Metropolis Rehab & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Metropolis, Illinois.
- Location
- 2299 Metropolis Street, Metropolis, Illinois 62960
- CMS Provider Number
- 145813
- Inspections on file
- 36
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 36 (1 serious)
Citation history
Health deficiencies cited at Metropolis Rehab & Hcc during CMS and state inspections, most recent first.
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 type 2 DM had physician orders for sliding-scale insulin lispro with instructions to call the provider for blood glucose values over 400 mg/dL. On one occasion, the resident’s morning blood glucose was not obtained at the ordered time, later registered as “HI” (>600 mg/dL) on the glucometer, and remained “HI” an hour after 20 units of insulin were given, yet the RN delayed contacting a provider for about two hours while continuing a late med pass and seeking contact information. The medical director stated he expected immediate notification for a “HI” reading and that repeat “HI” after insulin should prompt ER transfer, and the facility’s policy and glucometer guide both required immediate provider contact for such results. On another day, the same resident’s blood glucose readings of 411 mg/dL and 434 mg/dL were not checked or treated until several hours after the scheduled times, with insulin doses and provider notification delayed, contrary to orders and DON expectations for timely BG checks, insulin administration, and prompt MD notification for values above the set threshold.
Surveyors identified multiple medication administration errors and documentation issues affecting several residents. One resident with insomnia and diabetes reported not receiving a prescribed hypnotic, while pharmacy records showed limited deliveries of both the hypnotic and an oral antidiabetic, despite the MAR reflecting continuous administration and concurrent rising blood glucose levels. Another resident with diabetes had sliding-scale insulin repeatedly given more than an hour late. A resident with heart failure and hyponatremia had ordered sodium chloride tablets, but an RN admitted morning medications were routinely late and another nurse, unsure of prior administration times, chose to skip certain midday doses, with the MAR showing a held dose. Additional residents experienced late administration of antiepileptic medications and discrepancies between observed pregabalin administration and MAR entries, along with lack of documented use of PRN analgesics. These events demonstrate widespread noncompliance with the facility’s own medication administration policy and the requirement to keep residents free from significant medication errors.
The facility failed to provide adequate CNA staffing on a hall with 13 residents, including individuals with hemiplegia and quadriplegia who required extensive ADL assistance and two-person or mechanical lift transfers. On multiple occasions only one CNA was assigned to this hall, and CNAs were sometimes sent home mid-shift based on census, leaving dependent residents waiting for help from staff on adjacent halls. One cognitively intact resident reported going about a week without a shower and only receiving a bed bath instead of the scheduled shower, with visible facial hair growth noted during observation. Another cognitively intact resident who required a Hoyer lift reported that evening transfers to bed were often significantly delayed because staff had to locate a second person to assist. Staff interviews, shower documentation, and staffing schedules corroborated that ADL care and transfers were postponed or not completed as scheduled due to chronic short staffing on this hall.
Surveyors identified an extremely high medication error rate when an RN was observed still passing morning medications several hours after their scheduled time and reporting that it was not realistic to complete all passes on time. Multiple residents with conditions such as epilepsy, chronic pain, depression, diabetes, heart failure, and atrial fibrillation received 8:00 AM medications much later in the day, and some ordered medications were not available or not documented correctly on the MAR, including PRN Tylenol given without corresponding documentation. Facility policy allowed only a one-hour window around scheduled times and required immediate documentation and physician notification when orders could not be followed, but observations and record review showed widespread late administration, omitted doses, and documentation discrepancies, resulting in a calculated medication error rate of 96.8%.
A resident with diabetes, polyneuropathy, and hemiplegia, but intact cognition, was care-planned to require staff assistance with bathing and transfers and was scheduled for twice-weekly showers. Surveyors found that a prefilled shower sheet for the resident’s scheduled shower remained incomplete, and the resident instead received a bed bath on a later date. On observation, the resident had noticeable chin whiskers and reported not having a shower or shaving for about a week, stating that staff only shaved the chin during showers and that no one had offered the scheduled shower. A CNA confirmed the practice of returning uncompleted shower sheets to a box for the next shift, and the DON acknowledged there was no formal policy for ADL showering/bathing, though showers were expected to be offered twice weekly.
A resident who was always incontinent of bowel and bladder and required substantial/maximal assistance with toileting hygiene received incontinence care during which an ADON and a CNA failed to follow basic infection control practices. The CNA threw the resident’s wet pants and urine-soiled brief on the floor, used a single wet washcloth to clean the buttocks without proper folding, placed soiled washcloths on the bedrail, and then handled the chuck and draw sheet without hand hygiene or changing gloves. The ADON used a wet washcloth to clean the genital area, placed a soiled washcloth on a chair, and assisted with applying a clean brief and repositioning and covering the resident without changing gloves or performing hand hygiene. Both staff handled room surfaces, linens, and soiled items while gloved and ungloved inappropriately, and the Administrator later confirmed there was no incontinence care policy in place, though staff were expected to perform hand hygiene and change gloves when moving from soiled to clean tasks.
The facility failed to provide enough evening staff to meet residents’ needs and respond to call lights in a timely manner. On one evening, a single LPN was observed passing medications on two halls while repeatedly stopping to answer multiple call lights and residents yelling for help, with only one CNA assigned to each hall and no other staff visible for extended periods. A resident remained in a recliner at the nurses’ station for a prolonged time before being taken back to her room, while other residents called out in the hallway. Alert and oriented residents reported waiting over 30 minutes for toileting and incontinence care and sometimes having to clean themselves when staff were unavailable. CNAs and the DON acknowledged that staffing is often limited to one CNA per hall due to call-ins or no-shows, making it challenging to complete required tasks such as answering call lights, toileting, changing, dining assistance, and showers in a timely manner.
Multiple residents were observed eating their evening meals without any drinks at their tables, with some having consumed a significant portion of their food before beverages were offered. A CNA on duty was unsure why the residents had no drinks and only offered a beverage after being prompted, while the DON and Dietary Manager later confirmed that all residents should receive drinks with meals and that CNAs are responsible for preparing and delivering them. Facility policy requires staff to monitor food and fluid intake and address inadequate fluid consumption, but this was not followed for these residents during the observed meal.
A resident with advanced dementia, multiple chronic conditions, and severe cognitive impairment had a care plan addressing agitation and fall risk, including use of a call light and keeping the resident in a wheeled recliner near the nurses’ station, but the plan lacked any focus or interventions specific to bedtime behaviors or refusals to go to bed. Staff observations showed the resident could not appropriately use a call light and was moved between her room and the nurses’ station when she resisted going to bed, while the care plan coordinator and DON acknowledged uncertainty about call light use and described strategies for managing the resident’s bedtime agitation that were not documented in the care plan. The resident’s family member reported not being contacted during an episode of refusal and expressed concern about prolonged sitting due to a pressure sore, confirming the resident was not receiving medication for agitation, highlighting that known behavioral patterns and agreed-upon approaches were not incorporated into the written care plan.
A resident with severe cognitive impairment and a history of repeated falls did not consistently receive prescribed fall prevention interventions, such as keeping the bed in a low position, using a fall mat, and having a nonskid mat in the wheelchair. Staff interviews revealed inconsistent knowledge of the resident's care plan, and observations showed that interventions were not reliably in place. The facility lacked a formal fall policy, and new interventions were not always added after each fall.
Multiple residents experienced a lack of dignity and respect, including being removed from activities for an intimidating meeting about food complaints, being put to bed without toileting assistance resulting in incontinence, and enduring long call light response times due to staffing shortages. Additionally, staff stored personal belongings in a resident's room without consent, despite available staff lockers. These actions and inactions led to residents feeling vulnerable, belittled, and humiliated.
Two residents experienced staff abuse, including an incident where an LPN spat in a resident's face following a verbal and physical altercation, and another case where a resident reported being verbally abused and demeaned by the same LPN. Multiple staff members witnessed or were informed of these events, but there was confusion and lack of proper documentation and follow-up regarding the allegations, resulting in insufficient protection and support for the affected residents.
The facility failed to accurately implement and document physician orders for medication and wound care for three residents. One resident with CHF and COPD did not receive updated medication orders or consistent breathing treatments after hospitalization, and staff failed to communicate changes or assess her condition properly. Another resident with lymphedema and wounds did not receive prescribed compression wraps or wound care due to supply shortages and lack of staff follow-through, and refusals of care were not reported to medical providers. These failures led to significant discomfort, anxiety, and hospitalization for the affected residents.
Several residents with complex medical conditions and significant weight loss did not consistently receive their prescribed diets, nutritional supplements, or appropriate portion sizes as ordered. Observations and interviews revealed that residents missed fortified foods, double portions, and supplements, and sometimes received food textures they could not safely consume. Staff and family confirmed these omissions, and some residents were left without needed eating assistance.
Three residents experienced periods without their prescribed pain medications due to issues with pharmacy supply, physician prescription practices, and regulatory requirements. Pain assessments documented untreated pain, and staff interviews confirmed that alternative medications were ineffective and that required documentation was incomplete.
Multiple residents did not receive their prescribed pain medications or other critical medications as ordered due to issues with prescription processing, pharmacy supply, and lack of authorized prescribers, resulting in untreated pain and delayed medication administration. Staff reported frequent late administration of medications, especially when agency nurses were present, and medications were often left unattended in resident rooms or common areas, violating facility and pharmacy policies for secure storage and administration.
Insufficient staffing led to multiple residents experiencing delays in toileting assistance, hygiene care, and medication administration. Residents with significant care needs were left waiting for extended periods, sometimes resulting in incontinence episodes and late delivery of essential medications. Staff and family members reported that the number of CNAs on duty was often inadequate, particularly during evening and night shifts, and agency staff sometimes left their posts, further impacting care.
The facility did not have any certified dietary staff or a Dietary Manager present in the kitchen, despite policy requiring at least one certified individual during food service hours. This deficiency was confirmed through staff interviews and record review, affecting all 74 residents.
The facility failed to provide adequate and competent dietary staff, resulting in repeated delays in meal service, cold and incomplete meals, and missed dietary accommodations. Residents, family members, and staff reported ongoing issues with meal timeliness and quality, especially after the dietary staff left and non-dietary staff had to prepare and deliver meals without proper resources or training.
The facility did not consistently provide meals and snacks at scheduled times or in accordance with resident preferences and care plans. Several residents, including those with diabetes, reported not receiving bedtime snacks, and staff confirmed that snacks were often unavailable due to the kitchen being locked or not leaving out snack carts. Meals were also frequently served late, with delays attributed to equipment and staffing issues, and there was no formal policy ensuring snack availability for residents who required them.
The facility did not ensure proper operation and monitoring of the dishwashing machine's sanitizer levels, as staff were unfamiliar with testing procedures and documentation was inconsistent or missing. This resulted in dishware not being properly sanitized, potentially affecting all residents.
Surveyors found that the facility did not keep residents warm after showers and failed to provide nail care upon request for several residents. Multiple residents and their families reported that shower rooms were cold, and residents were often returned to their rooms wet or inadequately dressed, causing discomfort. Staff confirmed that residents frequently complained about the cold environment, and one resident repeatedly requested nail care that was not provided. These actions and inactions show a lack of support for resident self-determination and personal care preferences.
Several residents with significant cognitive and physical impairments did not receive timely incontinence care or regular assistance with bathing and showering as required by their care plans. Due to insufficient CNA staffing, residents were left in soiled clothing and bedding, and scheduled showers or bed baths were frequently missed or undocumented. Staff and family interviews confirmed that care was delayed or omitted, and facility leadership could not account for the gaps in care or documentation.
Multiple residents did not receive menu items, condiments, or supplements as ordered, with staff and residents reporting frequent omissions and inconsistencies between dietary tickets and actual food served. Issues included missing butter, jelly, tortillas, desserts, and supplements, as well as a day when only peanut butter and jelly sandwiches and oatmeal were served due to a staff walkout and lack of kitchen resources. Staff interviews confirmed ongoing problems with missing items and late meal service.
Multiple residents, all alert and oriented, reported receiving cold, burnt, or unappetizing food, including cold coffee, hard toast, and burnt sausage. Surveyors confirmed these complaints by measuring food temperatures below the facility's preferred minimum and observing poor food quality. Staff and family members corroborated ongoing issues, citing insufficient kitchen staffing and supplies, especially on evenings and weekends.
Several residents with complex medical needs did not receive food items according to their documented preferences and dietary restrictions, with missing substitutions, delayed service, and incorrect items provided. Staff and resident interviews revealed that dietary staff shortages, supply issues, and poor kitchen conditions led to non-dietary staff preparing limited meal options, resulting in missed supplements and incomplete trays. The facility's own policies for honoring resident preferences and care plans were not followed during this period.
Several residents who were dependent and incontinent did not receive the correct size or type of incontinence supplies due to repeated shortages. Staff reported using smaller or larger briefs, pull-ups instead of briefs, and makeshift alternatives like pillowcases and blankets when standard supplies were unavailable. These shortages affected residents with significant cognitive and physical impairments, leading to discomfort, leaks, and soiled bedding. Staff consistently reported the issue to administration, but the problem persisted over several weeks to months.
A resident with multiple medical and psychiatric diagnoses reported to CNAs that an LPN was verbally abusive, including yelling and making derogatory remarks. The initial CNA did not report the allegation to the Administrator, and although another CNA claimed to have reported it, both the Administrator and DON were unaware of the abuse allegations until informed by a surveyor. The facility's policy requiring immediate reporting of abuse was not followed, and the incident was not investigated until after surveyor intervention.
A resident with multiple medical and psychiatric diagnoses reported verbal abuse by an LPN, including being called 'crazy' and other upsetting remarks. Multiple CNAs and another resident confirmed the complaints, but the administrator and DON stated they were unaware of specific allegations. The facility did not document a care plan focus on abuse, failed to thoroughly investigate the reports, and did not complete required grievance follow-up, resulting in a deficiency.
Several residents with complex medical needs experienced repeated late administration of medications, including insulin and other critical drugs. Staff interviews revealed that high workload, interruptions for resident care, and unfamiliarity with residents contributed to these delays. Facility policy required timely medication administration, but this was not consistently followed.
A resident with a stage 4 pressure ulcer and severe malnutrition did not receive physician-ordered dietary supplements for wound healing. Despite clear orders and care plan interventions, the resident missed prescribed fortified foods, and staff interviews revealed that dietary staff often failed to read supplement instructions on meal tickets or provide requested items, citing time constraints and unavailability.
A resident with a history of falls and requiring assistance for toileting and transfers did not have access to a working call system in the bathroom for approximately two weeks. Staff were aware of the issue but delayed notifying administration and higher-level maintenance, and there was no policy in place for call light systems. The facility's outdated call system further contributed to the deficiency, and the resident's care plan specifically required a functional call light within reach.
Floors in hallways and the dining room were observed to have dried spills, sticky substances, and debris over several days, with staff and a family member confirming that cleanliness had declined due to housekeeping staff shortages and a broken floor cleaning machine. Housekeeping routines were reduced, and common areas were not cleaned daily as required, resulting in unsanitary conditions throughout the facility.
Two residents with cognitive and physical impairments were subjected to sexual and physical abuse by another resident with behavioral issues. In one incident, a female resident was groped in the dining room, and in another, a resident was struck on the head. Both incidents were witnessed by staff and the administrator, and were substantiated through investigation and interviews. The facility's abuse policy prohibits such actions, but these events occurred despite the policy.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility failed to ensure adequate safeguards against physical, mental, and sexual abuse, physical punishment, and neglect by any person.
A resident with multiple chronic conditions had a signed POLST form indicating a desire for full CPR, but the EHR and order summary incorrectly documented the resident as DNR. The administrator confirmed the inconsistency, which was contrary to facility policy requiring accurate code status documentation.
A resident with severe cognitive impairment and feeding difficulties did not receive the ordered ice cream supplement with meals for two days due to a supply shortage. Staff were unclear about appropriate substitutes, and the dietary director confirmed that fortified pudding should have been provided but was not. The resident's family also observed the missing supplement during meals.
A CNA failed to follow infection control protocols during urinary catheter care for a resident with severe cognitive impairment and multiple medical conditions. The CNA did not perform hand hygiene or change gloves at required times, handled multiple surfaces with contaminated gloves, and returned supplies from the resident's room to the hallway supply cart without proper precautions. The facility's policy required standard precautions and hand hygiene, but these were not followed during the observed care.
The facility failed to prevent falls and elopement for residents with complex medical histories and cognitive impairments. One resident fell from a chair, sustaining severe injuries, while another fell from bed during care, resulting in lacerations. Additionally, a resident with a history of elopement left the facility unnoticed. These incidents highlight inadequate supervision and ineffective implementation of care plans.
The facility failed to maintain a clean and homelike environment for three residents, as reported by residents, family, and staff. A resident reported overflowing trash and unclean surfaces, corroborated by family and staff observations. Another resident noted dust and mold-like substances in her room, requiring her to request cleaning. Staff confirmed issues with housekeeping, including overflowing trash and dirty floors, despite the facility's cleaning procedures.
A resident with cerebral palsy and diabetes type 2 did not receive the required twice-weekly showers, as documented in their care plan. Despite needing assistance, the resident only received one shower per week on several occasions. Interviews with family and CNAs highlighted inconsistencies in the shower schedule, and the facility lacked policies on bathing and ADL care, contributing to the deficiency.
A resident with Alzheimer's and mobility issues experienced multiple falls due to self-transfers. Despite a facility policy requiring updates to care plans after falls, no new interventions were added for several incidents. The RN confirmed the care plan was not updated as required.
A resident with a Foley catheter did not receive catheter care according to facility standards. The CNA failed to separate the labia or cleanse the urinary meatus during the procedure, contrary to the care plan and facility guidelines. The resident's care plan emphasized catheter care every shift and monitoring for UTI symptoms. The CNA acknowledged the oversight, attributing it to nervousness.
A resident with a history of cerebral infarction and gastrostomy status was not administered tube feeding according to physician's orders. The prescribed rate was 40 ml per hour, but observations showed the feeding pump infusing at 30 ml per hour. Staff were unable to recall the correct order, and the facility's protocol for verifying caloric content was not followed.
Two residents' insulin vials were found open without opening dates, violating medication storage protocols. An LPN confirmed the issue, necessitating disposal and replacement of the vials. The facility's policy mandates proper labeling and disposal of insulin after 28 days.
A resident requiring peritoneal dialysis was admitted to the facility without necessary supplies, and the staff were not adequately trained to assist. The resident missed dialysis treatments, leading to confusion and lethargy, and was eventually hospitalized and switched to hemodialysis.
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 Timely Notify Provider and Follow Orders for Critically High Blood Glucose
Penalty
Summary
The deficiency involves the facility’s failure to notify a medical provider in a timely manner of critically elevated blood glucose levels for one resident with type 2 diabetes mellitus. The resident was admitted with a diagnosis of type 2 diabetes and had a care plan intervention to receive diabetes medication as ordered and to be monitored for effectiveness and side effects. The physician’s order for insulin lispro (Humalog) specified a sliding scale with instructions to call the physician if the blood glucose was over 400 mg/dL, to be given subcutaneously before meals and at bedtime. On the morning in question, the resident’s blood glucose was not obtained at the ordered time, and the sliding scale insulin was not administered as ordered. According to the electronic medical record, a progress note later documented that the resident’s blood glucose was greater than 600 mg/dL and that 20 units of Humalog were given at that time, consistent with the highest dose on the sliding scale. A subsequent nursing progress note documented that the resident had hyperglycemia issues that day, with a blood glucose reading of greater than 600 at approximately 10:47 a.m. and again greater than 600 at approximately 11:57 a.m. The nurse reported that she did not contact a provider until about two hours after the initial high reading, after first attempting to obtain contact information for the telemedicine group. The provider’s progress note confirmed that nursing notified him two hours after the initial report of a blood glucose over 600 and that the blood sugar remained critically elevated when rechecked. In interviews, the nurse stated she was still passing 8:00 a.m. medications late, that she knew the glucometer reading of “HI” meant the blood glucose was over 600, and that she administered the highest dose on the sliding scale without immediately contacting a provider because the resident did not exhibit signs or symptoms of diabetic ketoacidosis. She also stated she had to find out how to contact a medical provider and called as soon as she could, approximately two hours later. The medical director stated he expected staff to contact a medical provider within 15 minutes when a glucometer reads “HI,” that a repeat “HI” reading after insulin treatment should result in the resident being sent to the emergency room, and that staff should call 911 if they did not know how to reach a provider. The facility’s policy on significant condition change required practitioner notification for abnormal blood glucose results above set parameters, and the glucometer user guide instructed staff to contact a physician or healthcare professional immediately if a repeat test still read “HI.” Additional documentation showed other instances of delayed blood glucose monitoring and insulin administration for the same resident. On another date, the medication administration audit showed that an 8:00 a.m. blood glucose check and insulin lispro dose were not administered until after noon, and an 11:00 a.m. blood glucose check and insulin dose were also delayed until after noon. The resident’s blood glucose readings at those times were 411 mg/dL and 434 mg/dL, and the nurse reported administering 20 units of insulin for each reading because it was the highest dose on the sliding scale. The DON stated she expected staff to obtain blood glucose readings and administer medications as ordered, to check blood glucose prior to the resident eating, and to contact a medical provider as soon as possible when blood glucose exceeded the ordered threshold for notification. These actions and inactions demonstrate that the facility did not follow physician orders, internal policies, or device instructions regarding timely monitoring, treatment, and provider notification for critically abnormal blood glucose values.
Multiple Medication Administration Errors and Late or Missed Doses Across Several Residents
Penalty
Summary
The deficiency involves multiple failures in medication administration and documentation that resulted in residents not being free from significant medication errors. One resident with insomnia, adult failure to thrive, and type 2 diabetes with polyneuropathy had physician orders for Belsomra at bedtime for insomnia and glyburide daily for diabetes. The resident reported not receiving her sleeping medication the prior week, stating she could not fall asleep, lay awake all night, and felt exhausted the next day. Pharmacy records showed Belsomra was delivered in limited quantities on specific dates and glyburide was only partially supplied due to insurance coverage, yet the Medication Administration Records (MARs) documented that both medications were administered daily over periods when the medications were not available in the building or in the emergency kit. During this same period, the resident’s blood glucose readings, which had previously fluctuated within a lower range, began to rise and remained consistently elevated. Another resident with type 2 diabetes had an order for insulin lispro on a sliding scale to be given subcutaneously before meals and at bedtime. Audit reports for a defined period showed that multiple doses scheduled for morning, late morning, and evening were administered more than an hour late on several days. A separate resident with heart failure, atrial fibrillation, and hypertension had an order for sodium chloride tablets to be given three times daily with meals. On the day of observation, the RN responsible for the 8:00 AM medication pass stated she never had medications administered on time and that it was not realistic to complete all medication passes due to the number of residents. She was still passing 8:00 AM medications late in the morning, and another nurse who took over her cart later stated she did not know when earlier doses had been given and decided that multiple midday doses for medications ordered three or four times daily would have to be skipped, acknowledging this would result in more medication errors. The MAR for the resident on sodium chloride showed the noon dose held with a code indicating “Hold – See Progress Notes,” and lab results around that time documented a low sodium level. Additional errors were observed with other residents. One resident with chronic pain, low back pain, and recurrent depressive disorders had an order for pregabalin three times daily for nerve pain. The nurse was observed administering pregabalin at a time corresponding to the 2:00 PM dose, but the MAR for that dose was marked as held with a “Hold – See Progress Notes” code, and there was no documentation that as-needed Tylenol ordered for mild pain had been given that day. Another resident with major depressive disorder, schizophrenia, and epilepsy had orders for lamotrigine, levetiracetam, and topiramate to be administered at 8:00 AM, yet these medications were observed being given late in the morning instead of at the scheduled time. The facility’s medication administration policy required medications to be recorded immediately after ingestion, required physician notification when orders could not be followed, and required checking physician orders against the MAR to assure proper administration, but the observed practices and documentation did not align with these requirements across multiple residents and medications. A further issue involved the facility’s own staff statements about systemic timeliness problems. The RN passing morning medications openly stated that medications were never administered on time and that there were no limits on how many residents a nurse could have, making it unrealistic to complete medication passes as scheduled. Another nurse, upon assuming responsibility for the medication cart mid-pass, expressed uncertainty about when earlier doses had been administered and indicated that, due to the lateness of the morning pass, she would skip certain scheduled doses for medications ordered multiple times per day. These statements, combined with the documented late administrations, held doses, and MAR entries indicating medications were given when pharmacy records showed they were not available, demonstrate a pattern of noncompliance with the facility’s own medication administration policy and the requirement to ensure residents are free from significant medication errors. The cumulative findings across these residents show that medications were not consistently available, were administered late, were skipped without clear clinical documentation, or were inaccurately documented as given. Residents with conditions such as diabetes, insomnia, epilepsy, chronic pain, and electrolyte abnormalities were directly affected by these practices. The facility’s policy expectations for timely administration, accurate documentation, and prompt physician notification when orders could not be followed were not met in these instances, leading to the cited deficiency in ensuring residents are free from significant medication errors.
Insufficient CNA Staffing Resulting in Missed ADLs and Delayed Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient CNA staffing to meet residents’ ADL needs, including bathing, grooming, and timely transfers, for dependent residents on the 100 hall. One resident (R9), cognitively intact with hemiplegia and an ADL self-care performance deficit, was care planned to require one staff for bathing and two staff for transfers. CNA staff reported that they were sometimes assigned alone to the hall where R9 resided and had to wait for staff from other halls to assist with residents requiring mechanical lifts or two-person assists. Staffing records showed that on multiple dates only one CNA was scheduled for the hall, and CNAs were sometimes sent home mid-shift due to census. The DON confirmed there was no facility policy for showering/bathing and stated that showers should be offered twice weekly per the Shower List. R9 reported that she had not received a shower for about a week and that when staffing was insufficient, she received a bed bath instead of a shower, although she preferred showers. She stated that staff only shaved the whiskers on her chin when she was in the shower, and at the time of observation she had approximately 0.5-inch whiskers on her chin. R9 said her scheduled shower day had passed without anyone offering a shower, and that a CNA later provided a bed bath. Documentation on the Skin Monitoring: Comprehensive CNA Shower Review sheets showed that R9 received a bed bath on one date, a shower on another, and then a bed bath on a date that had been scheduled for the previous day, indicating delays in providing scheduled bathing. Staff interviews indicated that shower sheets were prefilled with resident names and shower days, and if showers were not completed, the sheets were placed back in the box for the next shift, further reflecting that ADL care was deferred when staffing was limited. Another cognitively intact resident (R14), admitted with quadriplegia and cord compression and care planned to require two staff and a mechanical lift (Hoyer) for transfers, reported that he preferred to stay in his wheelchair during the day but that at night it was sometimes very late before staff could find someone to help transfer him to bed, sometimes as late as 10:00 PM. On one evening, an agency CNA assigned as the only CNA on the hall where R9 and R14 resided stated she had been told another CNA would arrive later to help with residents needing two-person or mechanical lift transfers, but no additional CNA arrived. As a result, all residents requiring two-person assistance remained up and had to wait until CNAs from an adjacent hall could assist. Staff, including an LPN, stated that the hall was too heavy for one CNA due to multiple residents requiring mechanical lifts and two-person assists, and that when a single CNA took a resident to the shower, the nurse was left to answer call lights for the hall, which was not always possible while passing medications or handling emergencies. These observations and interviews demonstrate that the facility did not consistently provide enough staff to meet the ADL and transfer needs of dependent residents on the 100 hall.
Extremely High Medication Error Rate Due to Late and Omitted Medication Administration
Penalty
Summary
The deficiency involves a failure to ensure medications were administered within ordered times, resulting in a calculated medication error rate of 96.8% (30 errors out of 31 opportunities) during a medication pass. On the survey date, an RN (V4) reported she was still passing 8:00 AM medications at 10:51 AM and stated she never had medications administered on time, noting there was no limit on how many residents a nurse could have and that it was not realistic to complete all medication passes on time. The facility’s policy allowed medications to be given one hour before or after the scheduled time, and anything outside that window was considered a medication error. For one resident with major depressive disorder, schizophrenia, and epilepsy, the RN was observed at 11:21 AM administering multiple medications (lamotrigine, levetiracetam, risperidone, sennosides-docusate, and topiramate) that were ordered to be given at 8:00 AM. For another resident with chronic pain due to trauma, low back pain, and recurrent depressive disorders, the RN was observed at 11:33 AM administering several 8:00 AM medications (amlodipine, pregabalin, sertraline, aspirin, docusate, dorzolamide, and Tylenol), while also stating that ordered 8:00 AM medications (esomeprazole, fluticasone nasal spray, and a multivitamin with iron) were not available to administer. The MAR showed Tylenol as a PRN medication with no documentation it had been given that day, despite being administered during the observation. For a resident with type 2 diabetes, metabolic encephalopathy, and hypertension, the RN was observed at 12:14 PM administering multiple medications ordered for 8:00 AM (including diltiazem, Lasix, Synthroid, magnesium oxide, metformin, Plavix, pravastatin, sodium chloride, duloxetine, and iron sulfate) and reported that folic acid, also ordered for 8:00 AM, was not available. Another resident with heart failure, atrial fibrillation, and hypertension was observed at 11:51 AM receiving several medications ordered for 8:00 AM (Eliquis, enalapril, ferrous gluconate, omeprazole, potassium, and sodium chloride with meals). The facility’s medication administration policy required medications to be recorded immediately after ingestion and required nursing staff to notify the physician if orders could not be followed or if medication errors occurred, and to ensure the MAR and physician orders matched for proper administration. The observations, interviews, and record reviews documented that morning medications were administered significantly later than ordered and that some ordered medications were not available or not documented as given, contributing to the high medication error rate.
Failure to Provide Scheduled Bathing and Grooming for Dependent Resident
Penalty
Summary
The facility failed to provide ADL care, specifically bathing and grooming, as care-planned for a dependent resident. The resident was admitted with diagnoses including insomnia, adult failure to thrive, and type 2 diabetes mellitus with diabetic polyneuropathy, and had a BIMS score of 15 indicating intact cognition. The care plan documented an ADL self-care performance deficit related to activity intolerance and hemiplegia, with interventions stating the resident required one staff member for bathing and two staff for transfers. The shower list showed the resident was scheduled for showers on the evening shift twice weekly, on Mondays and Thursdays. CNA documentation showed the resident received a bed bath on 3/9/26, a shower on 3/11/26, and a bed bath on 3/17/26, even though the 3/17/26 bed bath was recorded as due on 3/16/26. On the day of surveyor observation, a CNA reported that shower sheets are prefilled with resident names and shower days, and if staff do not complete a shower, they place the sheet back in the box for the next shift to complete. The CNA stated that when she arrived for her shift, the resident’s shower sheet dated 3/16/26 was still in the box, and she then assisted the resident with a bed bath on 3/17/26. When observed in bed later that morning, the resident had approximately 0.5-inch whiskers on the chin and reported it had been a week since receiving a shower and that staff only shaved the chin during showers, so shaving had also not been done for a week. The resident stated that the scheduled shower day had passed without anyone asking about going to the shower and that a bed bath was provided instead. The DON stated there was no facility policy for ADL care for showering/bathing and that showers or baths should be offered twice a week per the shower list.
Failure to Follow Infection Control Practices During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to follow accepted infection prevention and control practices during incontinence care for one resident. The resident had diagnoses including need for assistance with personal care, reduced mobility, and cognitive communication deficit, and was documented on the MDS as always incontinent of bowel and bladder and requiring substantial/maximal assistance with toileting hygiene. During an observation of incontinence care, the resident’s pants and a urine-soiled incontinence brief were removed and thrown onto the floor. A CNA used a wet washcloth to clean the resident’s buttocks in a circular motion without folding the cloth between wipes, then placed the soiled washcloth on the bedrail with another wet washcloth. The CNA then touched the chuck and draw sheet under the resident to assist with repositioning without performing hand hygiene or changing gloves. The ADON used a wet washcloth handed to her by the CNA to clean the resident’s mons pubis, groin folds, scrotum, and penile shaft, and partially retracted the foreskin without fully revealing the coronal ridge before wiping around the glans penis and returning the foreskin. The ADON then placed a soiled washcloth on a chair in the resident’s room and, without performing hand hygiene or changing gloves, assisted in applying a clean incontinence brief and repositioning and covering the resident, touching the chuck, draw sheet, top sheet, and blanket. The CNA collected the soiled washcloths, pants, and incontinence brief, placed them in plastic bags, and handled the door knob and soiled linen hamper while removing gloves in stages, then pushed the soiled linen hamper down the hallway. The ADON removed gloves, opened the bathroom door by the knob, and washed her hands afterward. The Administrator later stated the facility did not have an incontinence care policy, and acknowledged that staff were expected to perform hand hygiene and change gloves when going from soiled to clean.
Insufficient Evening Staffing Led to Delayed Call-Light Response and Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on the evening shift to meet residents’ needs and to ensure timely response to call lights. On the night of 02/27/26, there were 62 residents in the facility, with one CNA assigned to the 100 hall and one CNA to the 200 hall, and one LPN (V5) passing medications on both halls. Observations between approximately 9:00 PM and 10:07 PM showed repeated instances of call lights activating and residents yelling for assistance while V5 attempted to complete a medication pass. V5 repeatedly had to stop preparing and administering medications to respond to call lights and residents calling out, as no other staff were visible on the halls during much of this time. One resident (R1) was observed asleep in a wheeled recliner at the nurses’ station at 9:04 PM and was not taken back to her room until approximately 9:50 PM. Additional observations documented multiple residents yelling for a nurse or CNA and several call lights going unanswered for periods while V5 continued to juggle medication administration and responding to calls. Around 9:57 PM and again at 9:59 PM and 10:07 PM, two call lights were activated at a time and residents, including R5, were heard yelling in the hallway for help and to talk to someone. R1 was taken to her room by CNA V6 around 9:50 PM and then brought back to the nurses’ station shortly thereafter, with her clothes changed and mumbling to herself. Staff interviews confirmed that on 02/27/26 there was one CNA on each hall, and CNAs had to go back and forth between halls to assist each other, including for residents requiring two-person assistance. Resident and staff interviews, along with staffing records, further supported that staffing levels were insufficient at times to meet residents’ needs in a timely manner. One resident (R6), who was alert and oriented, reported having to wait over 30 minutes at times for assistance with toileting and changing, and stated that staff sometimes did not have time to provide a bed bath, leading him to use wipes to clean himself. Another resident (R8), also alert and oriented, reported having to wait quite a while in the afternoon and evening for help. A grievance form for R6 dated 02/17/26 documented a concern about call lights not being answered timely. CNAs V6 and V7 stated that having only one CNA on each hall can make it challenging to answer all call lights and meet care needs promptly, especially when residents such as R1 and R5 or those requiring two-person assists need more attention. The DON (V2) and Regional Nurse (V17) acknowledged that staffing is based on census, that there are times with only one CNA per hall due to call-ins or no-shows, and that this situation can be very challenging for timely completion of required duties such as answering call lights, toileting, changing, dining assistance, and showers.
Failure to Provide Drinks With Meals to Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide drinks with meals consistent with resident needs and preferences and sufficient to maintain hydration. During an evening meal observation on 03/01/26 at 5:28 PM, four residents (R1, R2, R3, and R4) were seated in the dining room with their meals in front of them but had no drinks at their tables. At that time, R2 and R3 had already eaten approximately one third of their food, and R4 had eaten approximately three quarters of his food, all without drinks present. By 5:44 PM, all four residents were still eating and still did not have drinks in front of them. At 5:45 PM, a CNA (V3) stated she did not know why the four residents did not have drinks and suggested they may have come late, and only then asked one resident (R2) if she wanted something to drink, to which R2 responded affirmatively. Later, the DON (V2) stated that all residents should receive a drink with their meals regardless of arrival time or table changes. The Dietary Manager (V4) confirmed that all residents should receive drinks with their meals, and that CNAs are responsible for preparing and delivering drinks, while the kitchen prepares beverage pitchers. The facility’s undated “24 hour Dining” policy states that staff will monitor residents’ food and fluid intake for adequate consumption and that any staff member observing inadequate fluid intake at meals will refer the resident to the DON and Dining Services Manager for follow-up, but this monitoring and provision of fluids did not occur for the four observed residents during the meal in question.
Failure to Update Care Plan for Cognitively Impaired Resident’s Bedtime Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to update and implement an adequate care plan addressing a cognitively impaired resident’s behaviors related to going to bed and remaining in bed. The resident was admitted with Alzheimer’s disease with late onset, dementia, COPD, acute and chronic respiratory failure with hypoxia, pleural effusion, abnormal posture, and low BMI, and was documented on the MDS as severely impaired in decision-making. The care plan identified impaired cognitive function/dementia and behavior problems with agitation, including physical and verbal aggression and rejection of care, with interventions such as offering to return later, calling family, and redirecting the resident. The resident was also care planned as at risk for falls with interventions including ensuring the call light was within reach, use of a nontraditional call light in a recliner, and a directive that when in a wheeled recliner the resident should be out of her room. However, the care plan did not include any focus area or interventions specifically addressing the resident’s behaviors around going to bed, methods to get her to go or stay in bed, or what to do if she refused. Surveyor observations and staff interviews showed that the resident’s actual needs and staff practices were not reflected in the written care plan. On one evening, the resident was observed asleep in a wheeled recliner at the nurses’ station, then taken to her room by a CNA and shortly thereafter brought back to the nurses’ station after refusing to go to bed. Multiple CNAs stated they did not think the resident could use a call light appropriately, and the care plan coordinator acknowledged not knowing if the resident could use a call light, while also stating that if the resident was in her recliner she was not to be left unattended and should be brought to the nurses’ station. The DON reported that the team had discussed strategies such as putting the resident to bed when she appeared tired, calling her daughter if she became agitated, and returning her to the nurses’ station if she remained agitated, but also stated this information should be on the care plan and that the resident could not cognitively use a call light or be left unattended in her room in the recliner. The resident’s family member reported not being called that night and expressed a desire for staff to make a real attempt to get the resident to lie down due to a pressure sore and prolonged sitting, while confirming the resident was not on medications for agitation. These facts demonstrate that the care plan was not updated to reflect known behavioral patterns, limitations in call light use, and agreed-upon approaches to bedtime care.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to provide and implement adequate preventative measures and interventions to prevent falls for a resident with a history of repeated falls and multiple complex medical diagnoses, including Alzheimer's disease, dementia, cirrhosis, heart failure, and reduced mobility. The resident was assessed as having severely compromised cognition and required partial to moderate assistance with transfers and ambulation. Despite being identified as a high fall risk, the care plan interventions were inconsistently implemented, and several falls occurred without new or revised interventions being added to the care plan after each incident. Documentation revealed that the resident experienced multiple falls over a period of time, some of which resulted in injuries such as abrasions and skin tears. Several falls were unwitnessed, and in some cases, the resident was unable to recall or communicate the circumstances of the fall. Observations by surveyors found that prescribed interventions, such as keeping the bed in a low position, using a fall mat, applying bright colored tape to the wheelchair, and providing a nonskid mat in the wheelchair, were not consistently in place. Additionally, the resident's call light was not always within reach, and the resident did not use it even when prompted, despite this being an intervention listed in the care plan. Interviews with staff indicated a lack of awareness and inconsistent knowledge of the resident's fall interventions. Some staff were unaware of specific interventions, and others noted that the resident rarely used the call light. The Director of Nursing confirmed that after each fall, a root cause analysis and new intervention should be implemented, but the care plan and records showed that this was not consistently done. Furthermore, the facility did not have a formal fall policy in place, contributing to the lack of consistent preventative measures and supervision for the resident.
Failure to Honor Resident Rights and Dignity
Penalty
Summary
The facility failed to honor residents' rights to dignity, respect, and self-determination in several ways, as evidenced by multiple incidents involving six residents. One cognitively intact resident was removed from a group activity and brought into a meeting with four department heads without prior notice or the opportunity to have a family member present. The meeting was prompted by the resident's voiced concerns about food quality and a family member's social media post about the food. The resident reported feeling intimidated and uncomfortable during the meeting, and staff acknowledged that the approach could have been perceived as intimidating. Documentation also showed that the resident did not initiate or sign a grievance form about the food, despite the form indicating otherwise. Another resident with severe cognitive impairment and dependent on staff for toileting was put to bed without being offered the opportunity to use the toilet, resulting in incontinence and soiled clothing and bedding. The CNA responsible stated that there was insufficient staff available to assist with toileting at the time, and the resident's private caregiver found the resident wet the following morning. Staff interviews confirmed that staffing shortages often led to delays in providing care, and the Director of Nursing acknowledged that this was unacceptable and that licensed nurses were expected to assist when needed. Additional residents reported long wait times for call lights to be answered, sometimes resulting in incontinence episodes. Staff and CNAs confirmed that frequent staffing shortages made it difficult to meet residents' needs in a timely manner. One resident also reported that staff stored their personal belongings in his room without his consent, which he found distressing. Staff admitted to using residents' closets for personal items despite the availability of staff lockers and break rooms, and facility leadership confirmed that this practice was inappropriate. Facility policies reviewed emphasized the importance of treating residents with dignity, respect, and privacy, but these standards were not consistently upheld.
Failure to Protect Residents from Staff Abuse and Inadequate Response to Allegations
Penalty
Summary
The facility failed to protect residents from staff abuse, as evidenced by two separate incidents involving two residents. In the first incident, a resident with severe cognitive impairment, legal blindness, and multiple medical conditions was involved in an altercation with an LPN. The resident, who is known to startle easily and exhibit physical aggression due to her blindness, was at the nurse's station when she began touching the LPN's personal items. The LPN responded by grabbing the resident's hands, leading to a physical exchange where the resident bent the LPN's thumb. The situation escalated verbally, and after the resident spat on the LPN, the LPN retaliated by spitting in the resident's face. Multiple staff members witnessed the event, and the resident was observed wiping her face and expressing distress immediately after the incident. In the second incident, another resident with a history of respiratory and cardiac issues, as well as dementia and anxiety, reported being verbally abused by the same LPN. The resident, who was alert and oriented at the time of the interview, described being called derogatory names and being told her symptoms were imaginary. She documented these statements and reported feeling scared and upset. Several CNAs corroborated that the resident had reported being verbally mistreated and was visibly distressed, with one CNA stating the resident was crying. However, there was confusion and lack of clarity among staff and administration regarding the reporting and investigation of these allegations, with some staff stating they reported the abuse to supervisors, while others, including the DON and Administrator, denied receiving such reports or stated they were unable to investigate further due to lack of specific information. Documentation related to the grievances and follow-up was incomplete. A grievance form was filed by the resident regarding staff conduct, but it lacked specific details, and there was no evidence of consistent follow-up as indicated in the action plan. Progress notes and interviews revealed that the resident continued to express concerns about staff behavior, but the facility's documentation and response to these concerns were insufficient, with missing records of required follow-up meetings and unclear communication among staff regarding the allegations.
Failure to Implement Physician Orders and Provide Wound Care
Penalty
Summary
The facility failed to ensure that physician orders were accurate and implemented for residents following hospitalization and changes in condition, as well as failed to assess and treat lymphedema and wounds per physician orders for three residents. For one resident with a history of acute respiratory failure, COPD, heart failure, and other comorbidities, the facility did not update or implement new orders for furosemide (Lasix) and albuterol as prescribed upon discharge from the hospital. The resident's hospital records indicated a new diagnosis of congestive heart failure and a change in furosemide from as-needed to daily dosing, but the facility continued to administer the medication only as needed. Additionally, the resident's albuterol nebulizer dosage did not match the hospital's discharge instructions, and there was no documentation of a required follow-up physician visit. The resident repeatedly reported difficulty breathing and requested breathing treatments, which were not consistently provided according to orders, and staff failed to assess or respond appropriately to her complaints. Documentation was inconsistent and did not reflect the resident's actual condition, and the nurse practitioner was not notified of the new diagnosis or medication changes due to lack of communication and updates in the electronic health record. Another resident with lymphedema, reduced mobility, and CHF had physician orders for daily compression wraps, wound care, and use of a lymphedema pump. The facility failed to consistently perform and document wound and skin assessments, including measurements and descriptions of wounds, and did not monitor weights to track lymphedema. The resident reported that dressing changes and compression wraps were frequently not performed, sometimes due to lack of supplies such as ace wraps, and staff confirmed that wound care supplies were often unavailable. When the resident refused treatments because they were not performed as she preferred, staff did not notify the physician or nurse practitioner of these refusals, nor did they document or address the resident's requests for alternative treatments. The lack of proper wound care and monitoring led to the resident developing redness, swelling, and altered mental status, resulting in hospitalization for cellulitis and septic shock. Throughout the report, there were multiple instances where staff failed to follow the facility's own medication administration policy, which requires accurate documentation and implementation of physician orders, as well as prompt reporting of changes in condition. There was also a lack of a significant change in condition policy, and communication breakdowns between nursing staff, administration, and medical providers contributed to the deficiencies. The failures resulted in significant discomfort, anxiety, and adverse health outcomes for the residents involved.
Failure to Provide Prescribed Diets, Supplements, and Portion Sizes
Penalty
Summary
The facility failed to provide prescribed diets, nutritional supplements, and appropriate portion sizes according to approved menus for seven residents reviewed for weight loss. Multiple observations and record reviews revealed that residents did not consistently receive the dietary supplements, fortified foods, or double portions as ordered by their physicians and dietitians. For example, several residents did not receive fortified pudding, ice cream, or other supplements at meals, despite these being documented on their dietary tickets and care plans. In some cases, residents received food items that were not appropriate for their dietary needs, such as hard taco shells and churros for a resident without teeth, making it difficult or impossible for them to consume the food provided. Residents affected by these deficiencies had significant medical histories, including diagnoses such as Alzheimer's disease, dementia, Huntington's disease, severe protein calorie malnutrition, dysphagia, and chronic obstructive pulmonary disease. Many of these residents were severely underweight or had experienced notable weight loss, with body mass indexes (BMIs) well below healthy thresholds. Despite care plans and dietary orders specifying the need for additional nutrition, such as fortified foods, double portions, and specific supplements, these interventions were not reliably implemented. Family members and staff interviews confirmed that residents sometimes did not receive the prescribed supplements, and in some cases, staff were either unaware of the orders or reported that the supplements were unavailable. Direct observations during meal times further documented that residents were left without necessary assistance to eat, did not receive the correct food textures, and were not provided with the full portions or supplements as ordered. For example, residents requiring supervision or assistance with eating were sometimes left unattended, and those with orders for pureed or mechanical soft diets received foods that were not suitable for their swallowing abilities. These failures contributed to ongoing harm for residents who were already at risk due to their medical conditions and nutritional status.
Failure to Provide Timely Pain Medication for Residents
Penalty
Summary
The facility failed to provide appropriate pain management for three residents who required such services, resulting in periods where prescribed pain medications were not available or administered as ordered. One resident with severe cognitive impairment and a diagnosis of polyneuropathy had a physician order for hydrocodone-acetaminophen to be given as needed for pain. Documentation showed that this medication was not administered for several days, despite pain assessments indicating moderate pain levels. Staff interviews confirmed that the resident was out of pain medication for over a week, during which time alternative medications like acetaminophen were offered but did not relieve the pain. The resident was observed to cry in pain, and staff were unsure why the medication was unavailable. Another resident with multiple sclerosis and moderate cognitive impairment had a physician order for gabapentin to be administered at bedtime. Medication administration records indicated that the resident did not receive gabapentin for about a week, with staff noting that the resident cried at night due to untreated pain. The lack of medication was attributed to issues with obtaining prescriptions from the physician, and staff were unclear about the reasons for the delay. Pain assessments during this period showed low but present pain levels, and staff interviews confirmed the resident's discomfort during the time the medication was unavailable. A third resident with polyneuropathy and intact cognition had a physician order for Lyrica to be administered twice daily. Medication records showed multiple instances where the medication was not available and not administered, with staff documenting this using a specific chart code but failing to provide corresponding progress notes as required by facility policy. Pain assessments indicated that the resident experienced pain on several days when the medication was not given. Staff interviews revealed ongoing issues with medication availability, particularly for controlled substances, due to challenges with pharmacy supply, physician prescription practices, and regulatory requirements for controlled substances.
Failure to Ensure Medication Availability, Timely Administration, and Secure Storage
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered, and that medications were stored securely for multiple residents. Several residents did not receive their prescribed pain medications, such as hydrocodone-acetaminophen, gabapentin, and Lyrica, for extended periods due to issues with prescription processing, pharmacy supply, and lack of authorized prescribers for controlled substances. Documentation showed that residents experienced untreated pain, with pain assessments indicating moderate to severe pain levels during periods when medications were not available or administered. Staff interviews confirmed that residents were left without their pain medications for up to a week, and alternative medications like acetaminophen were ineffective in relieving their pain. In addition to pain medications, other routine and critical medications, including insulin and diuretics, were administered late on multiple occasions. Medication administration records and audit reports documented numerous instances where medications were given hours after the scheduled time. Staff attributed these delays to high workloads, interruptions during medication passes, agency staff unfamiliarity, and technical issues with electronic systems. Residents and staff reported that late administration was a recurring issue, particularly when agency nurses were on duty, and that this affected the timely management of conditions such as diabetes and heart failure. The facility also failed to maintain secure storage and administration of medications. Observations and staff interviews revealed that medications were left unattended on medication carts, in resident rooms, and in common areas such as the dining room. Medications were sometimes left for residents to self-administer without proper orders or assessments for self-administration capability. Facility policies and pharmacy procedures required medications to be stored securely and not left unattended, but these protocols were not consistently followed, as confirmed by multiple staff and resident accounts.
Failure to Provide Sufficient Nursing Staff Results in Delayed Care and Late Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents in a timely manner, as evidenced by multiple incidents involving delayed care, unmet toileting needs, and late medication administration. Several residents with significant cognitive and physical impairments, including those with dementia, incontinence, and mobility deficits, were not assisted promptly with toileting or hygiene, resulting in episodes of incontinence and prolonged exposure to urine and feces. Staff interviews confirmed that there were often not enough CNAs on duty, particularly during evening and night shifts, leading to delays in responding to call lights and providing necessary assistance. Family members and residents reported instances where residents had to wait extended periods for care, sometimes sitting in soiled clothing or bedding. Medication administration was also negatively impacted by insufficient staffing. Multiple residents received their medications, including critical diabetes and heart medications, late on several occasions. Nursing staff, including RNs and LPNs, reported that high workloads, the need to assist with direct care, and interruptions during medication passes contributed to these delays. Agency staff unfamiliar with residents and facility routines further exacerbated the problem, with some agency CNAs reportedly leaving their posts for extended periods during shifts. Facility records and staff schedules revealed that the number of CNAs on duty frequently fell below the facility's stated minimums, especially on night shifts, with as few as two or three CNAs responsible for up to 74 residents. The Director of Nursing acknowledged discrepancies in staffing records and confirmed that licensed nurses were expected to assist with direct care when CNA staffing was insufficient. However, this expectation did not consistently result in timely care for residents, as documented by both staff and resident accounts.
Lack of Certified Dietary Staff in Food Service Department
Penalty
Summary
The facility failed to employ certified dietary staff in the kitchen, as required by their own policy and regulatory standards. On the date of the survey, interviews with the cook and the administrator confirmed that there was no Dietary Manager currently employed, and none of the kitchen staff held a food manager certification. The previous Dietary Manager had left the facility approximately two weeks prior, and no current staff had obtained the necessary certification in the interim. The administrator acknowledged that no one in the kitchen was certified and that someone from an external dining service was handling ordering and menu planning, but this individual was not present at the facility daily. Observation and record review further confirmed that at the time of the survey, there were no certified dietary staff present or working in the kitchen. Facility documentation outlined a policy requiring at least one individual in the food service department to be certified in sanitation during hours of operation, with certification to be kept current and renewed as directed. Despite this policy, the facility did not have any certified staff available, potentially affecting all 74 residents residing in the facility.
Failure to Provide Sufficient and Competent Dietary Staff for Meal Service
Penalty
Summary
The facility failed to provide sufficient and competent dietary staff to safely and effectively carry out the functions of the food and nutrition service, as evidenced by repeated delays in meal service, inadequate meal preparation, and missing dietary accommodations. Observations showed that meal trays were not delivered in a timely manner, with breakfast and lunch service running significantly behind scheduled times. Food items were often served cold, missing condiments, and in some cases, were not prepared according to residents' dietary needs, such as pureed diets or supplements. The facility's own policy required meals to be served no more than 30 minutes after scheduled times, but this standard was not met on multiple occasions. Interviews with residents, family members, and staff confirmed ongoing issues with meal timeliness and quality. Residents reported receiving cold food, missing items, and frequent delays, sometimes waiting over an hour past scheduled meal times. Some residents received only peanut butter and jelly sandwiches and oatmeal for meals, and dietary tickets were not always followed, resulting in incorrect or incomplete trays. Family members and staff corroborated these accounts, noting that meal service was especially problematic after the dietary staff walked out, and that non-dietary staff had to step in to prepare and deliver meals, often without adequate training or resources. The administrator and other staff confirmed that all previous dietary staff left the facility, leading to a period where nurses and CNAs prepared meals. During this time, residents did not consistently receive required supplements or special dietary items, and meal service was late and incomplete. Staff also reported ongoing struggles with insufficient supplies and staffing, which continued to impact the quality and timeliness of meal service for all 74 residents in the facility.
Failure to Provide Timely Meals and Snacks per Resident Needs and Preferences
Penalty
Summary
The facility failed to ensure that meals and snacks were consistently available and served in accordance with residents’ needs, preferences, and care plans. Multiple residents, including those with diabetes and moderate cognitive deficits, reported not receiving bedtime snacks as documented in their care plans. Staff interviews confirmed that snacks were not always available, with some staff stating that the kitchen was locked after supper, preventing access to snacks for residents. Residents and their families also reported that snacks were not being distributed, and that residents who were unable to leave their rooms did not receive snacks at all. Additionally, the facility did not serve meals within the required timelines. Residents and family members reported that meals were frequently late, sometimes by over an hour, and that the timing of meal service was inconsistent. Observations confirmed that meal trays were not delivered to all areas in a timely manner, with some residents waiting significantly past scheduled meal times. Staff attributed these delays to issues such as broken kitchen equipment, lack of supplies, and staffing shortages. The facility administrator acknowledged that there was no formal snack policy and could not confirm that residents with diabetes received routine snacks as required. Staff interviews further revealed a lack of consistent process for providing snacks, with some staff unaware of procedures or not receiving education on snack distribution. The facility’s own policy outlined specific meal times, but these were not adhered to, as evidenced by both staff and resident accounts and direct observation of meal delivery times.
Failure to Maintain and Monitor Dish Machine Sanitizer Levels
Penalty
Summary
The facility failed to ensure proper functioning and monitoring of the dishwashing machine, which is necessary for the sanitation of dishware. During an interview, a dishwasher stated he was unfamiliar with the process for checking sanitizer levels and did not know where the test strips were located. When the test strips were found and used, they showed no color change, indicating that no sanitizer was present in the dish machine. Further observation revealed that there was no liquid in the line running from the sanitizer container to the dish machine, and attempts to purge the line were initially unsuccessful. Additionally, the dishwasher admitted to never documenting sanitizer readings on the dish machine log because the numbers did not make sense to him. The administrator was also unaware of when the dish machine was last checked or what the correct sanitizer reading should be. Review of the dish machine log showed inconsistent and potentially inaccurate documentation, with repeated entries of the same value and missing entries for several days. The facility's policy requires daily checks and proper documentation of sanitizer levels, which was not followed. At the time of the deficiency, 74 residents resided in the facility.
Failure to Maintain Resident Comfort and Provide Requested Personal Care
Penalty
Summary
Surveyors identified that the facility failed to honor and support resident self-determination by not keeping residents warm after showers and not providing nail care upon request for multiple residents. Observations revealed that shower rooms consistently measured around 71 degrees Fahrenheit, and staff were instructed not to adjust the thermostats. Several residents and their families reported that the shower rooms were cold, and residents were often returned to their rooms wet, inadequately dressed, or only covered by a towel, leading to prolonged discomfort. Staff interviews confirmed that residents frequently complained about the cold environment during and after showers, and that the shower chairs were uncomfortable, especially for those with pressure sores. One resident with significant medical issues, including dementia, pressure ulcers, and mobility deficits, reported receiving a cold shower late at night, being left with wet hair, and not being properly covered or dressed, resulting in her feeling cold all night. Family members corroborated these accounts, stating that complaints about the cold showers and improper handling had been communicated to facility administration multiple times. Other residents, including those with cognitive impairments and chronic illnesses, also expressed discomfort with the cold shower rooms and reported refusing showers to avoid being cold. Staff acknowledged that the shower rooms could be cold and that residents often voiced their discomfort. Additionally, the facility failed to provide timely nail care upon resident request. One cognitively intact resident repeatedly asked staff to trim his nails, which were observed to be long and dirty over several days. Despite reminders to both CNAs and LPNs, the resident's request was not fulfilled, and he stated that he avoided showers due to the cold, further impacting his ability to receive nail care. These failures demonstrate a lack of responsiveness to resident preferences and needs regarding personal care and comfort.
Failure to Provide Timely Incontinence Care and Assistance with ADLs
Penalty
Summary
The facility failed to provide timely incontinence care and adequate assistance with activities of daily living (ADLs), including showering and bathing, for six residents who required such support. Multiple residents with severe cognitive and physical impairments, including diagnoses such as neurocognitive disorder, dementia, hemiplegia, and muscle weakness, were documented as being dependent on staff for toileting hygiene and bathing. Care plans for these residents specified the need for regular incontinence checks, assistance with toileting, and scheduled showers or bed baths, yet these interventions were not consistently implemented. Observations, interviews, and record reviews revealed that residents were left in soiled clothing and bedding for extended periods due to insufficient staffing. Family members and staff reported that there were often not enough CNAs on duty to meet residents' needs, resulting in delays in providing incontinence care and missed opportunities for toileting. In several instances, residents were not offered or provided showers or bed baths for periods exceeding the facility's stated minimum frequency, and there was a lack of documentation to indicate that showers were refused or even offered. Staff interviews confirmed that short staffing was a persistent issue, making it difficult to complete scheduled care tasks, including two-hour bed checks and regular bathing. Documentation gaps were also identified, with missing or incomplete records for showers and refusals, and no facility policy in place for incontinence care or showering. Residents and their caregivers reported missed showers, prolonged periods without bathing, and inadequate assistance with toileting, all of which were corroborated by staff statements and review of care records. The facility's leadership was unable to explain the lapses in care or documentation, and acknowledged that the frequency of care provided did not meet the expected standards outlined in residents' care plans.
Failure to Follow Menus and Dietary Orders for Multiple Residents
Penalty
Summary
The facility failed to follow its posted menus and dietary orders for nine residents reviewed, resulting in multiple instances where residents did not receive the food items, condiments, or supplements as specified on their dietary tickets and care plans. Residents with various medical conditions, including chronic kidney disease, dementia, diabetes, malnutrition, and dysphagia, were affected. For example, several residents did not receive butter or jelly with their breakfast toast, corn tortillas, or butterscotch pudding with lunch, despite these items being listed on the menu and dietary tickets. In some cases, residents specifically expressed their desire for these missing items, but they were not provided. Interviews and observations revealed that the dietary staff did not consistently provide menu items as ordered, and there were reports of missing condiments, desserts, and even entire meal components. Staff and residents reported that the food served often did not match the dietary tickets, and that substitutions were not always made when items were unavailable. On one occasion, due to a staff walkout and lack of kitchen resources, residents were served peanut butter and jelly sandwiches and oatmeal instead of the planned menu, and some dietary supplements and double protein orders were not provided. Staff also reported ongoing issues with missing items and late food service following this event. The report includes statements from dietary staff, CNAs, and residents confirming that menu items were frequently omitted, and that communication between dietary and nursing staff was insufficient to ensure residents received their prescribed diets. The Registered Dietician stated that the menu should be followed and that substitutions of equal nutritional value should be made if items are unavailable, but this was not consistently done. The deficiency was observed through interviews, record reviews, and direct observation of meal service.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
Surveyors identified that the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for all 12 residents reviewed for food service. Multiple residents, all of whom were alert and oriented or cognitively intact, reported receiving cold, burnt, or unappetizing food on several occasions. Specific examples included cold coffee and French fries, burnt sausage, hard and dry toast, and oatmeal that was cold and congealed. Family members and staff corroborated these complaints, noting repeated issues with food being served cold or burnt, and a lack of condiments such as butter or jelly on trays. Direct observations by surveyors confirmed these reports. Food temperatures were measured using a calibrated thermometer, revealing that hot foods such as coffee, French fries, eggs, and oatmeal were served well below the facility's preferred minimum of 120 degrees Fahrenheit for palatability. For example, coffee was measured at 93°F and French fries at 89°F. Toast was frequently observed to be hard, burnt, and difficult to eat, and some trays lacked necessary accompaniments. Residents often refused to eat the food due to its poor quality and temperature, and some expressed frustration about the lack of timely alternatives when food was sent back. Staff interviews indicated ongoing challenges in the kitchen, including insufficient supplies and staffing, particularly during evenings and weekends. CNAs and the Dietary Manager acknowledged that residents had complained about the quality and temperature of food, and that the kitchen had struggled to deliver meals that met expectations. The facility's own policy requires periodic checks of food temperatures at the point of service, with a preference for hot foods to be at least 120°F, but this standard was not consistently met during the survey period.
Failure to Provide Resident-Preferred and Prescribed Dietary Options
Penalty
Summary
The facility failed to provide food that accommodated resident allergies, intolerances, and preferences, as well as appealing options, for six out of seven residents reviewed for meal preferences and substitutions. Multiple residents with complex medical histories, including conditions such as diabetes, heart failure, dementia, and dysphagia, reported not receiving the food items listed on their dietary tickets, missing substitutions, and receiving items they specifically disliked or were not supposed to have. For example, one resident with dietary restrictions did not receive cranberry juice as ordered for several weeks, while another received rice despite a documented dislike, and another received beans despite a restriction against them. Several residents also reported not receiving requested or required items such as bananas, yogurt, or cereal, and noted that substitutions were often unavailable or significantly delayed. Staff interviews corroborated these resident reports, revealing that dietary staff shortages and supply issues contributed to the deficiencies. Staff described a period when all dietary staff walked out due to poor working conditions, including lack of gas for cooking and no air conditioning in the kitchen. During this time, non-dietary staff, including nurses and CNAs, prepared meals, which resulted in limited food options such as peanut butter and jelly sandwiches and oatmeal, with some residents missing supplements and double protein items. Staff also reported that food trays frequently lacked condiments and that substitutions and supplements were not consistently provided. The facility's dietary manager acknowledged ongoing issues with dietary tickets not being read carefully and missing items, and stated efforts were being made to address these problems. The facility's policy on dining experience emphasizes providing an exceptional dining experience that honors individual care plans and preferences, but observations, interviews, and record reviews demonstrated that these standards were not met during the survey period.
Failure to Provide Adequate Incontinence Supplies
Penalty
Summary
The facility failed to provide necessary incontinence supplies for three dependent, incontinent residents, resulting in the use of incorrect or inadequate products. Documentation for these residents showed that their care plans required specific interventions, such as the use of disposable briefs in the correct size, regular checks every two hours, and proper perineal care after incontinence episodes. However, interviews with residents and staff revealed that the facility repeatedly ran out of appropriately sized incontinence briefs, cleansing wipes, washcloths, and bed pads. Staff reported substituting smaller or larger briefs, using pull-ups instead of briefs, and resorting to makeshift alternatives such as pillowcases and blankets when standard supplies were unavailable. Residents affected by these shortages included individuals with significant cognitive and physical impairments, such as muscle weakness, unsteadiness, neurocognitive disorders, and complete dependence on staff for toileting hygiene. One cognitively intact resident reported discomfort from being provided with briefs that were too small, while staff described frequent leaks and skin contact with urine or feces when using ill-fitting or less absorbent products. Staff also noted that the use of pull-ups in place of briefs was not effective for residents with total incontinence, as these products did not provide adequate coverage or absorbency, leading to soiled bedding and increased risk of skin issues. Multiple CNAs and nurses confirmed that supply shortages had been ongoing for several weeks to months, with some reporting that the facility was out of certain supplies an average of three days per week. Staff consistently reported these shortages to administration, who sometimes responded by instructing staff to use alternative products or by stating that supplies were on back order. Despite these reports, administration was either unaware of the extent of the shortages or minimized their significance, attributing staff concerns to reluctance to retrieve supplies from laundry or misunderstanding the nature of grievances. The lack of a facility policy regarding towels was also noted during the investigation.
Failure to Timely Report Alleged Verbal Abuse to Administrator
Penalty
Summary
The facility failed to ensure that allegations of verbal abuse were reported to the Administrator or Abuse Coordinator as required by policy. A resident with multiple medical conditions, including dementia, anxiety disorder, and major depressive disorder, reported to a CNA that an LPN had yelled at her and made derogatory remarks, causing the resident to become visibly upset and cry. The CNA did not report the allegation to the Administrator, stating she did not witness the incident and advised the resident to report it herself. The resident also reported similar concerns to another CNA on multiple occasions, who stated she did report it to the Administrator and Director of Nursing, but both denied awareness of any such allegations. The resident documented the alleged verbal abuse on a piece of paper, which included statements such as "choke on that," "it's all in your head," and "you are crazy," but did not include dates or times. Despite the facility's policy requiring immediate reporting of abuse allegations to the Administrator, the incident was not reported or investigated until a state surveyor brought it to the attention of facility leadership. Interviews with staff revealed inconsistent reporting and a lack of documentation or care plan focus related to abuse or behaviors for the resident. The Director of Nursing recalled staff mentioning the resident was upset with a staff member but did not recall any specific abuse allegations. The Administrator only became aware of the situation after being informed by the surveyor, at which point an investigation was initiated.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that allegations of verbal abuse involving a resident and a staff member were thoroughly investigated. The resident, who had multiple medical diagnoses including dementia, anxiety disorder, and major depressive disorder, was documented as cognitively intact and able to make reasonable decisions. Multiple certified nursing assistants (CNAs) and another resident reported that the resident had complained about an LPN being verbally abusive, using phrases such as "you are crazy" and "it's all in your head." The resident was visibly upset and reported being afraid of the staff member in question. Despite these reports, there was no documentation of a care plan focus area related to abuse or behaviors for this resident. Several staff members, including CNAs, stated that they either reported the allegations to the administrator or the director of nursing, or advised the resident to do so. However, both the administrator and the director of nursing stated they were unaware of any specific allegations of verbal abuse involving the staff member and the resident. The director of nursing recalled being told the resident was upset but did not receive details or the name of the alleged perpetrator. A grievance form was filed by the resident, indicating a staff concern, but lacked specific details about the incident. Follow-up documentation regarding the grievance was incomplete, with only one progress note available and no evidence of the required weekly follow-up meetings. The facility's abuse prevention policy requires immediate reporting and thorough investigation of alleged violations, with specific steps to prevent further abuse during the investigation. However, the investigation into the allegations was only initiated after the state surveyor brought the issue to the attention of the administrator and director of nursing. By that time, both the staff member accused and the resident had already been discharged. The lack of timely and thorough investigation, incomplete documentation, and failure to follow policy requirements led to the deficiency.
Failure to Ensure Residents Are Free from Significant Medication Errors Due to Late Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple instances of late medication administration for three residents with complex medical conditions. For one resident with diagnoses including diabetes, heart failure, and cerebral infarct, medications such as insulin, antidiabetics, diuretics, and anticonvulsants were repeatedly administered outside the prescribed time frames, sometimes several hours late. The resident confirmed that medications, including insulin, were often given late, particularly when agency nurses were on duty. Medication administration records corroborated these delays, and staff interviews revealed that workload, interruptions for resident care, and unfamiliarity with residents contributed to the late administration. Another resident with diabetes, dementia, and hypertension also experienced late administration of critical medications, including Humalog and Lantus insulin. Documentation showed that insulin doses intended to be given with meals or at bedtime were administered significantly later than ordered. Staff interviews indicated that high workload, the need to verify medications, and interruptions during medication passes were common reasons for these delays. The resident's blood sugar records did not show significant abnormalities during the review period, but the pattern of late administration was consistent. A third resident with chronic conditions such as COPD, chronic kidney disease, and repeated falls also received medications late, including gabapentin and Seroquel. This resident reported not always receiving medications as ordered. Multiple nursing staff, including RNs and LPNs, acknowledged that medications were sometimes administered late due to factors such as high resident acuity, the need to provide direct care, technical issues with electronic systems, and the challenge of managing large numbers of residents per shift. The facility's own medication administration policy emphasized the importance of timely administration, but adherence was not consistently maintained.
Failure to Provide Prescribed Dietary Supplements for Wound Healing
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including a stage 4 sacral pressure ulcer, severe protein-calorie malnutrition, and dysphagia, did not receive prescribed dietary supplements intended to support wound healing. The resident's care plan and physician orders included a regular diet with mechanical soft texture and specific supplements such as fortified foods, arginaid, prostat, multivitamins, and nutritional drinks. Despite these orders, direct observation revealed that the resident did not receive fortified cereal as ordered for breakfast, and the resident reported that the food provided often did not match what was listed on the dietary ticket. Interviews with staff indicated ongoing issues with the dietary department's process for providing supplements. Certified Nurse Aides reported difficulty obtaining missing supplements from dietary staff, who sometimes refused requests due to lack of time or unavailability of items. Dietary staff admitted they did not consistently read the bottom of dietary tickets where supplements and preferences were listed, citing time constraints during meal service. The facility administrator acknowledged awareness of these issues, and the registered dietitian confirmed that all recommended supplements should have been provided as ordered.
Failure to Maintain Functional Call System in Resident Bathroom
Penalty
Summary
A deficiency occurred when the facility failed to provide a functional call system in the bathroom of a resident who was at risk for falls and required assistance with toileting and transfers. The resident's care plan specifically included interventions to ensure the call light was within reach and functional, due to diagnoses such as unsteadiness, repeated falls, and generalized muscle weakness. Despite these documented needs, the call light in the resident's bathroom was not working for approximately two weeks. Staff interviews revealed that the LPN was aware of the non-functioning call light and had submitted a work order, but the Environmental Operations Director was unable to repair it and delayed notifying higher-level maintenance and administration. The Director of Nursing and Administrator were not made aware of the issue until the day of the survey, and there was no existing policy on call light systems in the facility. The maintenance job description required regular checks and repairs of nurse call systems, but this was not effectively carried out in this instance. Further investigation showed that the facility's call system was outdated, with no available replacement parts, and the outside technician was only able to partially restore functionality after being notified. The lack of timely communication and follow-through on maintenance responsibilities contributed to the prolonged period during which the resident did not have access to a working call system in the bathroom, despite being dependent on staff for toileting and transfers.
Failure to Maintain Clean and Sanitary Floors Due to Housekeeping Shortages
Penalty
Summary
The facility failed to maintain floors in a clean and sanitary manner, as evidenced by repeated observations of dried, dark-colored spills, sticky substances, and scattered debris such as torn paper and food particles on the floors of the 100 and 200 halls, as well as in the dining room. These unsanitary conditions persisted over multiple days, with the same spills and debris noted in the same locations during subsequent observations. A resident grievance was also filed regarding dirty floors in a resident's room, and a family member reported that the dining room floors had been consistently dirty over the past couple of months, not just immediately after meals. Interviews with staff, including the housekeeping supervisor, housekeepers, CNAs, and the administrator, revealed that the facility had been short-staffed in housekeeping for one to two months due to staff resignations. As a result, routine cleaning of common area floors, such as hallways and the dining room, was reduced from daily to every other day, and the remaining staff prioritized cleaning resident bathrooms, rooms, and shower areas. Additionally, the facility's floor cleaning machine was out of service, further hindering thorough cleaning. The facility did not have a housekeeping policy, although written housekeeping routes indicated that all floors should be swept and mopped daily.
Failure to Prevent Resident-to-Resident Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in two separate incidents involving residents with cognitive and physical impairments. In the first incident, a female resident with a history of cerebral infarction, major depressive disorder, muscle wasting, and impaired mobility, who was not cognitively intact, was sexually assaulted by another resident. The perpetrator, who also had cognitive impairment and behavioral issues, approached the female resident in the dining room, made an inappropriate sexual comment, and groped her breast. This event was witnessed by an LPN, who observed the inappropriate contact and intervened to separate the residents. The incident was substantiated as sexual misconduct based on consistent staff accounts and documentation in the facility's investigation report. In the second incident, another resident with cognitive impairment, a history of traumatic brain injury, and limited mobility was physically assaulted by the same resident involved in the first incident. The administrator witnessed the perpetrator strike the other resident on the head with an open hand in the dining room. The two residents then engaged in a physical struggle, which was immediately broken up by the administrator. Both residents involved in this incident had cognitive deficits and required assistance with activities of daily living. There were no obvious injuries reported as a result of the altercation. Both incidents were documented in the facility's investigation reports and were reported to the appropriate authorities, including the residents' power of attorneys, police, and medical doctors. The facility's abuse policy states that every resident has the right to be free from abuse and that abuse is prohibited. Despite this policy, the facility failed to prevent these incidents of sexual and physical abuse between residents with known behavioral and cognitive issues.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Accurately Reflect POLST Status in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's Practitioner Orders for Life-Sustaining Treatment (POLST) status was accurately reflected throughout the Electronic Health Record (EHR). The resident, who had diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and hypertension, was admitted with an advanced directive indicating Do Not Resuscitate (DNR) status in the admission record and order summary. However, the resident's signed POLST form indicated a preference for full cardiopulmonary resuscitation (CPR) in the event of unresponsiveness. During the survey, the administrator confirmed that the medical record should have matched the resident's POLST wishes for CPR to be performed, but the record incorrectly documented the resident as DNR. The facility's policy requires staff to verify code status using the medical record and to initiate CPR or notify the provider based on that documentation. The discrepancy between the POLST form and the EHR documentation led to the deficiency.
Failure to Provide Ordered Dietary Supplement
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered for a resident with severe cognitive impairment, multiple diagnoses including dementia, dysphagia, and feeding difficulties. The resident's care plan and dietary orders specified daily ice cream as a nutritional supplement, with fortified pudding and high-calorie liquid supplements also documented. Observations on two consecutive days showed that the resident was served meals without the ordered ice cream or a substitute supplement. The resident's meal card confirmed the requirement for a 4-ounce ice cream supplement, but this was not provided. Interviews with staff revealed that the facility had been out of the ice cream supplement for two days, and staff were unclear about what should be provided as a substitute. The dietary director acknowledged the shortage and stated that fortified pudding should have been given in place of ice cream, but this was not done. The resident's family, present during meals, also noted the absence of the supplement. The administrator confirmed that staff are expected to follow therapeutic diet orders.
Failure to Follow Infection Control Standards During Catheter Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide urinary catheter care according to current infection control standards for a resident with severe cognitive impairment and multiple diagnoses, including neurocognitive disorder with Lewy bodies, Parkinson's disease with dyskinesia, and flaccid neuropathic bladder. The resident was dependent on staff for personal hygiene and had an order for catheter care every shift. During observed catheter care, the CNA placed wipes directly on the fitted sheet, used wipes to clean the resident's perineal area and catheter tubing, and repeatedly failed to perform hand hygiene or change gloves at appropriate times, such as after handling the trash can, after providing catheter care, and before emptying the catheter drainage bag. The CNA also used gloved hands to touch multiple surfaces, including the bathroom door, nightstand, and supply items, without changing gloves or performing hand hygiene between tasks. Additionally, the CNA returned a package of wipes from the resident's room to the supply cart in the hallway without performing hand hygiene, and the Director of Nursing (DON) confirmed that this was typical practice. The facility's policy required standard precautions, clean technique, and hand hygiene before and after glove use and handling of catheter supplies, but these procedures were not followed during the observed care. The DON stated that hand hygiene and glove changes were expected at several points during catheter care, but these expectations were not met during the observed incident.
Inadequate Supervision Leads to Falls and Elopement
Penalty
Summary
The facility failed to provide adequate assistance to prevent falls for two residents, resulting in significant injuries. One resident, with a complex medical history including cerebral infarction, hemiplegia, and repeated falls, fell from a tilt/recline chair in the dining room. The resident was left unattended while staff retrieved food, leading to a fall that caused a large intracranial hematoma, a left eyebrow laceration, and a left periorbital hematoma. The resident's care plan included interventions to prevent falls, such as using an anti-slip mat and not leaving the resident alone when sitting on the side of the bed. However, these measures were not effectively implemented, as the resident was left unsupervised in an upright position, contrary to the care plan's instructions. Another resident, diagnosed with dementia and severe cognitive impairment, fell from bed while receiving incontinence care. The resident, who had a history of falls and required one-person assistance for mobility, rolled off the bed during care, resulting in a forehead laceration requiring sutures and skin tears. The care plan included interventions such as using quarter side rails during care to prevent falls, but these were not in place at the time of the incident. The resident's bed was also raised higher than recommended during care, increasing the risk of falls. Additionally, the facility failed to provide adequate supervision to prevent elopement for a resident with severe cognitive impairment and a history of elopement. The resident was last seen in the dining area before being found outside the facility by a staff member's spouse. The resident's care plan included interventions such as using a wander alert device and providing structured activities to prevent elopement. However, the resident was able to leave the facility unnoticed, indicating a lack of effective supervision and monitoring. The facility's elopement prevention measures, including door alarms and staff awareness, were insufficient to prevent the resident from leaving the premises.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for three residents, as observed and reported by both residents and staff. Resident R5, who is cognitively intact, reported that his room was not kept clean, with a trash can that was consistently full and without a liner. His family member corroborated this, stating that the trash had not been emptied for several days. Observations confirmed the trash can was overflowing with soda bottles stacked on top. Resident R6, who is alert and oriented, expressed dissatisfaction with the cleanliness of her room upon arrival, noting dust behind the door and in her closet, and a mold-like substance around the toilet ring. She had to request the housekeepers to clean these areas. Resident R7, also alert and oriented, reported that his room was not cleaned well, with trash cans often full and the table not cleaned off. A friend who visits regularly confirmed these observations, stating he often had to clean the table himself. Staff members, including CNAs and a registered nurse, reported similar issues with housekeeping, noting overflowing trash cans, dirty floors, and inadequate bathroom cleaning. The facility's cleaning chart outlines a specific cleaning method, but it appears these procedures were not consistently followed, leading to the deficiencies observed.
Failure to Provide Twice-Weekly Showers for Resident
Penalty
Summary
The facility failed to provide twice-weekly showers for a resident with cerebral palsy and diabetes type 2, who requires partial or moderate assistance for bathing and hygiene. The resident's care plan indicated the need for staff assistance with bathing, yet documentation showed the resident received only one shower per week on multiple occasions. Interviews with the resident's family member and CNAs revealed inconsistencies in the shower schedule, with the family member expressing concerns about the resident's hair appearing dirty and greasy. The Director of Nurses confirmed the expectation for residents to receive two showers weekly, with hair washing included unless otherwise preferred by the resident. However, there was no documentation to support claims of the resident refusing showers or hair washing. The facility lacked policies related to bathing, ADL care, or hair care, as confirmed by the Administrator, contributing to the deficiency in providing adequate care for the resident.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident with a history of multiple falls. The resident, who has Alzheimer's Disease, Type 2 Diabetes, and mobility issues requiring a wheelchair, experienced numerous falls from self-transfers over several months. Despite these incidents, the resident's care plan did not include new interventions for falls that occurred on specific dates. The facility's fall policy mandates that after any fall, an occurrence report should be completed, causal factors identified, and interventions implemented with updates to the care plan. However, the care plan for this resident was not updated with new interventions following several falls, as confirmed by the Registered Nurse responsible for care planning.
Deficient Catheter Care for Resident
Penalty
Summary
The facility failed to provide catheter care in accordance with current standards of practice for a resident with a Foley catheter. The resident, who has a history of cerebral infarction, spastic hemiplegia, and dysphagia, was observed receiving catheter care that did not adhere to the facility's documented procedures. Specifically, during the catheter care, the CNA did not separate the labia or cleanse the urinary meatus, which are required steps according to the facility's catheter care guidelines. The resident's care plan included specific instructions for catheter care every shift and as needed, with a focus on monitoring for signs and symptoms of urinary tract infections. Despite these instructions, the CNA performing the care did not follow the proper technique, as confirmed by the Interim ADON and the DON, who both stated that they would expect the labia to be separated during catheter care. The CNA later admitted to not performing the procedure correctly due to nervousness.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to administer a resident's tube feeding in accordance with the physician's orders. The resident, identified as R47, was admitted with diagnoses including cerebral infarction, gastrostomy status, and cognitive communication deficits. The care plan indicated that R47 required tube feeding, with specific orders for Nutren 2.0 continuous feeding at a rate of 40 ml per hour and 120 ml water flush every two hours. However, observations on multiple occasions revealed that the feeding pump was infusing at a rate of 30 ml per hour, contrary to the prescribed 40 ml per hour. Interviews with staff, including an LPN and the Director of Nursing, revealed that they were unable to recall the correct tube feeding order for R47. Upon review of the electronic health record, it was confirmed that the infusion rate should have been 40 ml per hour. The facility's protocol for enteral tube medication administration emphasized the importance of verifying the caloric content per milliliter before administration to ensure the correct dosage is given, which was not adhered to in this case.
Failure to Label Insulin Vials with Opening Dates
Penalty
Summary
The facility failed to label insulin vials and insulin pens with the date of opening for two residents, leading to a deficiency in medication storage practices. Resident 49, who was admitted with diagnoses including type 2 diabetes mellitus and epilepsy, had orders for insulin Lispro and insulin Glargine. On a specific date, it was observed that both insulin types were open and lacked an opening date. A Licensed Practical Nurse (LPN) confirmed the absence of opening dates and stated that the insulin vials would need to be disposed of and replaced. Similarly, Resident 52, admitted with conditions such as acute kidney failure and type 2 diabetes mellitus, also had orders for insulin Lispro and insulin Glargine. These insulin vials were found open without opening dates during an inspection. The same LPN verified this issue and indicated that the vials would have to be discarded and new ones obtained. The facility's policy required medications to be stored securely and properly, following manufacturer recommendations, which include disposing of opened insulin after 28 days.
Failure to Provide Peritoneal Dialysis
Penalty
Summary
The facility failed to provide peritoneal dialysis treatments for a resident (R1) who required such services. R1 was admitted to the facility with a diagnosis of End Stage Renal Disease and a need for peritoneal dialysis. However, upon arrival, R1 did not have the necessary dialysis supplies, and the facility did not have the supplies or adequately trained staff to assist with the dialysis treatment. Despite being aware of R1's dialysis needs, the facility did not ensure that the supplies were available or that the staff were properly trained to assist R1 with her peritoneal dialysis. R1's condition deteriorated due to the lack of dialysis treatment. The facility's staff attempted to contact R1's family to obtain the necessary supplies, but there were delays in getting the supplies to the facility. R1 experienced confusion and lethargy due to missed dialysis treatments and was eventually sent to the hospital for evaluation. The hospital records indicated that R1 had not received peritoneal dialysis for at least two days, leading to a change in dialysis modality to hemodialysis during the hospital stay. Interviews with facility staff revealed that there was a lack of proper training and preparedness to handle peritoneal dialysis for R1. The Director of Nursing (DON) admitted that the staff had not been trained on a peritoneal dialysis machine by certified dialysis staff. The facility's failure to ensure the availability of supplies and adequately trained staff resulted in R1's hospitalization and a change in dialysis treatment modality.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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