Landmark Of Itasca Rehabilitation And Nursing Cent
Inspection history, citations, penalties and survey trends for this long-term care facility in Itasca, Illinois.
- Location
- 535 South Elm, Itasca, Illinois 60143
- CMS Provider Number
- 145752
- Inspections on file
- 51
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 34 (2 serious)
Citation history
Health deficiencies cited at Landmark Of Itasca Rehabilitation And Nursing Cent during CMS and state inspections, most recent first.
Two cognitively intact residents reported being physically mistreated by staff, including a dietary aide allegedly yelling at, pushing, and swearing at a resident seeking food, and a CNA allegedly striking another resident with a garbage bag during a dispute over dishes, with a roommate corroborating the latter event. Staff notified nurses and police in one case, and police responded in both, but the administrator did not believe abuse occurred in the first incident and did not investigate or report the second, despite facility policy prohibiting abuse and requiring protection from mistreatment.
The facility failed to follow its abuse prevention policy when a cognitively intact, independent resident alleged that a CNA struck her with a garbage bag after a dispute over dishes left in a shared bathroom, an event that was witnessed by another cognitively intact, independent resident with psychiatric diagnoses. The Administrator did not initially consider the event to meet the definition of abuse, did not promptly report it to the state agency, did not initiate a timely internal investigation, and allowed the CNA to continue working, despite a written policy requiring prompt reporting, investigation, and protection of residents during abuse investigations.
A cognitively intact resident with depression and COPD reported that a CNA hit her with a garbage bag after a dispute over dishes taken from a shared bathroom, and another cognitively intact resident with bipolar disorder and schizophrenia stated she witnessed the incident. The resident called police, who came to the facility. The Administrator/Abuse Coordinator did not initially report the allegation to the State Agency because he did not believe it met the facility’s definition of abuse, and the incident was not reported to the state until months later, when an internal investigation was started. Leadership later acknowledged the allegation had been overlooked and that the CNA was not removed from duty, care plans were not updated, and the incident was not reported in a timely manner, contrary to the facility’s abuse prevention policy.
A resident with multiple psychiatric and cognitive diagnoses, but documented as cognitively intact and independent in ADLs, was allegedly yelled at, pushed, and sworn at by a dietary aide near the kitchen when seeking food or coffee. A receptionist reported witnessing the incident, stated the resident was crying and said she had been hurt, and notified social services, an RN, and the administrator. Staff assessed the resident and contacted police, and the administrator later stated he did not believe abuse occurred. Review of the incident report showed it lacked a factual witness statement and signature, and the investigation did not meet the facility’s Abuse Prevention Program requirements for a complete, fact-based final report and review.
Surveyors found that the facility failed to provide meaningful and scheduled activities, particularly evening game and movie nights, after the activity director went on leave. Several cognitively intact residents with complex medical and psychiatric conditions reported that activities had decreased or stopped, and that staff substitutes sometimes did not know how to operate the TV for games. Activity aides confirmed they only worked daytime hours, were unaware of evening activities taking place, and noted that game and movie nights had not occurred for over a month despite being listed on the activity calendar. A social services assistant helping the activity department stated she did not conduct nighttime activities and that evenings were treated as independent time, while the administrator acknowledged that posted events should occur and that residents should be informed of cancellations, contrary to the facility’s own activities policy.
A resident with dementia and moderate cognitive impairment was photographed twice without authorization, including once while asleep, and the image was used on documentation. The POA later observed the photo during a meeting and reported that neither she nor the resident had consented to any photography. Multiple staff, including the HR/Business Office Manager, Dementia Coordinator, Social Services Director, and Administrator, acknowledged that a photographic authorization form in the admission packet must be signed before taking EMR photos and that a sleeping resident’s image does not demonstrate consent. The resident’s photographic authorization form on file showed the POA had selected “No” to all requested uses of photographs.
The facility failed to arrange transportation for multiple residents’ scheduled nephrology appointments, resulting in cancellation of all appointments on a planned clinic day. A group of residents with chronic kidney disease and related comorbidities, some cognitively intact and others with severe dementia requiring extensive ADL assistance, were supposed to travel together by facility bus, which had been in a repair shop for an extended period due to a fuel pump failure. The DON reported that transportation is normally arranged 72 hours in advance, but the staff member responsible for scheduling was out on vacation or sick leave, no designee was assigned, and alternative transportation through families or an outside company was not coordinated, leading to missed nephrology follow-up for all affected residents.
A resident reported that a CNA entered her room and made an inappropriate personal remark, telling her that she loved him, which the resident found upsetting and not a proper way to speak to a patient. The resident informed her sister/POA, who believed such comments should not be allowed and contacted the police. In interviews, the CNA admitted making the statement and described it as a joke, while the DON stated that staff are expected to remain respectful and professional and avoid jokes that could be misinterpreted. This conduct conflicted with the facility’s dignity policy, which requires staff to be polite, respectful, and to maintain all aspects of resident dignity.
A resident was admitted with no documented skin breakdown and initially had only blanchable redness to the buttocks with no coccyx involvement, but later was found to have an in-house acquired Stage III coccyx pressure injury with drainage, yellow slough, and significant pain. The wound care nurse reported the wound was first identified as Stage III, was unsure why it had not been found sooner, and noted the resident did not like the low air loss mattress and only moved when staff moved him. Staff stated they are expected to report skin changes immediately, and Braden Scale scores consistently showed the resident as low risk, despite facility guidelines emphasizing early risk identification and prompt reporting of new skin concerns.
Surveyors identified that staff did not consistently follow Enhanced Barrier Precautions (EBP) for two residents who required infection control measures. One resident with a Stage III sacral pressure ulcer and active wound care orders did not have EBP signage or a PPE bin outside the room, and a wound care nurse provided coccyx wound care without wearing a gown. Another resident on EBP for ESBL in the urine had appropriate signage and PPE supplies, but a CNA entered the room and changed the resident’s brief without donning a gown. The DON reported that residents with wounds or MDROs must be on EBP, with staff required to use gowns and gloves and perform hand hygiene before direct care such as incontinence care and wound care, and to remove PPE before exiting the room.
The facility failed to protect residents’ right to receive unopened personal mail. Two residents reported that personal checks from government sources arrived already opened, were handled by administrative staff, and were deposited into their accounts after delays. One resident showed an envelope addressed only to her that had been cleanly slit open before delivery. The Business Office Manager described a process in which reception sorts mail, activities delivers non-Medicaid items, and the business office opens mail bearing the facility’s name, while another staff member confirmed that bills and medical bills stay with the business office. These practices resulted in some residents receiving mail that had been opened before it reached them, contrary to the facility’s mail policy.
A resident with osteoporosis, who prefers milk and yogurt with meals and had a tray ticket indicating they should receive plain yogurt daily, did not receive yogurt with breakfast. Kitchen observations showed multiple tubs of yogurt available in the walk‑in cooler, while the resident reported being told the facility was out of yogurt and awaiting a shipment. A dietary aide confirmed the resident was to receive yogurt daily and that aides on the tray line are responsible for dishing yogurt for trays, indicating the resident’s documented dietary preference was not followed in practice.
Several dependent residents did not receive timely assistance with ADLs, including feeding and incontinence care. Observations revealed that some residents remained in soiled briefs or clothing for extended periods, and one was seen eating with his hands without prompt staff intervention. Staff and family interviews confirmed that required two-hour checks were not consistently performed, and facility policies for individualized care were not followed.
A resident with a history of elopement and cognitive impairment was able to exit the facility undetected by removing window hardware and using bed sheets to escape, after staff failed to recognize and address repeated exit-seeking behaviors. Other residents exhibiting similar behaviors were not reassessed or properly documented as elopement risks, and staff did not consistently respond to door alarms or maintain secure exits, resulting in a significant lapse in supervision and safety.
A facility with over 120 residents employed a Social Services Director who did not meet the required educational qualifications, as the individual only had a high school diploma rather than the necessary degree or licensure. The unqualified staff member continued in the role after this deficiency was previously identified, impacting all residents while the facility sought a replacement.
A resident with a history of suicidal ideation and prior incidents involving knives was not adequately monitored or protected, resulting in fatal self-inflicted injuries. The facility failed to consistently screen for suicide risk, altered assessment scores without justification, and did not implement or document necessary safety interventions such as room searches or removal of sharp objects. Multiple residents with moderate suicide risk were similarly affected, with care plans not reflecting their actual risk.
The facility failed to ensure that the Social Service Director met the required educational and certification qualifications, and did not provide proper oversight to guarantee that self-harm and suicide risk assessments were completed accurately, timely, or individualized for residents. Multiple residents were affected by these deficiencies, and the administrator was unable to confirm the SSD's qualifications.
The facility did not employ a qualified full-time social worker, as the Social Service Director only had a high school education and lacked the required degree or certification for the position, despite the facility's job description specifying these qualifications. Both the Administrator and Medical Director were unaware of the SSD's lack of qualifications.
Dietary staff did not follow the facility's menu extension for serving instructions and portion sizes, resulting in residents receiving incorrect portions of pasta with meat sauce and not receiving required bread items for mechanical soft and pureed diets. The dietitian confirmed that the menu extension was not followed and the facility's policy for meal accuracy was not adhered to.
Staff did not use heated plates, thermal bases, or closed carts when serving meals, resulting in food being delivered at temperatures below the facility's policy standard. Multiple residents reported that their hot food was often served cold, and a test tray confirmed food temperatures were below the required 125°F. The dietitian stated that proper equipment and procedures were not followed to maintain food temperature.
Menus were not consistently prepared in advance, followed as written, updated, or reviewed by a dietician, resulting in failure to meet the nutritional needs of residents.
Surveyors found that food and drink served to residents was not always palatable, attractive, or at a safe and appetizing temperature, indicating a failure to meet required standards for meal service.
The facility did not serve meals to residents within the scheduled timeframes, with multiple residents reporting frequent delays and some receiving dinner as late as 7:00 PM. Documentation and interviews confirmed that meal service was not consistently provided as per the posted schedule, affecting all residents on oral diets.
Staff used hairnets as coffee filters, failed to perform hand hygiene after handling soiled dishes, and did not properly sanitize kitchenware before use. Food items were improperly stored, with uncovered gelatin and uncapped milk in the cooler, and ready-to-eat foods placed beneath raw bacon, creating cross-contamination risks for all residents receiving oral diets.
The facility failed to ensure that residents were protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate protective measures and oversight.
A resident with dementia did not receive the necessary treatment and services to address their condition, resulting in a deficiency related to inadequate dementia care.
The facility did not provide meals that were nutritive, palatable, or attractive when staff prepared and served a main entrée without key ingredients due to missing supplies. Several cognitively intact residents with complex medical needs expressed dissatisfaction with the meal's appearance, taste, and nutritional value, and staff confirmed they were unable to follow the standardized recipe. Ongoing concerns about food quality were also documented in resident council notes.
A resident with severe cognitive impairments fell from a mechanical lift during a transfer performed by a CNA, resulting in severe injuries and eventual death. The CNA attempted the transfer alone, contrary to facility policy requiring two staff members. Only three of the four sling straps were attached, leading to the fall. The resident sustained multiple fractures and a subdural hematoma, and despite receiving care, they expired. The facility's policy mandates two trained operators for mechanical lift transfers.
The facility failed to maintain good personal hygiene for five residents needing assistance with ADLs. Observations showed overgrown fingernails with debris and unkempt grooming. Despite being alert, residents reported no offers for nail clipping or grooming help. Staff interviews revealed inconsistencies in following facility policies for personal hygiene and morning care routines.
The facility failed to ensure call lights were accessible to three residents who required assistance, as observed during a survey. The call lights were found on the floor or hanging out of reach, preventing residents from calling for help. This issue was acknowledged by the nursing staff, who confirmed that call lights should be within reach at all times. The residents involved were at risk for falls and needed extensive assistance for activities of daily living (ADLs).
The facility failed to reposition three residents as required, despite their care plans indicating a need for frequent repositioning to prevent skin integrity issues. Observations showed these residents remained in a supine position for extended periods, and staff interviews confirmed the expectation of repositioning every two hours, which was not adhered to.
A facility failed to document a resident's death in the medical records, despite the resident being under hospice care with multiple diagnoses. Interviews with staff confirmed the absence of required documentation, such as a progress note or death assessment form, which is against the facility's guidelines for nursing documentation.
The facility failed to protect resident privacy when a CNA took unauthorized photos of residents in the dementia unit and shared them with other staff members. The photos, depicting residents in compromising positions, were taken without consent, violating the facility's policy against non-medical photography without a signed release form. The administration was unaware of these actions until informed by a staff member.
Facility staff failed to report suspicions of abuse as per policy, affecting four residents. A CNA took photos of residents in potentially abusive situations and shared them with another CNA, but did not report the incidents. The facility's Administrator only learned of the situation when a verbal report was made, leading to an investigation. Photos showed residents restrained or blocked from exiting, and the facility's policy required immediate reporting, which was not followed.
A resident was given both 5 PM and 9 PM medications simultaneously by an LPN, who incorrectly assumed it was the resident's preference. The medications were left for the resident to take later, contrary to the facility's policy requiring nurse supervision during administration. This practice was confirmed as unsafe by the facility's staff.
A resident, who was cognitively intact, was served a hamburger bun with mold at the facility. The resident and a family member reported the mold, and the cook confirmed the complaint with photographic evidence. The Social Services Director was informed by a CNA and notified the Administrator, who contacted the dietary manager. The facility's policy requires food storage areas to be clean and mold-free, which was not followed in this case.
The facility failed to provide timely incontinent care to two residents with cognitive impairments. A male resident was found with a double diaper, the inner one soaked, while a female resident was left wet due to her CNA being on break. Both residents required assistance with personal hygiene, and the facility's policy mandates checks every two hours, which were not followed.
A resident with dementia and Alzheimer's was sent to the hospital due to a significant change in condition, but the facility failed to notify the resident's family. The nurse mistakenly called the resident's own phone number instead of the emergency contacts, leaving the family unaware of the hospitalization until they visited the facility days later.
A resident's photo was posted on social media without her permission, despite her explicit refusal on the Photographic Authorization and Release form. The facility's Activity Director admitted the error, and the Social Worker reported the issue to the Administrator, who contacted corporate to remove the photo.
A resident with a history of fractures and decreased bone density was improperly transferred using a gait belt instead of a sit-to-stand lift, resulting in a left femur fracture that required surgical repair. Staff involved were unaware of the correct transfer method, and the facility's policy on safe transfers was not followed.
The facility failed to properly label, date, seal, and store food items in the kitchen, affecting all residents receiving oral nutrition. Observations included unlabeled and undated food items, opened and unsealed bags, and contamination risks in the dry storage area. The Dietary Manager confirmed that these practices did not comply with the facility's food safety policies.
The facility failed to provide appropriate catheter care and ensure catheter collection bags were placed below the bladder level for four residents. Issues included uncleaned catheters, detached anchoring devices, and improper placement of catheter bags, leading to potential infection risks.
The facility failed to obtain physician orders and complete self-administration assessments for three residents who had medications at their bedside. One resident had two Albuterol Sulfate inhalers without a physician's order or assessment, another was observed taking medications without a nurse present and lacked an order or assessment, and a third had an inhaler with an order but no assessment or care plan.
The facility failed to ensure proper handling of linens and hand hygiene, leading to potential cross-contamination. CNAs were observed throwing soiled sheets on the floor and not performing hand hygiene or changing gloves after providing perineal care. Soiled linens were also placed directly on the floor and transported unbagged for disposal.
Failure to Protect Residents From Staff Physical Abuse and to Investigate Allegations
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by staff and to investigate and report alleged abuse. In the first incident, a receptionist reported that a cognitively intact resident with multiple psychiatric diagnoses, including dementia, Alzheimer’s disease, psychosis, schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder, approached the kitchen area seeking food or coffee. The receptionist stated she witnessed a dietary aide yelling, pushing, and swearing at the resident, then closing the kitchen door. The resident then reported to the receptionist that the dietary aide had hurt her, and another nurse assessed the resident and contacted the police, who met with the resident. Despite this, the administrator, who acknowledged residents’ right to be free from abuse, stated he believed the dietary aide was simply loud by nature and did not think abuse had occurred, even though the facility’s Abuse Prevention Program prohibits abuse and the resident’s care plan called for her to remain safe and free from mistreatment. In the second incident, another cognitively intact resident with diagnoses including depression, COPD, and GERD reported that, after returning from dinner, she learned from her roommate that a CNA had taken her dishes from the shared bathroom. When the resident confronted the CNA, she stated the CNA hit her with a garbage bag, prompting her to call the police, who came to the facility. Nursing progress notes documented the confrontation and the resident’s allegation that the CNA hit her with a garbage bag. The roommate, who also had intact cognition and multiple psychiatric diagnoses, reported witnessing the CNA hit the resident with a garbage bag. The administrator later stated that he had not investigated or reported this incident because he did not see any significant concerns, and the DON reported she was unaware that the investigation had not been completed, despite the facility’s Abuse Prevention Program defining abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish.
Failure to Implement Abuse Reporting and Investigation Policy After Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse prevention program policy related to prohibiting and preventing abuse, investigating allegations, protecting residents during investigations, and reporting abuse. One cognitively intact resident (R4), who has diagnoses including depression, COPD, and GERD and is independent in daily activities, reported that after returning from dinner she was told by her roommate that a CNA (V26) had taken dishes she left on the shared bathroom sink. When R4 confronted the CNA, she stated the CNA hit her with a garbage bag. R4 reported that she called the police, who came to the facility, and that the next day the Administrator (V1) spoke with her but did not take action regarding the allegation. Another cognitively intact resident (R9), with diagnoses including bipolar disorder, schizophrenia, major depressive disorder, and anxiety disorder and who is also independent in activities of daily living, stated she witnessed the CNA hitting R4 with a garbage bag. Despite these allegations and the facility’s written Abuse Prevention Program policy, the Administrator/Abuse Coordinator (V1) acknowledged that he did not report the incident to the state agency at the time because he did not believe it met the facility’s definition of abuse. The incident was not reported to the Illinois Department of Public Health until months later, and no internal investigation was initiated at the time of the allegation. V1 further acknowledged that the CNA continued to work after the allegation. The DON (V2) and ADON (V3) later stated that the facility had overlooked the incident and that the abuse allegation should have been addressed in a timely manner. The facility’s policy, revised 01/2019, states that the facility will not tolerate incidents of abuse and that the policy defines how investigations of abuse allegations will be conducted and outlines the process of reporting, investigating, and reaching conclusions on allegations, which was not followed in this case.
Failure to Timely Report and Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention policies and procedures after an allegation that a certified nursing assistant (CNA) struck a resident with a garbage bag. One resident, who has diagnoses including depression, chronic obstructive pulmonary disease, and gastroesophageal reflux disease and is documented as cognitively intact and independent in daily activities, reported that after returning from dinner she learned from her roommate that the CNA had taken her dishes from the shared bathroom. When the resident questioned the CNA, the CNA allegedly hit her with a garbage bag. The resident called the police, who came to the facility. Another cognitively intact resident, with diagnoses including bipolar disorder, schizophrenia, major depressive disorder, and anxiety disorder and who is also independent in activities of daily living, stated that she witnessed the CNA hitting the resident with a garbage bag. The Administrator/Abuse Coordinator acknowledged that he did not report the incident to the State Agency at the time it occurred because he did not believe it met the facility’s definition of abuse, and that the incident was not reported to the Illinois Department of Public Health until nearly five months later, when an internal investigation was initiated. The Director of Nursing and Assistant Director of Nursing stated that the facility overlooked the incident and that the abuse allegation should have been addressed. They further stated that the employee should have been removed from the facility during the investigation, that resident care plans should have been updated, and that the incident should have been reported in a timely manner. These actions and inactions conflicted with the facility’s written Abuse Prevention Program policy, which requires reporting, identification, investigation, removal of employees from the facility during the investigation, completion of the final investigation within five working days, and updating interventions in care plans.
Failure to Thoroughly Investigate Alleged Staff Abuse of a Resident
Penalty
Summary
The facility failed to thoroughly investigate an allegation that an employee abused a resident and failed to ensure appropriate documentation of the incident. The involved resident had diagnoses including dementia, Alzheimer's disease, psychosis, schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder, but was documented on the MDS as having intact cognition and being independent in activities of daily living. Her care plan stated she would remain safe, be treated with respect and dignity, and be free from mistreatment, including abuse and neglect. A receptionist reported witnessing a dietary aide yelling, pushing, and swearing at the resident near the kitchen area when the resident was looking for food or coffee, then closing the kitchen door. The receptionist stated the resident came to her, said the dietary aide hurt her, and was crying, after which the receptionist notified the social service assistant, an RN, and the administrator. The assistant DON reported that the administrator conducted the investigation and that she only assisted nurses with follow-up. The RN stated that after the incident was reported, staff brought the resident to the unit, assessed her for pain, injury, or bruising, and contacted the police, who came to the facility and met with the resident; the RN also stated the resident complained of pain and refused medication. The administrator stated that the dietary aide was loud by nature and that he did not think abuse occurred, and he acknowledged that he completed the investigation based on the information he received. Review of the incident report showed it lacked the witness’s factual statement and signature, despite the facility’s Abuse Prevention Program requiring that the final report include facts determined during the investigation and a conclusion based on those facts, and that the administrator or DON review the findings to determine if further training or corrective action is needed.
Failure to Provide Scheduled and Meaningful Resident Activities
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide meaningful activities as scheduled and as needed to meet residents’ interests and needs. Multiple cognitively intact residents reported that the frequency of activities, particularly evening activities such as game nights and movie nights, had decreased or stopped after the activity director went on leave. One resident with multiple medical conditions including multiple sclerosis, cardiac arrhythmia, chronic kidney disease, osteoporosis, hypothyroidism, major depressive disorder, and other diagnoses stated that there were fewer activities and that game and movie nights were no longer held. Another resident with dementia, anxiety disorder, psychosis, and weakness reported that for three to four weeks there were fewer activities, that substitute staff did not always know how to operate the television for games, and that there were no evening activities like game or movie nights during the activity director’s absence. Additional residents with diagnoses such as osteoarthritis, acute and chronic kidney failure, anxiety disorder, adult failure to thrive, bipolar disorder, COPD, type 2 diabetes mellitus, major depressive disorder, dysphagia, Bell’s palsy, and schizophrenia also reported that movie and game nights had not been held because activity staff were not available. Activity aides confirmed that they worked daytime shifts, generally leaving by 4–5 PM, and were unaware of any evening activities occurring, despite the posted activity calendar listing regular Monday movie nights and Thursday game nights. One aide stated that if game or movie nights were not being held, they should not be posted on the calendar, and estimated it had been 1.5 to 2 months since those activities occurred. The social services assistant, who was helping the activity department, stated that she did not conduct nighttime activities and that after late afternoon it was considered independent time for residents. The administrator acknowledged that events posted on the calendar should be carried out and that residents should be notified if events were cancelled or moved, while facility policy required an ongoing program of activities designed to appeal to each resident’s interests and enhance their physical, mental, and psychosocial well-being.
Failure to Obtain Consent Before Photographing a Resident
Penalty
Summary
The deficiency involves the facility’s failure to obtain consent from a resident or her POA before taking photographs of the resident for use in the medical record. A family member reported that during a meeting with facility staff, she observed a picture of the resident included in documents, showing the resident asleep. The family member stated that the resident, who was particular about her appearance, would not have approved of such a picture and that she, as POA, had not consented to any photographs being taken. Staff interviews confirmed that the picture was taken while the resident was sleeping and that this was considered a “bad picture.” The resident’s face sheet showed admission with diagnoses including dementia, type 2 diabetes mellitus, unspecified psychosis, weakness, and need for assistance with personal care, and an MDS indicating moderate cognitive impairment. Facility staff, including the HR/Business Office Manager, Dementia Coordinator, Social Services Director, and Administrator, all stated that a photographic authorization release form in the admission packet must be signed prior to taking pictures for the EMR and that a sleeping resident’s image would not demonstrate consent. The resident’s Photographic Authorization Release Form showed that the POA had selected “No” to all listed uses of photographs, and a facility Concern Form documented that the resident’s picture had been taken twice without authorization, including once while she was asleep.
Failure to Arrange Transportation for Nephrology Appointments
Penalty
Summary
The deficiency involves the facility’s failure to arrange and provide transportation for multiple residents’ scheduled nephrology appointments, resulting in the cancellation of all six residents’ visits on the same day. Review of the appointment calendar showed that six residents had nephrology appointments scheduled for 11:15 AM that were canceled. The DON reported that all residents were supposed to travel together by facility bus, but the bus was not available because it had been in a repair shop since late January for a fuel pump failure. A repair receipt documented that the bus had very low fuel pressure, could not be repaired at the initial shop, and required transfer to a heavy truck repair facility. The DON further stated that transportation was supposed to be arranged 72 hours before the appointment, but the records staff responsible for scheduling were out due to vacation and sickness, and no designee was assigned to complete the arrangements. Resident interviews and record reviews confirmed the impact of this failure on six residents with significant renal and related comorbidities. One cognitively intact female resident with hypertensive kidney disease, type 2 diabetes, UTI, and anxiety disorder reported being upset that her kidney appointment was canceled due to lack of transportation; her appointment had been scheduled two months earlier. A cognitively intact male resident with chronic kidney disease, hypertensive heart failure, anemia, and BPH stated he canceled his quarterly kidney follow-up because the bus had been in the repair shop for a while. Another cognitively intact male resident with chronic kidney disease, type 2 diabetes, hypertensive heart disease, and peripheral vascular disease reported his kidney appointment was canceled because the bus was not available. Three additional residents with severely impaired cognition and extensive ADL assistance needs, including diagnoses such as obstructive and reflux uropathy, urinary retention, dementia, transplant kidney status, and Alzheimer’s disease, also had nephrology appointments scheduled and then canceled. The Administrator acknowledged the failure to arrange transportation, either through family or an outside transportation company, when the bus was unavailable and the responsible staff were absent.
Inappropriate CNA Remarks Undermining Resident Dignity
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to dignity and respectful treatment when a CNA made inappropriate personal remarks to a resident. During an interview, the resident reported that a few weeks prior, the CNA entered her room and told her, "I believe you love me; you know that you love me." The resident stated she did not like this comment, felt it was not an appropriate way to speak to a patient, and considered it unfair. The incident continued to bother her at the time of the interview, and she reported the situation to her sister, who is also her POA. The resident’s sister/POA stated that the CNA’s comment should not be allowed in the nursing home and reported that she called the police regarding the CNA’s behavior. In a separate interview, the CNA confirmed making the statement to the resident and characterized it as a joke. The facility’s DON stated that staff are expected to always be respectful and professional and to avoid making jokes that could be misinterpreted, and the facility’s dignity policy requires staff to always be polite and respectful and to maintain all aspects of residents’ dignity regardless of cognitive level or understanding. The CNA’s admitted conduct and the resident’s and POA’s reports demonstrate that the resident was not treated with dignity and respect as required by facility policy and resident rights standards.
Failure to Identify and Assess Coccyx Pressure Injury Before Progression to Stage III
Penalty
Summary
The facility failed to identify and assess a pressure wound before it progressed to a Stage III pressure injury for one resident. On admission/readmission skin assessment dated 12/17/25, the resident was documented as having no open areas or skin breakdown. A weekly wound evaluation on 12/18/25 noted blanchable redness to the buttocks with no open areas and no redness or open areas to the coccyx. Despite this, a later weekly wound evaluation dated 1/2/26 documented that a Stage III, in-house acquired pressure injury to the coccyx had been found on 12/30/25, with moderate thin, watery, serous drainage, yellow slough, and a resident pain rating of eight. A wound physician’s note dated 12/30/25 also documented a Stage III coccyx pressure wound reported on that date. During observation on 1/17/26, the wound care nurse was seen providing treatment to the resident’s coccyx, which had an open area, while the buttocks showed no redness or open areas. The wound care nurse stated that the coccyx wound was first identified on 12/30/25 as a Stage III pressure wound, confirmed it was acquired in the facility, and acknowledged uncertainty about why it had not been found sooner. She also stated that healing was initially difficult because the resident did not like the low air loss mattress and only moved when staff moved him. A CNA reported that it is important to inform the wound care nurse and floor nurse immediately about any changes in residents’ skin. The resident’s Braden Scale assessments on multiple dates all showed the resident as low risk, and the facility’s pressure injury prevention guidelines require early risk identification and immediate reporting of new skin concerns or painful skin areas to the nurse for assessment.
Failure to Follow Enhanced Barrier Precautions for Residents Requiring Infection Control
Penalty
Summary
Surveyors found that the facility failed to implement and follow Enhanced Barrier Precautions (EBP) for two residents requiring infection control measures. One resident with a Stage III sacral pressure ulcer and an active order for daily and as-needed wound care to the coccyx did not have an EBP sign or PPE bin outside the room, and the wound care nurse entered the room and performed wound care without donning a gown. Another resident with an active order for EBP due to ESBL, a multidrug-resistant organism in the urine, had an EBP sign and PPE bin outside the room, but a CNA entered the room without a gown to provide incontinence care by changing the resident’s brief. The DON stated that any resident with wounds or a history of MDROs must be on EBP, with signage on the door and PPE, and that staff are required to perform hand hygiene and don a gown and gloves before entering the room for direct resident care such as incontinence care and wound care, and remove PPE before exiting the room. These observations, interviews, and record reviews demonstrate that staff did not consistently follow the facility’s stated EBP requirements for residents with wounds or MDROs, resulting in failures to use required PPE and to ensure appropriate EBP signage and supplies were in place for affected residents.
Failure to Protect Residents’ Right to Unopened Personal Mail
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ personal mail was delivered unopened, as required by its Resident Mail Delivery policy. One resident reported that his mail was sometimes open and described receiving a State-issued check for missing or lost property in an envelope that had already been opened before the Administrator brought it to him for endorsement, after which the funds were deposited into his account. Another resident reported that her mail from Social Security had been opened for her, that the check was cashed, and that there was a delay before the funds appeared in her account. She stated she had to threaten to call the police due to the delay and showed surveyors a piece of mail bearing her name, with no facility name on it, that had been cleanly slit open across the top with a letter opener when it was given to her. Staff interviews and observations further detailed the facility’s mail-handling practices. The Business Office Manager stated that reception receives the mail, separates it, and gives activities any mail that is not Medicaid-related, while she opens mail that has the facility name on it, typically Medicaid applications, denials, or statements. During the interview, she produced two unopened envelopes that appeared to be from the same Medicaid source, one addressed to the facility and one to a resident, and stated she had not yet sorted them but would open the one addressed to the facility and send the one addressed to the resident on for delivery, asserting that she does not open resident mail. The Activities Director stated that the front desk gives activities cards, gifts, and similar items for delivery six days a week, while bills and medical bills remain with the business office and are not delivered by activities. These practices and resident reports demonstrate that some residents’ mail was opened prior to being delivered, contrary to the facility’s written policy that all residents receive mail unopened and in a timely manner.
Failure to Provide Daily Yogurt per Resident Dietary Preference
Penalty
Summary
The facility failed to provide a resident with yogurt at breakfast in accordance with the resident’s documented dietary preferences and the facility’s own policy on accommodating such preferences. The resident had a diagnosis of osteoporosis listed on the Facesheet and, per a Dietary Progress Note dated 5/19/23, preferred milk and yogurt with meals. The resident’s breakfast tray ticket for 1/12/26 specified that the resident was to receive plain yogurt daily. On the morning of 1/12/26, surveyors observed a case of six bulk 5‑pound tubs of yogurt in the walk‑in cooler, with five unopened and one opened, and the Interim Food Service Director stated that one case of yogurt typically lasts about a week and that yogurt is an item residents must request to receive. Despite the availability of yogurt and the tray ticket instruction, the resident did not receive yogurt with breakfast on 1/12/26. The resident reported having started ordering yogurt at all meals to encourage optimal calcium levels after being diagnosed with osteoporosis and stated that staff told them the facility was out of yogurt and waiting on a shipment. The resident also stated that most, if not all, kitchen staff knew of their preference for yogurt. A Dietary Aide later confirmed that the resident was supposed to receive yogurt daily, that tray tickets list requested or daily items, and that dietary aides on the tray line are responsible for dishing yogurt into bowls for resident trays. The facility’s written policy dated 10/30/25 states that the facility will make every reasonable effort to accommodate each resident’s personal dietary preferences while meeting nutritional requirements, which did not occur in this instance.
Failure to Provide Timely Assistance with ADLs and Incontinence Care
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs), including feeding, dressing, and incontinence care, for five residents who were dependent on staff for these needs. Observations showed that several residents remained in the dining room for extended periods without being checked for incontinence, and some were found with soiled briefs or clothing. For example, one resident was left in a soaking wet incontinence brief with a bowel movement, and another was observed with a brown substance on his fingers and pants, later identified as stool, which was not fully cleaned after initial attempts by staff. Residents with significant medical histories, such as dementia, diabetes, mobility impairments, and self-care deficits, were not provided with the necessary assistance in a timely manner. One resident, dependent on staff for eating, was observed eating chili with his hands and drinking from the bowl, while staff were occupied assisting another resident. The resident was only assisted with feeding after several minutes, and incontinence care was delayed for multiple residents, with checks and changes occurring well after the recommended intervals. Interviews with staff and family members confirmed that residents were not being checked for incontinence every two hours as required by facility policy. Family members reported finding residents in bed late in the morning with dirty hands, and staff acknowledged that residents' clothing should be changed if soiled. Facility guidelines specify that feeding and incontinence care should be provided according to individual needs and at least every two hours, but these standards were not consistently met for the residents reviewed.
Failure to Prevent Elopement Due to Inadequate Assessment, Monitoring, and Environmental Controls
Penalty
Summary
The facility failed to ensure that a resident with a known history of elopement was properly assessed and monitored to prevent elopement. The resident, who had diagnoses including mild cognitive impairment, chronic kidney disease, congestive heart failure, and a history of elopement from a previous assisted living facility, was admitted without adequate recognition of their elopement risk. Despite prior incidents, such as the resident packing belongings and attempting to leave the locked memory care unit, staff did not update the resident’s elopement risk status or implement appropriate interventions. The resident was able to remove window lock hardware, tie bed sheets together, and exit from a second-floor window undetected, ultimately being found days later approximately ten miles away, disoriented and with physical evidence of being outdoors for an extended period. The facility also failed to identify and assess other residents who exhibited exit-seeking or elopement behaviors. Several residents with cognitive impairments and histories of wandering or elopement were not reassessed after incidents of attempting to exit the locked unit. Staff interviews revealed that some residents repeatedly tried to leave the unit, but these behaviors were not consistently reported, reassessed, or documented in the elopement risk binder. Additionally, the facility did not maintain an accurate and current list of residents at risk for elopement at the front desk as required by policy, and some residents with documented risk were not included in the binder or on the list provided by nursing leadership. Environmental safety measures were also lacking. Exit doors and windows were not consistently secured or monitored, and staff did not respond promptly or effectively to door alarms. On one occasion, a staff member left an external door propped open and unattended while the alarm sounded, and no immediate search or head count was conducted to ensure resident safety. Maintenance staff were not informed of missing or tampered window locks, and there was no consistent process for verifying the integrity of security measures. These failures contributed to the facility’s inability to prevent or promptly respond to elopement incidents.
Removal Plan
- Residents R2 - R9 were reassessed for elopement risk by Social Services and DON; interventions were added to care plans.
- All exit doors and windows were checked and secured by Maintenance; window hardware was replaced or reinforced with tamper-proof locks.
- Resident head counts and census verification were conducted by Charge Nurse and DON; all residents were confirmed present.
- Elopement risk list was updated and placed at front reception and nurse's stations.
- All staff were in-serviced on elopement protocol, alarm response, and head-count procedure.
- Facility-wide audit was completed by the DON to identify any residents exhibiting exit-seeking behaviors.
- Environmental rounds will be completed to confirm window locks and alarm integrity by Administrator, Maintenance Director, or Maintenance assistant.
- Reception desk binder will be updated with a list of elopement-risk residents.
- Alarm response protocol: immediate head count and documentation is required after response to door alarms with no identifiable cause.
- Nurses and Social Services were trained on how to accurately complete the elopement assessment by outside Social Services Consulting group.
- Initial Elopement Risk Assessment will be completed by nursing, and assessments by social services reviewed and supervised by Social Services Consulting completed upon admission, quarterly, significant change, or any observed exit-seeking behavior.
- Staff training will be integrated into new-hire orientation and annual in-services; includes training for elopement vs wandering risk and interventions.
- Elopement binder will be updated by social service consultant based on results of elopement risk assessment.
- Binder reviewed by Administrator/DON.
- Facility to complete elopement drills for all shift by Social Services consultant, Administrator and DON.
- Results of drills to be reviewed Administrator/DON.
- QA Committee to audit elopement-risk residents for compliance with interventions and monitoring.
- DON/Social Services Consultant to review all elopement risk assessments completed and report findings in QAPI.
- Maintenance to conduct door alarm and window lock checks and log results.
Unqualified Social Services Director Employed
Penalty
Summary
The facility failed to employ a qualified full-time Social Services Director as required for a facility with more than 120 beds, affecting all 129 residents. The daily census confirmed the facility's population exceeded the threshold, and employment records showed that the current Social Services Director's highest level of education was a high school diploma, which did not meet the job description's requirements of a bachelor's degree in psychology, sociology, or social work, or a Licensed Clinical Social Worker's Certificate. Despite this, the individual continued in the role after being identified as unqualified during a prior complaint survey, and remained in the position while the facility was recruiting for a new, qualified Social Services Director.
Failure to Monitor and Intervene for Residents at Risk of Self-Harm
Penalty
Summary
The facility failed to provide necessary monitoring and supervision for a resident with a known history of suicidal ideation and prior incidents involving the acquisition of knives. Despite documented evidence of the resident's mental health diagnoses, including major depressive disorder and previous threats and attempts of self-harm, the facility did not implement or document consistent safety interventions such as regular room searches or removal of sharp objects. The resident was able to keep multiple knives in his room, which were ultimately used in a fatal self-inflicted injury. Staff interviews revealed that although the resident had previously been placed on one-to-one supervision and had knives confiscated, there was no ongoing system to prevent the reintroduction of dangerous items, nor was there documentation of education or consistent safety checks. The facility also lacked a timely and accurate system for screening residents for suicide risk. The suicide risk assessment tool in use was not applied as intended; staff responsible for completing the assessments altered the scores from moderate to low risk without clinical justification, and did not repeat screenings quarterly or after significant changes in condition or new threats of self-harm. This practice was not limited to one resident; multiple residents with moderate risk scores had their assessments inappropriately lowered, and corresponding care plans were not developed or updated to address the actual risk level. Documentation showed that care plan interventions for suicide risk were either not implemented or were only to be used "as warranted," with no clear criteria or consistent application. The failure to accurately identify, monitor, and intervene for residents at risk of self-harm resulted in a resident sustaining fatal self-inflicted stab wounds. The lack of a systematic approach to suicide risk screening, care planning, and environmental safety checks placed all residents with a history of suicidal ideation at risk. The deficiency was identified as Immediate Jeopardy due to the facility's lack of effective interventions and processes to protect residents from harm.
Removal Plan
- R5 - R17's suicide risk screening has been reviewed, reassessed and revised.
- R5 - R17's Care plans were audited to ensure appropriate interventions are in place and were updated as necessary.
- All residents' self-harm care plans were reviewed and updated as necessary by Social Service Director (SSD), MDS coordinator and or designee.
- The facility identified no other residents who were at risk of self-harm and had a significant history of obtaining knives or other potential weapons identified via audit /record review.
- Of those residents who did have a suicide ideation/verbalization there were no significant findings identified via room search, placing them at risk for self-harm.
- All residents' suicide risk screenings were audited and updated as necessary.
- All residents self-harm care plans were reviewed and updated where necessary.
- SSD/designee is responsible for completing suicide risk screening assessments and have been in-serviced by V20 (Consultant Social Worker), V21 (RNC-Regional Nurse Consultant) completing self-harm/suicide risk screening assessments accurately, including properly recording the assessment score, completing timely and accurately with appropriate, individualized interventions in place.
- Suicide risk assessments need to be completed upon admission, quarterly, upon significant changes, and as needed.
- The facility created a process to address the results of the self-harm/suicide risk screening assessment to ensure recommendations from the screening, and measurable care plan interventions are put in place to instruct staff on how to keep residents safe.
- The facility created a policy and guidelines to the self-harm/suicide risk assessment and implemented.
- Nursing staff were in-serviced by DON/ADON (Director of Nursing/Assistant Director of Nursing) to ensure that residents with suicidal ideation will be monitored every shift under behavior monitoring and will be documented in the EMR (Electronic Medical Record).
- Residents with a history of obtaining sharp objects will have room searches conducted during angel rounds as permitted by residents or POA (Power of Attorney).
- An audit tool will be completed by Administrator, DON and or ADON on every resident upon admission, re-admission, quarterly and with significant changes to ensure that suicide risk screening assessments are completed accurately with appropriate individualized care plans as follows: Three times a week for the first two weeks, two times a week for two weeks, one time week for two weeks, and one time a month for two months.
- QAPI (Quality Assurance Performance Improvement) Committee will review for compliance, and determine that compliance has been met.
- An emergency QAPI meeting was held and attended by the Medical Director and interdisciplinary team.
Unqualified Social Service Director and Inadequate Suicide Risk Assessments
Penalty
Summary
The administration failed to provide adequate oversight and leadership to ensure that the Social Service Director (SSD) was qualified for the position, as required by the facility's job description. The SSD was hired with only a high school education and did not possess a bachelor's or master's degree in social work, psychology, or sociology, nor a Licensed Clinical Social Worker's Certificate, as specified in the job requirements. The administrator was unable to confirm whether the SSD met the necessary qualifications, and the employment record lacked documentation of the required education or certification. Additionally, the administration did not ensure that self-harm and suicide risk screening assessments were completed accurately, timely, or individualized for residents identified as at risk. Multiple residents were affected by these deficiencies, as evidenced by concerns regarding the accuracy, timeliness, and individualized care plan interventions for several residents screened by the unqualified SSD. The lack of proper assessments and care planning impacted all 130 residents in the facility.
Failure to Employ Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker as required for a facility with more than 120 beds, affecting all 130 residents. The Social Service Director (SSD) was hired as a full-time employee but only had a high school education, with no college degree or relevant certification documented in her employment record. The facility's job description for the Director of Social Services position specifies that a bachelor's degree in psychology or sociology, a B.A. or M.A. in social work, or a Licensed Clinical Social Worker's Certificate is required. The SSD signed the job description acknowledging these requirements, but there was no evidence she met them. The Administrator was unsure of the SSD's qualifications, and the Medical Director was unaware that the SSD did not meet the necessary requirements.
Failure to Serve Menu-Specified Food Portions and Items
Penalty
Summary
The facility failed to serve food portions as specified on the facility menu spreadsheet for 129 residents receiving oral diets. During lunch tray line service, it was observed that staff used a 4 oz spoodle to serve pasta mixed with meat sauce for regular diet trays, and a 4 oz scoop for chopped pasta and mashed potatoes for mechanical soft trays, rather than the required 8 oz pasta with 4 oz sauce for a total of 12 oz as indicated on the menu extension. Additionally, soft garlic bread was not served with mechanical soft trays, and pureed bread was not provided with pureed trays, despite these items being listed on the menu extension for those diets. The tray line also lacked a container of pureed garlic bread for pureed diets. Interviews with dietary staff and the dietitian confirmed that the menu extension instructions and portion sizes were not followed. The dietitian stated that dietary staff should adhere strictly to the menu extension for serving instructions and portion sizes, and acknowledged that the correct portions and items were not served. The facility's policy requires that all meals be checked for accuracy, including correct portion sizes and adherence to the therapeutic diet extension, but these procedures were not followed during the observed meal service.
Failure to Serve Food at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to follow its own policies regarding the serving of food at palatable and safe temperatures for all six residents reviewed for dietary services. During lunch tray line service, staff served meal trays on hard plastic, non-warmed plates without using thermal bases or heated plates, and placed the trays on open-air carts. A test meal tray prepared and delivered in the same manner was found to have food temperatures of 110 degrees Fahrenheit for both pasta with meat sauce and green beans, which were described as lukewarm. The facility's policy requires hot foods to be served at temperatures not less than 125 degrees Fahrenheit and specifies the use of thermal lids, bases, and closed carts to maintain proper food temperatures. Multiple residents reported that their warm food was frequently or usually served cold, and one resident stated that food intended to be cold was sometimes served warm. The facility dietitian confirmed that dietary staff should be using heated plates, warming bases, plate covers, and closed carts to ensure food is served at appropriate temperatures, in line with facility policy. The observations, interviews, and record reviews demonstrate a consistent failure to maintain food temperatures at the point of service, resulting in food being served at temperatures below the facility's required standard.
Deficiency in Menu Planning and Nutritional Oversight
Penalty
Summary
Menus did not consistently meet the nutritional needs of residents, as they were not always prepared in advance, not always followed as written, and were not consistently updated or reviewed by a dietician. The menus also failed to address the specific needs of the residents as required. These deficiencies were observed during the survey and were based on direct findings related to menu planning and implementation.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the meals did not consistently meet standards for taste, appearance, or temperature at the time of service.
Failure to Serve Meals According to Scheduled Times
Penalty
Summary
The facility failed to serve meals to residents according to the established meal schedule, resulting in late meal service for all 128 residents receiving oral diets. Observations showed that on 7/10/25, the last lunch tray was served at 1:13 PM on 1 South, despite the scheduled lunch period for that unit being between 12:25 and 12:35 PM. Facility documentation indicated that meals were to be served within specific timeframes for breakfast, lunch, and dinner, but resident interviews revealed that meals were often served late, with some residents reporting dinner being served as late as 7:00 PM. The Corporate Food Service Manager acknowledged recent awareness of these concerns, and resident council meeting minutes documented complaints about delays in food service by CNAs. One resident was noted to be NPO per physician orders, but the deficiency applied to all other residents on oral diets.
Failure to Follow Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation practices in several key areas. Staff were observed using white bouffant hairnets as coffee filters in the coffee machine for approximately two weeks, despite the availability of appropriate coffee filters. The hairnets, not designed for food preparation, were used to brew coffee for residents. Additionally, a cook was seen handling soiled food equipment at the dish machine without wearing disposable gloves and then, without performing hand hygiene, proceeded to handle clean and sanitized kitchen equipment intended for resident food preparation. Further deficiencies included the improper sanitization of kitchenware, as a cook removed a steamtable pan from the rinse compartment of a three-compartment sink without it being sanitized. In the walk-in cooler, uncovered bowls of gelatin were stored in dish machine racks, and a milk carton was found without a cap. There was also improper storage of food items, with ready-to-eat foods such as flour tortillas, hot dogs, and deli turkey stored beneath uncooked bacon, increasing the risk of cross-contamination. The facility census at the time was 129 residents, with one resident on NPO status.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect residents from all forms of abuse, including physical, mental, and sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded against these types of mistreatment, indicating lapses in the facility's protective measures and oversight. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A resident who displays or is diagnosed with dementia did not receive the appropriate treatment and services. The facility failed to ensure that the necessary care was provided to address the resident's dementia-related needs, as required by regulatory standards. This deficiency was identified during the survey process.
Failure to Provide Nutritive, Palatable, and Attractive Meals Due to Missing Ingredients
Penalty
Summary
The facility failed to ensure that food prepared for residents was nutritive, palatable, and attractive, affecting all 119 residents who received meals from the kitchen. On the day in question, the main entrée, Skillet Lasagna, was served without key ingredients such as ground beef and parmesan cheese, and with insufficient amounts of mozzarella and ricotta or cottage cheese. Dietary staff confirmed they were instructed to prepare the dish with whatever ingredients were available, as the kitchen had not received all necessary supplies from the new food service company. Observations and interviews revealed that the lasagna lacked the expected appearance, texture, and flavor, and residents expressed dissatisfaction with the meal's quality and nutritional value. Multiple residents, all cognitively intact and with various medical conditions including diabetes, cardiac disease, depression, multiple sclerosis, chronic kidney disease, and cancer, voiced concerns about the food's appearance, taste, and nutritional adequacy. Resident council meeting notes also documented ongoing complaints about excessive starches and declining food quality. The facility's policy required staff to notify supervisors if ingredients were missing, but this protocol was not followed, resulting in the preparation and service of substandard meals.
Improper Mechanical Lift Transfer Leads to Resident's Death
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in severe injuries and the eventual death of the resident. The resident, who had severe cognitive impairments and was dependent on staff for transfers, fell from the lift during a transfer performed by a Certified Nursing Assistant (CNA). The CNA attempted to transfer the resident alone, contrary to the facility's policy requiring two staff members for such transfers. During the transfer, the resident became spastic and leaned forward, causing the CNA to try to catch the resident, but both fell to the floor. The incident report and witness statements indicate that only three of the four sling straps were attached to the mechanical lift, suggesting improper attachment. The Director of Nursing confirmed that the CNA attempted the transfer alone and that the mechanical lift and sling were inspected with no concerns identified. The resident sustained multiple facial fractures, a nondisplaced fracture of C2, a subdural hematoma, and other injuries as a result of the fall. The resident was sent to the emergency department for evaluation and treatment but later returned to the facility with significant injuries and was placed on hospice care. Despite receiving continuous care for pain control and other symptoms, the resident's condition deteriorated, and they eventually expired. The facility's policy clearly states that mechanical lift transfers require two trained operators, highlighting a breach in protocol that led to this tragic outcome.
Deficiency in Resident Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for five residents who required assistance with activities of daily living (ADLs). Observations revealed that these residents had overgrown fingernails with brown debris underneath, and some had unkempt beards or disheveled hair. Despite being alert and oriented, residents reported that no one had offered to clip their nails or assist with grooming. The Minimum Data Set (MDS) assessments indicated that these residents needed extensive or total assistance with ADLs, yet their hygiene needs were not being met. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and the Director of Nursing (DON), highlighted a lack of adherence to facility policies regarding personal hygiene and morning care. The CNA stated that nail trimming was only performed if requested by the resident or if long nails were observed. The DON mentioned that CNAs are expected to perform grooming tasks during morning routines, including washing, oral care, and shaving. However, the facility's policies on nail care and morning care were not being consistently followed, resulting in the observed deficiencies in resident hygiene.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to residents who required assistance, affecting three residents in the sample. Observations revealed that the call lights for these residents were consistently out of reach, either on the floor or hanging over the bed, making it difficult for them to call for help. This was confirmed by both the residents and the nursing staff, who acknowledged that call lights should be within reach at all times. The residents involved were all at risk for falls due to generalized weakness and decreased mobility, and their care plans specifically included the use of call lights to request assistance. Resident 1 was observed in a semi-Fowler's position with the call light on the floor, and he reported that the call lights did not always work, forcing him to yell or knock for assistance. Resident 2, who was using oxygen, was unable to find the call light, which was observed on the floor and later on a chair handle, both out of reach. Resident 3, who was alert and oriented, also could not find his call light, which was observed across the bed and later hanging on the side, both out of reach. The facility's policy clearly stated that call lights should never be on the floor or bedside stand, and staff interviews confirmed the expectation that call lights be accessible to residents at all times.
Failure to Reposition Residents as Required
Penalty
Summary
The facility failed to ensure that residents were assisted in repositioning in bed, which is crucial for preventing skin integrity issues. Three residents, identified as R3, R4, and R5, were observed to remain in a supine position for extended periods without being repositioned. R3, who is alert and oriented, reported that he is only turned for brief changes or linen changes and expressed a desire to lie on his side. His care plan indicated an increased risk for skin integrity issues, requiring frequent repositioning, yet there was no documentation of refusal to reposition. Similarly, R4, who also has no cognitive impairment, was observed in a supine position for several hours and stated that he is only repositioned during bathing or brief changes. His care plan also highlighted the need for frequent repositioning due to the risk of skin integrity issues. R5, who has cerebral palsy and other conditions, was observed in a supine position while watching television and stated that she is mostly positioned on her back. Her care plan also required frequent repositioning to prevent skin integrity issues. Interviews with staff, including a registered nurse and certified nursing assistants, confirmed that residents needing extensive assistance with ADLs should be repositioned every two hours. The facility's policy also mandates a two-hour repositioning schedule. However, the observations and resident statements indicate that this policy was not consistently followed, leading to the deficiency.
Incomplete Documentation of Resident's Death
Penalty
Summary
The facility failed to ensure complete documentation of a resident's death in the medical records, which is a deficiency in maintaining accurate and comprehensive records. The resident in question was a male with multiple diagnoses, including COPD, dementia, and heart disease, who was under hospice care. Despite the resident's passing, there was no documentation in the electronic medical records regarding his death, such as a progress note or a death assessment form. Interviews with facility staff, including an LPN and the Assistant Director of Nursing (ADON), revealed that it is standard practice to document any change in a resident's condition, including death, in the medical records. The ADON confirmed that the resident expired at the facility, yet there was no record of the death, including details such as the time of death, notifications made, or the funeral home involved. This lack of documentation was contrary to the facility's guidelines for nursing documentation, which emphasize timely and complete record-keeping.
Breach of Resident Privacy Due to Unauthorized Photography
Penalty
Summary
The facility failed to protect the privacy of its residents by allowing staff to take photographs of residents without their consent. This deficiency was identified when a CNA admitted to taking photos of residents on multiple occasions and sharing them with another CNA. The photos, which depicted residents in compromising positions, were taken in the dementia unit and shared among staff members without any consent from the residents involved. The facility's policy explicitly prohibits staff from photographing or recording residents for non-medical purposes without a signed release form, yet this policy was not adhered to. The residents involved in the photographs included two unidentified female residents seated in wheelchairs, a female resident lying in bed with the bed blocking the door, and a male resident lying in bed with wheelchairs blocking his exit. The facility's administration and Director of Nursing were unaware of these photographs until they were brought to their attention by a staff member. The lack of consent and the sharing of these images among staff members highlight a significant breach of resident privacy and confidentiality, as outlined in the facility's Abuse Prevention Program.
Failure to Report Suspected Abuse in a Timely Manner
Penalty
Summary
The facility staff failed to immediately report suspicions of abuse in accordance with their policy, affecting four residents reviewed for allegations of abuse. A Certified Nursing Assistant (CNA), identified as V33, admitted to taking photos of residents on the dementia unit on three separate occasions and sharing them with another CNA, V46. Despite recognizing the potential abuse depicted in the photos, V33 did not report the incidents to the facility's administration. The facility's incident reports from May 2023 to September 2024 did not document any abuse incidents corresponding to the dates the photos were taken. The facility's Administrator, V1, only became aware of the situation when V46 verbally reported the allegations on September 7, 2024, prompting an investigation. Photos reviewed by V1 and the Director of Nursing (DON), V2, showed residents in potentially abusive situations, such as being restrained with sheets or having their exits blocked by furniture. The identities of some residents in the photos could not be confirmed, and the facility's policy required immediate reporting of any suspicion of abuse, which was not adhered to by the staff involved.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered under the supervision of a licensed nurse, affecting one resident (R3) out of a sample of 13. On one occasion, R3 was given her 5 PM and 9 PM medications at the same time by an LPN, who mistakenly believed it was the resident's preference. This resulted in the resident being instructed to take the medications at different times without supervision, which is against the facility's medication administration policy. A family member and the resident confirmed the incident, and a social services assistant observed medications left at the bedside, which was not standard practice. The facility's Director of Nursing and a registered nurse confirmed that the proper procedure is for nurses to remain with residents until medications are taken to prevent errors such as double dosing or missed doses. The facility's policies explicitly state that medications should not be left in a resident's room without orders to do so. The incident highlights a deviation from these policies, as the LPN left medications for the resident to take later, which was deemed unsafe by the facility's staff.
Resident Served Moldy Food
Penalty
Summary
The facility failed to prevent a resident from being served spoiled food, specifically a hamburger bun with mold. This incident involved a resident, identified as R2, who was cognitively intact according to their Minimum Data Set dated August 13, 2024. On September 5, 2024, R2 and a family member reported the presence of mold on the bottom of R2's hamburger bun. The cook, identified as V16, confirmed that R2 had previously complained about mold on the bread and showed a picture of the moldy bun to the surveyor. The Social Services Director, V6, was informed by a CNA about the moldy food and subsequently notified the Administrator, V1, who contacted the dietary manager. The facility's Cold Food Storage policy, dated April 2022, mandates that food storage areas be kept clean and free of mold, which was not adhered to in this instance.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to two residents, R1 and R2, who were dependent on assistance for activities of daily living. R1, a male resident with severe cognitive impairment, was found in bed with a double diaper, the inner one soaked in urine with blackish discoloration. The Licensed Practical Nurse (LPN) acknowledged that R1's certified nursing assistant (CNA) was attending to another resident and confirmed that double diapering should not be used, especially for R1, who cannot express preferences due to cognitive impairment. The Director of Nursing (DON) also confirmed that double diapering is not appropriate for R1 and emphasized the policy of checking residents every two hours for incontinence. R2, a female resident with moderate cognitive impairment, reported being wet and was later found with a soaked incontinent brief by a Registered Nurse (RN) after her CNA had been on a break for 30 minutes. R2's care plan indicated a history of recurrent urinary tract infections (UTIs) and required assistance with personal hygiene, including peri-care after each incontinent episode. The facility's guidelines for incontinent care mandate assistance with cleansing after each episode and routine checks every two hours, which were not adhered to in these cases.
Failure to Notify Family of Resident's Hospitalization
Penalty
Summary
The facility failed to notify the legal representative of a resident, identified as R3, regarding a significant change in condition when R3 was sent to the hospital. R3, an elderly resident with multiple diagnoses including dementia and Alzheimer's disease, experienced a significant change in condition on 6/4/2024. The resident was restless, had a near fall, and was found smearing feces, which was a new behavior. Despite these changes, the nurse, identified as V10, mistakenly called R3's own phone number instead of the emergency contacts listed on the face sheet, which included R3's daughter and husband. This error resulted in the family not being informed of R3's hospitalization until they visited the facility days later. The facility's policy requires notifying the resident's representative of significant changes in condition, but this was not followed. The nurse left a message on the wrong phone number and did not report this mistake to the incoming nurse. As a result, R3's family was unaware of the hospitalization until they visited the facility on 6/8/2024. The social worker and the Director of Admission acknowledged the mistake, but there was no follow-up to ensure the family was notified. This oversight highlights a failure in communication and adherence to the facility's notification policy.
Unauthorized Posting of Resident Photo on Social Media
Penalty
Summary
The facility failed to provide privacy and confidentiality for a resident by posting her photo on social media without her permission. The resident, who is cognitively intact with a BIMS score of 15, had explicitly declined to have her photo posted on social media as indicated on her Photographic Authorization and Release form. Despite this, her photo was taken during a Nursing Home Week event and subsequently posted on the facility's social media page. The resident's family member, who holds Power of Attorney, discovered the photo and expressed concern, noting that consent had not been given for such use. The facility's Activity Director acknowledged the mistake, stating that the resident's photo was posted in error and that the resident's image was later partially removed from the social media page, although her body was still visible. The facility's policy requires written authorization from residents before using their photos for publicity purposes. The Activity Director admitted to the error, explaining that the resident's refusal was overlooked, and the photo was mistakenly included in the batch sent to corporate for posting. The Social Worker also noticed the unauthorized photo on social media and reported it to the Administrator, who then contacted corporate to have it removed. The resident reiterated her lack of consent and desire for the photo to be removed from social media, highlighting the facility's failure to adhere to its own privacy policies and procedures.
Improper Transfer Method Leads to Resident's Femur Fracture
Penalty
Summary
The facility failed to use the proper equipment to transfer a resident, resulting in a left femur fracture that required surgical repair. The resident, who has a history of multiple fractures and decreased bone density, was supposed to be transferred using a sit-to-stand lift but was instead transferred using a gait belt. This improper transfer method led to the resident's leg twisting and immediate complaints of pain, which were later confirmed to be due to a femur fracture. The resident's care plan and physical therapy discharge summary both indicated the need for a sit-to-stand lift for safe transfers, but this was not followed by the staff involved in the incident. Interviews with staff revealed that the LPN and CNA involved in the transfer were unaware of the proper transfer method required for the resident. The Assistant Director of Nursing acknowledged that not using the correct transfer mode could contribute to the injury. The facility's initial investigation confirmed that the resident's leg twisted during the transfer, leading to the fracture. The facility's policy on the use of sit-to-stand lifts was not adhered to, resulting in the resident's injury and subsequent hospitalization for surgical repair of the fracture.
Improper Food Labeling and Storage in Facility Kitchen
Penalty
Summary
The facility failed to properly label, date, seal, and store food items in the kitchen, affecting all residents receiving oral nutrition and foods prepared in the facility kitchen. During a tour of the facility kitchen, several deficiencies were observed, including unlabeled and undated food items such as ground ham, sliced cheese, and processed oven-roasted turkey breast in the walk-in cooler. Additionally, in the dry storage area, there were opened and unsealed bags of sundried raisins, a 32-gallon bin of flour and oatmeal with a black/gray sticky substance on the lids, and a scooper lying face down on the wire shelving rack, not contained or covered. An opened and unsealed bag of potato chips, identified as staff food, was also found in the dry storage area, along with an expired 8.8-ounce bag of British Tea. The Dietary Manager confirmed that all food items in the kitchen should be labeled and dated to ensure food safety and prevent contamination. The manager acknowledged that expired items should be discarded to avoid potential health risks to residents. The facility's policies on storage of dry foods and date marking and labeling were not followed, as evidenced by the improper storage and handling of food items. The presence of staff food in the kitchen and the contamination risks posed by the unclean bins and improperly stored scooper further highlight the facility's failure to adhere to its own food safety protocols.
Failure to Provide Proper Catheter Care and Positioning
Penalty
Summary
The facility failed to provide appropriate catheter care for residents with indwelling urinary catheters and did not ensure that catheter collection bags were placed below the level of the bladder. This deficiency was observed in four residents (R33, R39, R68, and R122) out of a sample of 32. For instance, R122, who had multiple diagnoses including sepsis and a stage 4 pressure ulcer, was found with a detached catheter anchoring device and a soiled incontinence brief. The CNA providing care did not clean the catheter or secure the anchoring device. Similarly, R39, who had a clostridium difficile infection and pressure ulcers, had dry brown residue on his catheter and outer meatus area that was not cleaned during incontinence care by the CNA. R33, with a history of urinary tract infections, also did not receive proper catheter care during incontinence care by the CNA. Additionally, R68's catheter bag was observed on top of the mattress, causing urine to backflow into the tubing, which was acknowledged by both the LPN and ADON as improper practice that could lead to infections. The facility's policies on indwelling urinary catheterization were not followed, as evidenced by the improper placement of catheter bags and inadequate cleaning of catheters. The Assistant Director of Nursing confirmed that staff should clean the catheter from the tip to the base and ensure any residue is removed to prevent infections. The facility's policy also stated that the collection bag should always be placed below the bladder level to prevent urine backflow, which was not adhered to in the case of R68. These lapses in care and adherence to policy contributed to the deficiencies observed by the surveyors.
Failure to Obtain Physician Orders and Complete Self-Administration Assessments
Penalty
Summary
The facility failed to obtain physician orders for resident medications to be at the bedside and did not complete self-administration of medication assessments for three residents. During an initial tour, it was observed that one resident had two Albuterol Sulfate inhalers on his end table and stated that he prefers them in his room because it takes too long for nurses to administer them. This resident, who is cognitively intact with a BIMS score of 15, did not have a physician's order for the inhalers to be at the bedside, nor was there a self-administration assessment or care plan in place. Another resident was observed taking her morning medication pills without a nurse present, and an Albuterol Sulfate inhaler was found on her dresser. This resident, also cognitively intact with a BIMS score of 15, had multiple medication orders but no order to self-administer her medications. There was no self-administration assessment or care plan regarding self-administration of medications in her electronic medical record. An LPN confirmed that residents need to be watched while taking medications, especially those with dementia. A third resident's room was found to have an Albuterol Sulfate inhaler on the end table during an initial tour and a follow-up visit. This resident had a physician's order to self-administer the inhaler but lacked a self-administration assessment and care plan in her chart. The facility's policy requires an interdisciplinary team assessment and a physician's order for residents to self-administer medications, which was not followed in these cases.
Improper Linen Handling and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper handling of linens and hand hygiene, leading to potential cross-contamination. On multiple occasions, a CNA was observed throwing soiled sheets on the floor while making beds for residents. Additionally, the CNA did not perform hand hygiene or change gloves after providing perineal care, and continued to touch other surfaces and handle clean linens with the same gloves. This practice was confirmed by the CNA, who admitted that throwing linens on the floor was her usual practice and that she would later pick them up and dispose of them in a plastic bag in the linen room. Another CNA was observed placing a soiled incontinence cloth pad directly on the floor while providing incontinence care to a resident. The CNA then walked down the hallway with the unbagged soiled pad for disposal in the soiled utility room. The Regional Nurse Consultant and the Assistant Director of Nursing confirmed that soiled linens should never be placed directly on surfaces like the floor and should be bagged immediately to prevent contamination. The facility's guidelines for linen handling and incontinence care were not followed, leading to these deficiencies.
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A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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