, so he had to wait until she had time. A registered nurse reported that there were not enough CNAs to properly care for residents, that residents complained about waiting to be cleaned after incontinence, that beds were not being stripped and linens changed, and that water was not passed daily because of insufficient CNA staffing. A CNA stated that staffing had been better recently but that there had been times when only two CNAs were in the building, including a weekend when there were only two CNAs for most of the day. The Administrator stated there was no policy related to staffing, and both the Regional Director of Clinical Services and the Administrator confirmed there was no policy related to call lights. The daily census documented 67 residents in the facility.
Failure to Hold Quarterly QAA/QAPI Meetings With Required Medical Director Participation
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA)/QAPI program met regulatory requirements for quarterly meetings and required membership. Review of Quality Assurance meeting sign-in sheets and minutes dated 1/23/25, 3/13/25, 7/30/25, and 1/9/26 showed no signature from the facility’s medical director, indicating the medical director did not attend these meetings. In an interview on 3/24/26 at 11:20 AM, the Administrator (V1) stated that a QAPI meeting was not held for the 4th quarter of 2025 and that meetings were only held in January, March, and July of 2025. V1 further stated that the medical director had never attended the QAPI meetings. On 4/13/26 at 3:00 PM, V1 confirmed there was no facility policy related to quarterly quality assurance meetings, but acknowledged that meetings were supposed to be held quarterly and that the medical director should be in attendance. The facility’s daily census report dated 3/17/26 documented that 67 residents were residing in the facility at the time of the survey. No additional resident-specific medical histories or conditions were described in the report beyond the total number of residents potentially affected.
Failure to Provide Required Staff Training on Communication and Behavioral Health
Penalty
Summary
The facility failed to ensure staff were trained on effective communication and other required topics, affecting all 67 residents in the building. During review of staff in-service records on 3/24/26 at 11:00 AM, the surveyor and the Administrator (V1) identified that training subjects such as communication, behavioral health, and required annual nursing aide training were missing. At 12:50 PM, the Regional Director of Clinical Services (V7) confirmed he could only locate staff training on QAPI, infection control, resident rights, and abuse, and that he was unable to find any staff training on communication, compliance and ethics, behavioral health, or any required nursing aide training. At 1:00 PM, the Administrator acknowledged that staff had not been trained on communication or behavioral health and that nurse aides had not received their required annual training hours, stating she was not aware these were required. On 4/13/26 at 3:00 PM, the Administrator further stated that the facility did not have a policy related to staff training. The facility’s daily census report dated 3/17/26 documented 67 residents residing in the facility. No additional resident-specific clinical details, medical histories, or conditions at the time of the deficiency were provided in the report.
Failure to Provide Timely Diabetic Toenail Care and Shaving Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide timely ADL assistance for diabetic toenail care and shaving for multiple dependent residents. One resident with type 2 diabetes, moderate cognitive impairment, and an ADL self-care deficit had an order allowing podiatry visits, but on observation his toenails were long, curling around and under the toes. The LPN acknowledged the nails needed trimming and stated she did not know why this had not been done, adding that a podiatrist no longer comes to the facility. Another resident with type 2 diabetes, severe cognitive impairment, and dependence for personal hygiene had thick toenails that needed trimming; the LPN stated she was not comfortable trimming them due to their thickness and that the resident needed a podiatry referral. A third resident with type 2 diabetes, intact cognition, and a care plan intervention to refer to podiatry/foot care and cut long nails also had long toenails on observation, reported toe pain, and stated the toenails needed trimming. The deficiency also includes failures related to shaving and personal hygiene for residents dependent on staff for these ADLs. One resident with Parkinson’s disease, dementia, and dependence for personal hygiene was observed with facial hair and stated staff had not shaved him and that he did not like having facial hair. His roommate/family member reported that only one staff member at the facility shaves residents, so this resident has to wait until she has time. Another resident with arthritis, glaucoma, moderately impaired cognition, and dependence for personal hygiene was repeatedly observed with facial hair and later with facial hair and dirty-appearing hair. This resident reported that staff did not shave him with his last shower, that he did not receive a scheduled shower, hair wash, or shave, and that he had not refused any of these services, stating CNAs were always in a hurry and acted like they did not have time. Interviews with staff and review of facility policy further describe the circumstances leading to the deficiency. The LPN stated nurses are supposed to trim toenails for diabetic residents and that CNAs should notify nurses when trimming is needed, but she was unsure whether this should occur on shower days or skin check days. The ADON stated nurses oversee toenail trimming for diabetic residents but reported that it always ends up being done by her and that she has not had time due to short staffing. The Administrator stated toenail care for diabetic residents should be done when nails need trimming, that there is no schedule or designated nurse responsible, and that the facility no longer has an on-site podiatrist, instead referring residents out. The ADON stated residents are supposed to be shaved on shower days and as needed, while the Regional Director of Clinical Services reported there is no policy regarding shaving of residents’ faces. The facility’s written policy on fingernail/toenail care states that RNs are to trim toenails of residents with diabetes mellitus.
Failure to Consistently Pass Water and Maintain Resident Hydration
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide and pass water to four residents reviewed for hydration needs. One resident with COPD, type 2 diabetes, hypertension, atherosclerotic heart disease, moderate cognitive impairment, and a care plan intervention to encourage good nutrition and hydration was repeatedly observed without water in his room on multiple dates. He reported that he did not get water very often, that water was not brought every day, and that when present it was old and warm. His family member/POA stated that almost every time she visited, he did not have water in his room, leading her to bring in a cup for staff to fill, which still often remained without water. Another resident with diagnoses including dehydration, muscle wasting and atrophy, UTI, adult failure to thrive, and moderate cognitive impairment had dehydration identified as an active diagnosis and a triggered care area on the MDS, with a care plan intervention to encourage good nutrition and hydration. This resident stated she did not get water passed every day and emphasized the importance of drinking enough water due to a prior hospitalization for dehydration. She reported that when first admitted she never got water passed, so her daughter began bringing her fresh ice water almost daily. A family member present confirmed there had been an issue with the resident not getting anything to drink during the day, prompting the family to bring water. Two additional residents, both with care plans including interventions to encourage good nutrition and hydration to promote skin integrity, also reported not having water passed regularly. One resident with intact cognition, chronic kidney disease, recurrent UTIs, and impaired skin integrity stated that water was not passed every day, that she only received water when she asked, and questioned what happens to residents who cannot ask. She reported that her water was from the night before and that no fresh water had been passed that day, with observations confirming the absence of water in her room at different times. Another resident with limited mobility and potential skin integrity impairment was repeatedly observed without a cup of water in her room and stated that water was only occasionally brought, that she sometimes became thirsty, and that no one had brought her water on several observed days. Staff interviews, including a helping hand, an RN, and the administrator, confirmed that water was supposed to be passed multiple times per day, that it often was not passed due to CNA staffing shortages, and that the facility did not have a policy related to hydration and passing water.
Failure to Timely Respond to Call Lights and Assess Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to answer resident call lights in a timely manner and in a way that promotes dignity for two residents. One resident, admitted with anxiety disorder, chronic kidney disease, and essential tremors, had a BIMS score indicating moderate cognitive impairment and was care planned as a fall risk with interventions to keep the call light within reach and to provide a prompt response to all requests for assistance. On observation, this resident’s call light was already activated at 1:35 PM and was not answered until 1:56 PM by the ADON, who stated she responded as quickly as she could due to multiple CNA call-ins and her need to work the floor. The resident reported that she always has a long wait after activating her call light and usually waits at least 20 minutes. Another resident, admitted with hemiplegia and hemiparesis following cerebral infarction, morbid obesity, cystitis, weakness, and polyarthritis, had a BIMS score indicating moderately impaired cognition and was documented as dependent for toileting hygiene. The care plan documented bowel/bladder incontinence, a need for assistance with toileting, and a pattern of repeatedly turning the call light on, with interventions requiring staff to respond each time and verify needs. During observation, this resident’s call light was already on when the surveyor arrived. The Activities Director entered the room but did not ask if the resident needed anything and left while the call light remained on. The resident told the surveyor she needed to be cleaned up after incontinence. Sixteen minutes after the initial observation, Medical Records staff entered, asked what was needed, and the resident again stated she needed to be cleaned. Three minutes later, two CNAs arrived to provide incontinence care, with one CNA stating she was the only CNA on the hallway and was training the other on her first day. The Regional Director of Clinical Services and the facility administrator both stated there was no call light policy, and the administrator stated that anyone can answer call lights and she would hope they are answered within 15 minutes at most.
Failure to Notify Physician and Family After Resident Elopements
Penalty
Summary
The deficiency involves the facility’s failure to notify physicians and resident representatives after two residents with severe cognitive impairment eloped from the building. One resident, admitted with diagnoses including dementia, osteoarthritis of the knee, and hypertension, had an MDS showing a BIMS score of 07 and daily wandering behavior. On a documented date, this resident was found up the street pushing another resident in a wheelchair to look at a cemetery, with no signs of injury noted, and was brought back to the facility in a company van. The Risk Management and Progress Note entries describe the elopement, the resident’s confusion, and staff observations, but contain no documentation that the attending physician or the resident’s representative was notified of the incident, despite facility policy requiring such notifications after an elopement. The second resident, admitted with diagnoses including anxiety disorder, COPD, muscle weakness, cerebral atherosclerosis, primary hypertension, history of falling, metabolic encephalopathy, and osteoarthritis, had an MDS showing a BIMS score of 04, indicating severely impaired cognition. On the same date, this resident left the building with a roommate on a “walk,” following smokers out and going in the opposite direction, and later returned with no signs of injury noted. The Risk Management document and a late-entry Progress Note describe the event and immediate staff response but do not document any notification to the physician or the resident’s family. The resident’s power of attorney/family member reported that he was not informed of the elopement at the time and only learned of it later during a care plan meeting. The RN assigned to the residents’ hall on the day of the elopements stated she did not notify the physician, and another staff member confirmed the physician was not notified, contrary to the facility’s written elopement policy requiring notification of the attending physician and the resident’s legal representative and documentation of these notifications in the medical record.
Failure to Care Plan Communication Needs for Hearing‑Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive care plan addressing the communication needs of a hearing‑impaired resident. The resident was admitted with a diagnosis of bilateral hearing loss, and both a Quarterly and a Comprehensive MDS documented that the resident’s hearing was highly impaired, with an absence of useful hearing. The MDS also showed that the resident usually understood others but missed parts of messages, and the Communication Care Area was triggered. Despite this, the resident’s current care plan did not include a focus area for hearing loss or any interventions related to communication needs. Progress notes documented that the resident was deaf, could read lips well, and that staff sometimes used a text‑to‑speech device to communicate, indicating known communication barriers. One RN note also described that the resident did not seem to grasp the severity of his cancer that had spread, while still being described as alert, oriented, and able to make needs known. During observation, a CNA spoke to the resident from the bathroom with her face out of his sight, and the resident stated he could not hear and did not know what she was saying. The CNA reported she had been told the resident could hear in one ear. The MDS coordinator later acknowledged that the communication care area should have been care planned, believed she had missed the trigger, and stated she did not know how the resident’s communication needs were communicated to the rest of the staff.
Resident Injury from Improper Securement During Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was safely secured during transport in the facility van, resulting in the resident falling from his wheelchair when the van made a sudden stop. The resident had a history of myocardial infarction, heart failure, hypertension, atrial fibrillation, COPD, and required oxygen, and his care plan documented limited physical mobility and the need for a wheelchair for ambulation. Despite being cognitively intact per the MDS, he was dependent on staff to properly secure his wheelchair and seat belt during transport. On the day of the incident, the van driver reported that a deer ran in front of the van, requiring abrupt braking, after which the resident was found on the floor of the van. Facility documentation initially recorded that the resident was taken to the hospital and returned with no injuries noted, and the fall report identified a malfunction of the seat belt as the root cause. The Administrator later stated that the resident had been in the wheelchair with a seat belt on, which allegedly came unlatched when the van stopped suddenly, causing the fall. The resident himself reported that he hit the dashboard and that the wheelchair landed on top of him, and he stated he did not remember whether he or the wheelchair had been buckled but believed they must not have been secured for the wheelchair to end up on top of him. Staff accounts regarding proper securement were inconsistent. The van driver (a CNA) stated that there are four clamps to lock the wheelchair in place and a seat belt for the resident, and she asserted that she had buckled both the resident and the chair before starting the trip. However, another CNA stated she knew the resident was not buckled in properly on the day of the incident and reported that the resident told her he was not buckled in. Facility policy in the Drive Safe Program states that the driver is responsible to ensure all passengers are securely seated and using seat belts. Following the incident, subsequent clinical documentation and imaging confirmed that the resident sustained an acute non-displaced right lateral 10th rib fracture and an acute distal clavicle fracture related to the fall in the van.
Failure to Maintain Clean and Sanitary Resident Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain clean, safe, and sanitary resident bathrooms, resulting in unclean commodes and bathroom areas for multiple residents. One resident with heart disease, osteoarthritis, muscle weakness, fatigue, and a moderate cognitive deficit reported that while staff clean earlier in the day, the room does not remain clean later. He and his cognitively intact roommate both stated that the shared bathroom commode was so dirty one evening that it could not be used, and when they requested cleaning, an unidentified staff member told them it was not their job. The commode was not cleaned until the housekeeper addressed it the following morning, and the housekeeper later confirmed there had been feces on the inside of the toilet lid area and that she would not have been comfortable using it in that condition. Another cognitively intact resident with diabetes, morbid obesity, heart failure, and chronic kidney disease was observed to have feces stuck to her toilet riser, which remained present later the same day. A resident with dementia, peripheral vascular disease, muscle weakness, and fatigue was found to have a commode with a dried red/brown substance around the fixtures and splattered down the wall. CNAs interviewed acknowledged that resident bathrooms are sometimes “horrible,” that housekeeping does not always take the initiative to clean bathrooms without being asked, and that toilets are often dirty around the bowl. The housekeeping supervisor stated he had not received complaints about cleaning and indicated he would reeducate staff if concerns were brought to him, despite the facility’s written quality control policy requiring identification of deficiencies and ongoing monitoring of environmental services quality.
Failure to Honor Resident Diet Orders and Food Preferences During Regular and Emergency Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to honor resident food preferences and diet specifications, including during a period when the main kitchen was under renovation and an emergency menu was in use. One resident with Parkinson’s disease, COPD, heart disease, adult failure to thrive, anxiety, and a moderate cognitive deficit had physician orders and a care plan for a no concentrated sweets (NCS) diet with mechanical soft/regular texture, thin liquids, super cereal at breakfast, fortified foods three times daily, and health shakes three times daily. Despite this, the resident was observed at breakfast with a tray containing Fruit Loops, orange juice, milk, a mighty shake, coffee, cookies, pears, and a bowl of milk. The resident’s meal card documented a preference for Cheerios, and the Dietary Manager acknowledged that residents with diabetes should receive non‑sugar cereals such as Cheerios or Rice Krispies and that this resident should have been served the preferred cereal. Another resident with a diagnosis of diabetes reported being served peanut butter and jelly sandwiches for the past few days because the kitchen was down, and he was getting tired of them. Surveyors observed the kitchen under renovation, with appliances, cabinets, flooring, and sinks removed, and staff serving meals from tables in the dining room. The facility was using an emergency menu consisting largely of shelf‑stable foods. The written emergency menu for multiple days specified repetitive items such as juice, dry cereal, canned fruit, peanut butter cookies, pudding, reconstituted milk, and peanut butter and jelly sandwiches, indicating limited variety and repeated use of the same items over several days. Resident council documentation showed that residents had been informed of the upcoming kitchen renovation and menu changes, and that some residents expressed they did not want corned beef. The emergency menu nonetheless included corned beef on specified days, and on one such day kitchen staff served corned beef hash, green beans, cookies, and beverages. One resident refused the corned beef hash, telling staff to take it away and was then offered a corn dog or sandwich. Another resident, alert to person, place, and time, stated lunch was awful and reported eating a ham sandwich instead of the corned beef hash. A third resident, also alert, was observed making a deli sandwich from personal food and described lunch as awful and terrible. The Social Services Director confirmed that several residents at resident council had said they did not want corned beef, and the Dietary Manager acknowledged awareness that a few residents did not want corned beef hash but stated they did not ask all residents about their preference, despite a facility policy stating that individual food preferences would be assessed on admission and communicated to the interdisciplinary team.
Failure to Maintain Safe Hot Holding Temperatures for Served Food
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure hot foods were served at safe temperatures in accordance with professional standards and the FDA Food Code. The daily census documented 63 residents in the facility. One cognitively intact resident with diabetes, morbid obesity, heart failure, and chronic kidney disease, who was on a NAS diet with a 2-liter fluid restriction and protein supplements, reported that her corned beef hash at the noon meal was served cold. Her care plan required that her nutritional diet be prepared and served as ordered. When surveyors entered the dining room shortly after this complaint, dietary staff were serving the noon meal from roasting pans because the kitchen was being remodeled. At the time of observation, the cook checked the temperatures of the foods in the roasting pans using a facility thermometer she stated was calibrated and accurate. The thermometer showed the corned beef hash at 110.0°F and the green beans at 130.0°F. The dietary manager stated that the corned beef hash should be 155–165°F and the green beans 145°F. Later, the cook rechecked the temperatures and found the green beans at 168.0°F and the corned beef hash at 129.0°F. The facility was unable to provide a policy related to food temperatures. According to the 2022 FDA Food Code, hot holding temperatures for TCS food must be maintained at 135°F or greater, and the measured temperatures of the corned beef hash and green beans were below this standard at the time of the initial check.
Failure to Provide Properly Fitting Linens for Bariatric Mattress
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences by not maintaining linens that properly fit a bariatric specialty mattress. The resident, who was admitted with COPD and morbid obesity and was cognitively intact with a BIMS score of 15, reported that the facility did not have sheets that fit her bariatric bed. Surveyor observations on multiple occasions showed the resident’s bed either with only a partially tucked flat sheet and no fitted sheet, or with a fitted sheet that had come off the upper corner of the mattress. The resident stated that the facility had only two sets of sheets that fit her mattress, that staff could not always find them, and that when incorrect or half sheets were used, they did not stay on the mattress. Staff interviews confirmed an ongoing shortage of properly sized bariatric sheets. One CNA stated there were not enough sheets for bariatric beds, and another CNA acknowledged that they did not really have enough bariatric-size sheets and that the resident specifically requested sheets with orange stitching because those were the only ones that fit, while the green stretchy sheets did not really work. The Housekeeping/Laundry Supervisor reported finding only three sheets that fit the resident’s bed, stated that previously purchased sheets were the wrong size, and indicated he did not know how many bariatric beds were in the facility and would need to count sheets to determine if there were enough. The Administrator could not explain why the resident did not have properly fitting sheets, and the facility was unable to provide a policy related to supplies. The resident’s care plan did not address linens or mattress needs in any focus area or intervention.
Failure to Provide Ordered Breakfast Nutritional Supplement
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered nutritional supplements as prescribed by the physician for one resident. The resident was admitted with multiple diagnoses including Parkinson’s disease, spondylolysis, repeated falls, COPD, heart disease, adult failure to thrive, anxiety, and a cognitive communication deficit, and had a BIMS score of 09 indicating a moderate cognitive deficit. The physician’s order summary directed that the resident receive an NCS diet with mechanical soft texture, thin liquids, super cereal at breakfast, health shakes TID with meals, and fortified foods TID. The resident’s care plan also identified a nutrition focus area, noting potential nutritional problems and specifying interventions including an NCS diet, super cereal at breakfast, fortified foods TID, and health shakes TID, with an intervention to provide and serve supplements and diet as ordered. On the morning of the survey observation, the resident’s breakfast tray contained fruit loops, orange juice, milk, a mighty shake, coffee, cookies, pears, and a bowl of milk, with no super cereal present. The resident’s meal card for breakfast documented “Fortified Super Cereal – 1 serving” under breakfast supplements, but this item was not on the tray. When interviewed, the Dietary Manager identified the super cereal as oatmeal and confirmed that the resident should have been served oatmeal as a super cereal with breakfast. The facility’s Therapeutic Diets Policy states that therapeutic diets are prescribed by the attending physician and that the Food Services Manager will establish and use a tray identification system to ensure each resident receives the diet as ordered. Despite this policy, the ordered super cereal supplement was not provided with the resident’s breakfast.
Failure to Provide Physician-Ordered Mechanical Soft Diet Consistency
Penalty
Summary
The deficiency involves the facility’s failure to provide food in the physician-ordered mechanical soft (dental soft) consistency for a resident with multiple medical conditions and a moderate cognitive deficit. The resident was admitted with diagnoses including Parkinson’s disease, spondylolysis, repeated falls, COPD, heart disease, adult failure to thrive, anxiety, and a cognitive communication deficit. The resident’s MDS documented a Brief Interview for Mental Status score of 09, indicating a moderate cognitive deficit. The physician’s order summary specified an NCS (no concentrated sweets) diet with mechanical soft texture and thin liquids, along with super cereal at breakfast, health shakes three times daily with meals, and fortified foods three times daily. The current care plan documented a nutrition focus area noting potential nutritional problems and referenced both a mechanical soft texture diet and, in a later intervention entry, a regular texture diet, while also instructing staff to provide and serve the diet and supplements as ordered. On the morning of the survey observation, the resident was observed in his room with a breakfast tray that included fruit loops, orange juice, milk, a mighty shake, coffee, cookies, pears, and a bowl of milk. The resident’s meal card identified the required texture as dental soft (mechanical soft). The resident reported that staff told him to dunk his cookie in the bowl of milk, and he demonstrated dunking a cookie and attempting to bite it, stating that he only had one set of teeth and that the cookies were not soft enough for him to eat. The facility dietitian stated that peanut butter cookies for any resident on a mechanical soft diet should have been softened prior to being served. The dietary manager stated that the peanut butter cookies were supposed to be softened in milk before serving but that a cognitively intact resident could do this themselves. The facility’s Therapeutic Diets Policy required that mechanically altered diets be treated as therapeutic diets and that a tray identification system be used to ensure each resident receives the diet as ordered, but the resident nonetheless received cookies that were not pre-softened to the ordered mechanical soft consistency.
Failure to Implement Ordered Pressure-Relieving Boot for Diabetic Foot Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered interventions to promote safety and healing of a diabetic foot ulcer for one resident. The resident had multiple diagnoses including COPD, acute respiratory failure, type 2 diabetes mellitus, a non‑pressure chronic ulcer of the right plantar foot with fat layer exposed, lymphedema, CHF, and hypothyroidism, and required extensive assistance with ADLs and mobility. The MDS documented a diabetic foot ulcer, and the care plan identified a right plantar foot wound related to diabetes with goals for weekly improvement and interventions including twice‑daily wound treatments, non‑weight‑bearing (NWB) status to the right lower extremity, staff assistance with ADLs, and skin inspections. The facility’s wound log documented a sizable right plantar diabetic ulcer. Wound physician notes on multiple dates documented an order for a pressure‑relieving boot for the resident’s feet, and the regional clinical director acknowledged that these electronically signed notes should have been processed as physician orders. However, review of the care plan, physician orders, and treatment administration records showed no documented order for a pressure‑relieving boot. The wound physician stated he placed the order for a pressure‑relieving boot in his notes as part of his usual practice for foot wounds and that the resident needed to keep pressure off the right foot. The assistant DON/wound nurse, who stated she makes rounds with the wound physician and enters orders based on those rounds, reported she had never seen the resident with a boot and was not aware of the pressure‑relieving boot order in the wound physician’s notes. Staff and family interviews further demonstrated that the ordered pressure‑relieving device was not implemented. A CNA reported the resident was often noncompliant with lying down and elevating his feet, that his foot was always wrapped, and that she had only seen heel protectors a couple of times when he was in bed, but never any kind of boot while he was up in his wheelchair. A family member stated the resident had a long‑standing diabetic foot wound, was NWB on the right foot, and that she brought a specialized boot from home at admission but never saw the resident wearing that or any boot during frequent visits. A PTA recalled the family‑provided pressure‑relieving boot did not fit and was unsure if anyone attempted to obtain a better‑fitting boot. An RN stated she had never seen the resident with a boot and was unaware of any boot order. The facility’s preventative skin care policy allowed for pressure‑relieving devices and required proper fitting of devices, but no pressure‑relieving boot was obtained or consistently used for this resident despite the wound physician’s documented order.
Failure to Maintain Required Pressure-Relieving Mattress for Resident With Stage IV Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement required pressure ulcer prevention and treatment interventions for a resident with a known Stage IV pressure ulcer to the right medial buttocks. The resident had multiple diagnoses including sequelae of cerebral infarction, vascular dementia, muscle weakness, and a documented Stage IV pressure ulcer, and was assessed as severely cognitively impaired, totally dependent for all ADLs, and always incontinent of bowel and bladder. The MDS and care plan identified the resident as at high risk for skin breakdown, with a Braden score of 12, and the care plan called for monitoring factors that could lead to skin alterations and following facility policies and protocols for prevention and treatment of skin breakdown, including evaluation and treatment by a wound physician. The facility’s written Preventative Skin Care policy required special mattresses and/or chair cushions for any resident identified as high risk for skin breakdown. The wound log documented that the resident’s right medial buttock wound, categorized as end-stage skin failure, had an air loss mattress listed as preventative equipment. However, surveyor observations on two separate dates showed that the resident’s bed had a standard mattress in place while the resident had a Stage IV buttock wound and was at high risk for further breakdown. Staff interviews revealed uncertainty about whether the resident had been on an air loss mattress prior to a room change, and the business office records showed the last room move occurred several months earlier. The DON confirmed the resident had been on an air loss mattress before the room change and acknowledged not knowing why the air loss mattress was not moved with the resident, despite believing the resident still needed it. Wound measurements documented by the wound physician over multiple weeks showed ongoing depth and changes in the wound dimensions, and the wound physician stated that he initially categorized the wound as end-of-life and did not change that category, although he acknowledged it should be classified as a Stage IV pressure ulcer. The wound physician, the regional clinical director, and the medical director each stated that a resident with a Stage IV buttock wound should be on an air loss mattress and that lack of such a mattress could contribute to deterioration or impaired healing of the wound. During a wound treatment observation, an LPN measured the wound at a greater depth than previously recorded. The facility’s failure to ensure that the resident remained on an air loss mattress in accordance with the care plan, policy, and clinical expectations led to the worsening of the resident’s Stage IV pressure ulcer to the buttocks.
Failure to Provide Incontinence Products Compromises Resident Dignity
Penalty
Summary
The facility failed to provide appropriate incontinence products to four residents, resulting in a lack of dignity and embarrassment for those affected. Multiple residents with significant medical conditions, including pressure ulcers, diabetes, hemiplegia, and chronic kidney disease, reported that they were not provided with incontinence briefs, particularly at nighttime. Some residents stated that they were forced to wet themselves on bed pads or in their clothing, leading to feelings of embarrassment and discomfort. Residents also reported that staff refused their requests for incontinence briefs at night, and that the facility frequently ran out of the correct sizes, forcing them to use ill-fitting products or go without. Staff interviews confirmed that the facility had a recurring issue with running out of incontinence briefs, especially in larger sizes. Certified Nurse Assistants (CNAs) and supervisors stated that they had to inform the administrator when supplies were low, and sometimes had to use alternative sources or go without briefs for residents. Observations of storage areas revealed limited stock, with some sizes missing entirely. Staff also reported that the administrator instructed them not to use incontinence briefs at night unless specifically requested by alert residents, and that families of non-alert residents were not consulted about their preferences. The administrator cited concerns about skin breakdown as a reason for not using briefs at night, but acknowledged there was no physician order for this practice. Facility documentation, including grievance forms and resident council memoranda, showed ongoing concerns from residents about the lack of appropriate incontinence supplies, particularly larger sizes. The facility's own admission packet and dignity policy stated that incontinence care and supplies were to be provided to all residents as part of routine care. Despite these policies, the facility did not have a specific policy on incontinence care or supplies, and failed to address repeated grievances about the issue. This resulted in residents experiencing embarrassment, discomfort, and a lack of dignity due to inadequate incontinence care.
Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and consistently maintain interventions to prevent future falls for a resident with significant cognitive and physical impairments. The resident had diagnoses including Alzheimer's disease, legal blindness, abnormalities of gait and mobility, and lack of coordination, and was assessed as being at high risk for falls. The care plan included interventions such as promptly laying the resident down after meals, reclining the wheelchair for safety, and ensuring the wheelchair was locked and positioned under the table. Despite these documented interventions, the resident experienced multiple falls, including incidents where the wheelchair was not reclined as required and where staff were unsure about the use of foot pedals. On several occasions, the resident was found on the floor after falling from the wheelchair, sustaining injuries including lacerations to the face that required sutures. Staff interviews revealed inconsistent application of safety interventions, such as not reclining the wheelchair when transporting the resident and uncertainty about the use of foot pedals. The resident's physical condition, including contractures and a tendency to lean forward, further increased the risk of falls, yet interventions were not reliably implemented to address these risks. Facility records and staff statements indicated that the resident was unable to self-propel and was not educatable due to severe cognitive impairment. Despite being identified as high risk and having a care plan in place, the facility did not ensure that interventions were consistently followed, resulting in repeated falls and injuries. The facility's fall management policy required ongoing and consistent implementation of safety precautions for at-risk residents, which was not achieved in this case.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple reports from residents, family members, and staff. Several residents with significant medical conditions, including diabetes, COPD, hemiplegia, and chronic kidney disease, reported delays in response to call lights, infrequent showers, and unmet personal care needs. One resident stated it sometimes took staff 30 minutes or more to answer his call light and that he only received a shower once a week instead of the expected two times. Another resident reported waiting up to an hour for assistance and not consistently receiving scheduled showers. A family member also expressed concerns about a resident not receiving showers as required. Staff interviews corroborated these concerns, with several CNAs stating that the facility was often short-staffed, particularly on the day shift. Staff described difficulties in completing all required resident care, including showers and personal hygiene, due to insufficient staffing. Some staff reported having to cover multiple halls or pass on care tasks to the next shift, and noted that staffing levels had recently decreased from three to two staff members per hall. The Assistant Director of Nursing acknowledged that on certain days, the facility did not meet the calculated required nurse aide hours based on the facility assessment tool. Review of facility schedules and census reports confirmed that on several days, the number of CNAs scheduled was below the level needed to provide adequate care for the 63 residents. The Administrator confirmed that there was no facility policy on staffing, and the Assistant Director of Nursing stated that daily assignment sheets were not updated to reflect when staff left early or did not show up. These actions and inactions resulted in insufficient staffing to meet residents' needs for timely assistance and personal care.
Failure to Maintain Clean, Comfortable, and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for five residents reviewed for environmental conditions. Multiple residents reported frequent issues with the availability of bed linens and bed pads, sometimes waiting until late in the day or being unable to rest due to the lack of clean linens. Staff interviews confirmed that shortages of linens, bed pads, and wash cloths were common, especially when the facility's dryer was not functioning, leading to the use of towels, bath blankets, or even cut-up towels as substitutes for proper bedding and hygiene supplies. Physical observations revealed significant environmental deficiencies in resident rooms, including large holes in the walls above air conditioning units that were covered with duct tape. These holes were present in at least two rooms, and residents stated that the damage existed prior to their occupancy. The Maintenance Director measured the holes, confirming their size, and acknowledged a backlog of maintenance requests. Staff also reported that termites were present in certain areas, and that the wall damage was extensive enough for a hand to go through in one instance. Residents affected by these deficiencies had various medical conditions, including hemiplegia, cognitive impairment, depression, and incontinence. Some residents with intact cognition expressed discomfort and dissatisfaction with the lack of proper linens and the use of makeshift substitutes, particularly when dealing with incontinence. Facility policies reviewed emphasized the responsibility of department directors to report maintenance needs and the importance of resident dignity, but these were not consistently upheld in practice.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that residents who required assistance with activities of daily living, specifically bathing or showers, consistently received this care as scheduled. Four residents with varying degrees of cognitive and physical impairment were identified as not receiving showers according to the facility's established schedule. Documentation and interviews revealed that showers were missed on multiple occasions for these residents, with gaps in the shower review sheets indicating that the care was not provided as required. Residents affected included individuals with significant medical histories such as diabetes, chronic obstructive pulmonary disease, pressure ulcers, hemiplegia, and severe cognitive impairment. These residents were documented as dependent or requiring substantial assistance for bathing. Interviews with the residents, a family member, and multiple CNAs confirmed that showers were often missed, and the lack of consistent care was attributed to frequent staffing shortages. Residents and family members expressed concerns about the infrequency of showers, and staff reported difficulty in completing all required showers due to insufficient staffing levels. The facility did not have a policy on bathing or showers, as confirmed by the administrator. The assistant director of nursing was unable to provide additional documentation to show that showers were completed on the missing dates, indicating that the care was likely not provided. The lack of documentation and staff statements further supported the finding that the facility failed to provide necessary assistance with bathing for residents who were unable to perform this activity independently.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately identify, evaluate, and intervene in the case of a resident, R42, who experienced significant weight loss over a period of nine months. R42 was admitted with diagnoses including mild protein-calorie malnutrition and moderate cognitive impairment. Despite these conditions, the facility did not provide any nutritional approaches as noted in the Minimum Data Set (MDS) and failed to document any nutritional assessments. The resident's care plan, initiated in June 2023, included interventions such as providing a diet as ordered and monitoring for signs of malnutrition, but these were not effectively implemented. Throughout the period from January to September 2024, R42's weight decreased significantly from 175 lbs to 131 lbs, indicating a substantial weight loss that was not adequately addressed by the facility. The Registered Dietitian (RD) noted the resident's high risk due to weight loss and made several dietary recommendations, including the addition of health shakes and consideration of an appetite stimulant. However, there was a lack of documentation and follow-up on whether these interventions were implemented. The RD did not see the resident in April, May, and August 2024 due to a lack of weight records, and there was no documentation of progress notes by the RD for these months. The facility's failure to monitor and document the resident's weight and nutritional intake, as well as the lack of communication and follow-up on dietary recommendations, contributed to the ongoing weight loss. The facility did not maintain records of when supplements were given, and there was no evidence that the resident received the recommended health shakes or appetite stimulant until late September 2024. Additionally, the facility did not document the resident's food preferences, which could have informed more effective nutritional interventions. The interdisciplinary team meetings did not adequately address the resident's weight loss, and the facility's procedures for weight assessment and intervention were not followed, leading to a deficiency in the resident's care.
Failure to Transmit Resident Assessments Timely
Penalty
Summary
The facility failed to ensure timely transmission of assessments for two residents, resulting in a deficiency. Resident 12, diagnosed with cognitive communication deficit, dementia, anxiety, and weakness, had a quarterly Minimum Data Set (MDS) completed on 8/22/24. Resident 31, diagnosed with cognitive communication deficit, depression, Parkinson's, and diabetes, had a quarterly MDS completed on 8/21/24. However, both assessments were not transmitted to the State within the required 7-day period. The MDS Coordinator, V3, admitted to not knowing how to transmit the assessments until consulting with a supervisor on 9/25/24. Consequently, both residents' assessments were transmitted and accepted on 9/25/24, well past the deadline.
Failure to Conduct Level II PASRR Evaluations for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for three residents with diagnosed mental disorders. Resident R37 was admitted with a diagnosis of unspecified psychosis, but the Business Office Manager, V4, did not refer R37 for a Level II PASRR evaluation, believing that the dementia diagnosis overruled the unspecified psychosis diagnosis. Similarly, Resident R46, who was admitted with a diagnosis of post-traumatic stress disorder (PTSD), was not referred for a Level II PASRR evaluation. V4 stated that she was unaware that PTSD would be considered a serious mental illness. Resident R47 was admitted with diagnoses including unspecified psychosis, cognitive communication deficit, and dementia, but a Level II PASRR was not completed. The Administrator, V1, confirmed that the evaluation was not conducted due to the presence of a dementia diagnosis. Additionally, V1 stated that the facility does not have a PASRR policy and instead follows the regulation, which contributed to the oversight in conducting the necessary evaluations for these residents.
Insufficient Staffing During Night Shift
Penalty
Summary
The facility failed to ensure sufficient staff were available to meet resident needs, particularly during the night shift. On one occasion, a resident who had returned from dialysis had to wait a long time to be laid down due to insufficient staffing. The resident, who has moderately impaired cognition and is dependent on staff for transfers and other activities of daily living, was not put to bed until after 10:00 PM, despite being dropped off at the facility at 6:23 PM. This delay was due to the absence of sufficient staff, as one certified nurse assistant (CNA) called off and another refused to clock in without additional support. Interviews with various staff members, including the Director of Nursing (DON) and the Care Plan Coordinator (CPC), confirmed that on the night in question, the facility had only one nurse and one laundry staff member until additional staff arrived later in the evening. The CPC arrived at around 9:00 PM, and another CNA came in at around 10:00 PM. The DON acknowledged that this was an unusual situation and that the facility typically has more staff on the night shift, but also noted that the staff who do work often do not provide quality care. Multiple residents and staff members expressed concerns about the staffing levels, particularly during the night shift. Residents reported that they often felt there were not enough staff to meet their needs, and staff members confirmed that the night shift is frequently understaffed. The facility's Resident Listing Report documented that there were 56 residents living in the facility at the time of the incident.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to immediately report allegations of abuse to the Administrator for four residents. Certified Nurse Assistants (CNAs) reported that a Licensed Practical Nurse (LPN) was verbally abusive to residents, including yelling and making derogatory comments. Additionally, there were reports of physical abuse, such as pushing and slapping residents. The CNAs were unaware of the abuse reporting protocol and did not know who the abuse coordinator was. They also mentioned that the Administrator did not provide them with the contact number for public health to report the abuse. The residents involved had severe cognitive impairments and required varying levels of assistance with daily activities. The Administrator was unaware of the abuse allegations until informed by the surveyor. The facility's Abuse Prevention Training Program requires immediate reporting of any suspected abuse to the Administrator or a designated individual in their absence. However, this protocol was not followed, leading to a delay in addressing the abuse allegations.
Failure to Provide Timely Assistance with Transfers
Penalty
Summary
The facility failed to ensure timely assistance for a resident who required help with transfers into bed. The resident, who has diagnoses including Type 2 diabetes mellitus, hypertension, chronic kidney disease stage 4, and arthritis, reported having to wait a long time to be laid down after returning from dialysis. The resident, who has moderately impaired cognition and is dependent on staff for transfers, stated that the delay occurred because there were not enough staff available to assist him. On the specific date in question, the resident was dropped off at the facility at 6:23 PM but was not put to bed until after 10:00 PM due to staffing shortages. The facility's staffing issues were confirmed through interviews with various staff members. On the night in question, the facility had only one nurse and one laundry staff member on duty from 7:00 PM until 9:00 PM, when additional staff arrived. One certified nurse assistant (CNA) called off, and another CNA refused to clock in because she did not want to work alone. The Care Plan Coordinator Nurse arrived at 9:00 PM, and another CNA came in at 10:00 PM. The Director of Nursing and the Administrator were aware of the staffing shortage and confirmed that the resident was not put to bed until after 10:00 PM due to the lack of available staff. The facility typically has 1-2 nurses and 2-6 CNAs scheduled for the night shift, but on this occasion, they were significantly understaffed. The Director of Nursing acknowledged that this was an unusual situation and that they usually have enough staff on the night shift. However, the staff that were present did not provide the necessary quality of care, leading to the delay in assisting the resident with his transfer into bed. The facility does not have a specific policy for activities of daily living, relying instead on standards of practice.
Failure to Identify and Treat Pressure Ulcers
Penalty
Summary
The facility failed to identify, assess, and implement treatment and interventions for pressure ulcers for two residents. One resident (R1) was admitted with a small scabbed area on her left buttock, which was not measured or treated upon admission. Despite being at high risk for skin breakdown, weekly skin checks were not consistently completed, and the resident developed a stage III pressure ulcer on her left buttock. The facility also failed to document and follow up on the resident's left heel wound treatment as ordered, leading to further complications and a referral to a wound clinic only after significant deterioration. Another resident (R2) was admitted with multiple diagnoses and required substantial assistance with daily activities. Despite being at low risk for skin breakdown according to the Braden assessment, the resident developed a stage II pressure ulcer on the left buttock. The resident reported not being turned enough and experienced pain from prolonged sitting without a pressure-relieving cushion. The facility's documentation and care plan did not adequately address the resident's skin integrity issues, and the resident's complaints of pain and discomfort were not promptly addressed. The facility's policies on decubitus/pressure area care and preventative skin care were not followed, leading to inadequate assessment, documentation, and treatment of pressure ulcers. The failure to adhere to these policies resulted in the development and worsening of pressure ulcers in both residents, highlighting significant lapses in care and oversight by the facility's staff and administration.
Failure to Implement Interventions for Self-Injurious Behaviors
Penalty
Summary
The facility failed to implement necessary interventions for a resident with self-injurious behaviors and did not obtain the required behavioral health services. The resident, who had a history of Bipolar Disorder and Intellectual Disabilities, was admitted to the facility without proper documentation of her self-injurious behaviors. Despite multiple staff members observing the resident's repetitive scratching and reporting it to the nursing staff, appropriate measures were not taken to address the behavior effectively. The resident's care plan did not document her self-injurious behaviors, and the facility did not have mittens available, which were previously used to prevent the resident from scratching herself. The resident's primary physician, who had been involved in her care for years, confirmed her history of self-injurious behavior and recommended the use of mittens. However, the facility did not follow through with this recommendation, and instead, staff used socks and non-latex gloves, which were ineffective in preventing the resident from scratching herself. The facility's Director of Nursing and other staff members were unaware of the resident's chronic self-injurious behaviors and did not take appropriate steps to obtain a physician's order for mittens or other suitable interventions. As a result of the facility's failure to implement proper interventions and obtain necessary behavioral health services, the resident developed cellulitis from a self-inflicted wound on her chest. The facility's policies on behavioral assessment, intervention, and monitoring were not followed, leading to inadequate care and oversight of the resident's condition. The lack of communication and proper documentation contributed to the resident's deteriorating health and eventual hospitalization for cellulitis and other complications.
Failure to Complete Baseline Care Plans for Residents
Penalty
Summary
The facility failed to complete baseline care plans for four residents (R1, R2, R4, R6) within 48 hours of their admission. For R1, the baseline care plan was undated and unsigned, with several critical areas left blank, including the name of the resident's representative, advanced directives, active diagnoses, initial admission goals, and medication reconciliation. R1 was admitted with serious conditions such as sepsis, urinary tract infection, and bipolar disorder, and was discharged after being sent to a local hospital emergency room. R2's baseline care plan was also undated and unsigned, with missing information such as the name of the resident's representative, active diagnoses, initial admission goals, and medication reconciliation. R2 was admitted with multiple severe conditions, including acute respiratory failure, cardiac arrest, and atrial fibrillation. The care plan failed to document essential details like black box medications and the resident's diabetic status. Similarly, R4 and R6 had incomplete baseline care plans that were undated and unsigned. R4's care plan lacked information on advanced directives, active diagnoses, initial admission goals, and medication reconciliation, despite the resident having conditions like Alzheimer's disease and urinary tract infection. R6's care plan was missing details on active diagnoses, initial admission goals, and medication reconciliation, even though the resident had conditions such as rhabdomyolysis and sleep apnea. The facility's administrator confirmed that they follow RAI guidelines but do not have specific policies for care plans, and the Regional Director of Clinical Reimbursement acknowledged issues with timely completion of care plans.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in their care. For instance, a resident with a history of self-injurious behavior and multiple medical conditions did not have a comprehensive care plan initiated until nearly a month after admission. This delay resulted in inadequate management of her skin issues and behavioral problems, as staff were not fully informed or prepared to address her needs. Communication lapses were evident, as the resident's physician was not informed about the lack of mittens to prevent scratching, and the guardian was not invited to care plan meetings. Another resident, at risk for pressure ulcers, had no interventions listed in her care plan related to skin integrity, despite having pressure-reducing devices in place. This oversight indicates a failure to document and implement necessary preventive measures. Similarly, a male resident with severe cognitive impairment and an indwelling catheter had incomplete care plans with no interventions for his limited mobility, catheter care, or psychotropic medication use. A fourth resident with multiple diagnoses, including sleep apnea and shortness of breath, had no care plan addressing these conditions or the use of oxygen. The facility's Regional Director of Clinical Reimbursement acknowledged issues with timely completion of care plans and noted that the staff responsible for care plans was overburdened and often worked on the floor. The facility's policy on behavioral assessment and care planning was not adequately followed, contributing to these deficiencies.
Improper Use of Physical Restraints
Penalty
Summary
The facility failed to properly assess and monitor the use of physical restraints for three residents. For Resident 1, the facility did not conduct a restraint assessment before placing socks over her hands to prevent self-scratching. Multiple staff members confirmed that socks were used as a makeshift restraint without proper assessment or documentation. The primary physician was not informed that mittens were unavailable, and the Director of Nursing admitted that no assessment was conducted for the use of socks as restraints. Resident 4 was using a lap buddy and a tray table on a geri-chair without proper assessment and consent. The lap buddy was used to aid in positioning due to the resident's history of falls and cognitive impairment. However, the assessment and consent for the lap buddy were obtained after its use had already begun. Similarly, the tray table was used during mealtimes without a physician's order, and the resident was observed using it outside of mealtimes, contrary to the facility's policy. Resident 5 was also using a tray table on a geri-chair during mealtimes without a proper physician's order. The tray table was intended to increase independence with consumption and serve as a boundary identifier. However, the resident was observed using the tray table outside of mealtimes, and the facility's Director of Nursing confirmed that it should have been removed after meals. The facility's policies on abuse prevention and behavioral assessment were not followed, leading to the improper use of physical restraints for these residents.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) coding for three residents, leading to deficiencies in their assessments. For Resident 1, the MDS documented a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitive intactness, which was contradicted by staff interviews and observations. Additionally, the MDS inaccurately reported that Resident 1 did not receive any high-risk medications, despite being prescribed Clonazepam and Eliquis. The resident's guardian was also not involved in the care plan development, contrary to what was documented in the MDS. Resident 2's MDS inaccurately documented that no mobility devices were used in the past seven days and that the resident was dependent on admission for various mobility activities. However, observations and the resident's own statements confirmed that she had been using a wheelchair before admission and continued to do so. The baseline care plan also documented the use of a wheelchair, further contradicting the MDS. For Resident 4, the MDS inaccurately coded urinary continence, failing to account for the resident's use of an indwelling catheter. Observations confirmed the presence of a urinary drainage bag attached to the resident's chair. The MDS coordinator admitted to not completing the assessments accurately and timely due to an extensive workload and being new to the role. These inaccuracies in MDS coding led to deficiencies in the residents' assessments and care plans.
Failure to Assess and Treat Self-Inflicted Injury
Penalty
Summary
The facility failed to assess and seek timely treatment for a self-inflicted injury for a resident (R1) who was admitted with a history of self-injurious behavior, including scratching, picking, and occasionally biting. Upon admission, R1 had multiple skin impairments, including a circumferential sore on the left forearm and a stage III pressure ulcer on the left heel. Despite these conditions, the facility did not maintain consistent weekly skin monitoring records, missing documentation for the week of 2/28/2024. Additionally, the facility did not adequately address R1's self-inflicted scratches, which were reported by multiple CNAs but not effectively managed by the nursing staff or the primary physician (V13). The facility's failure to provide timely and appropriate treatment for R1's self-inflicted injuries led to the development of cellulitis and other complications, ultimately resulting in R1's transfer to a higher level of care hospital. R1's care plan included interventions for skin care, but these were not consistently implemented. For instance, the use of mittens to prevent scratching was recommended by the primary physician (V13), but the facility did not have mittens available and instead used soft socks, which R1 was able to remove. The facility's LPN (V12) reported the issue to the primary physician, who did not follow up after the initial phone call. The facility's standing orders for abrasions were not effectively utilized, and there was a lack of documentation for treatment orders prior to 3/19/2024. This lack of timely and appropriate intervention contributed to the worsening of R1's condition. The facility's policies for decubitus care and change in a resident's condition or status were not followed. The policies required notifying the physician for treatment orders upon identification of skin breakdown and documenting the type, frequency, and site of treatment. However, the facility failed to adhere to these procedures, resulting in inadequate care for R1's self-inflicted injuries. The facility's inaction and lack of timely treatment led to R1 developing cellulitis and other complications, necessitating transfer to a higher level of care hospital.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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