Nexus At Palos
Inspection history, citations, penalties and survey trends for this long-term care facility in Palos Hills, Illinois.
- Location
- 10426 South Roberts, Palos Hills, Illinois 60465
- CMS Provider Number
- 145650
- Inspections on file
- 54
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 18 (2 serious)
Citation history
Health deficiencies cited at Nexus At Palos during CMS and state inspections, most recent first.
A resident with dementia, bipolar disorder, moderate cognitive impairment, and documented high elopement risk repeatedly packed bags, attempted to access exits, and was observed trying to leave the unit, yet continued to ambulate independently with only intermittent redirection. Facility assessments showed the resident could not safely navigate the community and was not capable of unsupervised outside passes, but the assigned CNA reported not being informed of the elopement risk. On one evening, the resident was last seen in the room with belongings packed and stating an intent to leave; later, staff discovered the resident missing, and a family member ultimately located the resident miles away after the resident had crossed at least one unsecured exit and traveled by public bus. Surveyors found multiple exit doors that could be opened without a code, delay, or audible alarm, residents who knew exit codes, non-recording cameras, and inconsistent staff accounts of search efforts, demonstrating a failure to maintain secure egress points and provide adequate supervision for a known elopement-risk resident.
A resident who was alert and oriented reported that a CNA struck his upper arm with an open hand and verbally abused him, and he informed a nurse and later the Administrator. Nursing documentation reflected the resident’s statement that he had been hit and was calling the police, and that the DON and Administrator were notified. However, no abuse allegation report was submitted to the state agency at the time of the allegation, and the Regional office later confirmed there was no report on file for that incident. The Administrator acknowledged missing the initial call from the nurse and, believing the reporting window had passed, did not submit the initial abuse allegation report as required by the facility’s abuse policy, which mandates reporting allegations of abuse within 2 hours.
A resident with multiple chronic conditions and moderate cognitive impairment reported repeatedly pressing a non-functioning call light for incontinence care without staff response, stating this lack of response happens frequently. When a CNA eventually entered, the CNA provided incontinence care and then fed the resident while standing, using a Styrofoam plate and plastic fork, despite facility leadership stating staff are expected to sit at eye level when feeding residents and that the resident had no restriction requiring paper products. Facility policies require CNAs to provide care and meals in a manner that upholds resident dignity and respect.
A resident with multiple comorbidities, moderate cognitive impairment, high fall risk, incontinence, and aphasia was care planned to have a call light within reach and to receive extensive staff assistance with ADLs. During observation, the resident reported needing to be changed and demonstrated pressing the call light, but no light illuminated at the panel or above the door and no audible alarm sounded. A CNA and the Maintenance Director confirmed the call light for that bed space was not functioning properly despite facility policies and leadership statements that call lights are to be checked each shift and defective equipment promptly reported and addressed.
A resident with multiple chronic conditions and moderate cognitive impairment reported not receiving scheduled medications, and review of the MAR showed several morning and noon doses of famotidine, hydrocodone-acetaminophen, nystatin powder, primidone, buspirone, and vitamin D3 were not documented as given, with no reasons recorded for the omissions. The DON stated that medications must be administered within a defined time window and that any missed doses require documentation and provider/resident notification, while one LPN claimed to have given the medications but admitted she likely failed to document them, and another LPN confirmed that blank MAR entries indicate medications were not administered, demonstrating noncompliance with facility medication administration policy.
A resident with multiple chronic conditions and moderate cognitive impairment requested assistance for incontinence care after using the call light without response. A CNA eventually provided incontinence care but, after completing the task, failed to change soiled gloves or perform hand hygiene before touching the bedside table, the resident’s clothing and bed, and then preparing and providing the resident’s meal. The CNA later removed the soiled gloves and donned clean gloves without hand hygiene and continued resident care. This conduct was inconsistent with facility policy, CDC hand hygiene guidance, and the CNA job description, all of which require hand hygiene before and after resident care and specify that gloves are not a substitute for hand hygiene.
A resident with cognitive communication deficit and depression reported that a CNA walked up behind her and kissed her on the cheek, stating this was not the first such attempt and that it made her uncomfortable and unsafe. The resident’s family member also reported that the resident was kissed on the cheek and felt the facility treated the behavior as acceptable. Nursing staff relayed the complaint to the ADON and administrator, and documentation such as an abuse care plan, witness statement, and incident report reflected the allegation. Despite an abuse policy that prohibits abuse and requires screening, training, and immediate protection of residents, the resident reported experiencing unwanted physical contact from staff and feeling unsafe.
A resident with ESRD dependent on hemodialysis was discharged home without a confirmed dialysis chair date and time, despite a care plan specifying scheduled dialysis and a facility policy requiring Social Services to arrange outside services and equipment before discharge. Documentation showed that at the time of discharge the dialysis time was still pending, yet the resident’s family proceeded with discharge and leadership was notified. The family reported they were told they would be called with the dialysis schedule but never received a call, and the resident subsequently required dialysis at a local hospital ER. The DON later stated that Social Services were expected to arrange all home health services, including confirmed dialysis, and to notify the physician if a resident insisted on leaving.
A resident with end stage renal disease and dependence on renal dialysis was discharged home with the wrong medications after an LPN completed discharge teaching and sent the family home with medications that did not belong to the resident. Later, the LPN realized the resident’s medications were still at the facility and contacted the family, who reported they had received medications that were not theirs and returned them. The DON stated that a two-nurse verification system is expected for discharge medications. Records showed discharge orders, a medication list, a care plan for medication administration, discharge teaching documentation, and an incident report for the wrong medications, along with a policy requiring review of discharge instructions and medication lists and provision of appropriate medications per MD orders at discharge.
A resident with COPD, asthma, and dependence on supplemental O2 had a physician order for nightly BiPAP at 20/7 with 25–30% FiO2 via full face mask, with staff to assist in application. A nurse practitioner documented that the resident did not receive the BiPAP, and the MAR showed the treatment as not administered over multiple consecutive nights. During interviews, an LPN confirmed the order but was unsure if the resident actually received BiPAP, and the DON explained that the MAR coding indicated it was not given. The facility could not provide a general policy on following physician orders and only had a BiPAP policy stating that nursing/respiratory staff must verify orders and document appropriately, which was not followed for this resident.
Surveyors determined that the facility did not post the required daily nurse staffing information at the front desk. During observations, no staffing posting was visible in the receptionist area where it was expected to be displayed. The administrator stated that the staffing coordinator is responsible for placing the daily posting at the receptionist area and acknowledged that if it is not there, it has not been posted. The DON confirmed that the daily staffing information is supposed to be posted at the main lobby receptionist desk each day. The administrator also reported that the facility had no written policy for daily staff posting, although it is recognized as a requirement, and the facility could not provide such a policy. This failure had the potential to affect 164 residents receiving care.
Two residents at risk for falls did not receive care as outlined in their fall prevention plans. One resident with intact cognition, who had a prior fall, was observed with her bed in the highest position and her call light on the floor, despite care plan directives for the bed to be kept low and the call light within reach. Another resident with mild cognitive impairment and a high fall risk, who had experienced two prior falls, had a care plan calling for bedside floor mats, but no floor mat was present or available during multiple observations. Staff, including an LPN, a CNA, and a unit manager, acknowledged that these interventions should have been in place according to the residents’ care plans and the facility’s fall prevention policy.
A resident with chronic respiratory failure, tracheostomy, severe cognitive impairment, and total dependence on staff was observed with a tracheostomy tube lacking the ordered inner cannula during trach care. Two respiratory therapists confirmed the absence of the inner cannula despite a physician order for twice-daily inner cannula changes and routine assessments, and the RT Director stated the expectation that an inner cannula be in place and changed each shift. Facility policy on tracheostomy care, which includes removal and reinsertion of an inner cannula as part of routine care, was not followed at the time of the surveyor’s observation.
A resident with end stage renal disease and high fall risk, requiring two-person assistance for turning and hygiene, fell and sustained a scalp hematoma when one staff member left the bedside during incontinence care, leaving only one staff member present. The fall occurred as the resident slid out of bed while being cleaned, leading to hospital evaluation.
A resident who was fully dependent on staff for toileting and always incontinent did not receive incontinence care for over four hours, resulting in the resident being found soiled and saturated with urine while attempting to eat lunch. Staff confirmed that care was last provided in the morning, despite the expectation of care every two hours, and facility policy required residents to be kept dry and comfortable.
A resident with a history of pulling at her tracheostomy tube was not provided with ordered hand mitten restraints, as required by her care plan and physician orders. Staff failed to apply and monitor the mittens, and communication breakdowns occurred due to lack of proper handoff and inaccessible electronic medical records. The resident was found unresponsive after self-decannulation and later died, with no incident report or complete documentation provided for the event.
Multiple residents experienced loss and misappropriation of personal property, including bank cards and state IDs, due to the facility's failure to follow its abuse policy. In several cases, personal items were lost, discarded, or used for unauthorized transactions while under facility care, and staff were not consistently aware of or able to prevent these incidents.
Two high-risk residents did not have required fall prevention interventions in place, including floor mats and accessible call systems, as specified in their care plans. Observations showed missing or improperly placed floor padding and a nonfunctional call light, despite both residents being identified as high fall risk.
A resident who was fully dependent on staff for toileting and incontinence care was left soiled in feces for several hours, despite using the call light and contacting family for help. The resident experienced emotional distress and discomfort, and police intervention was required before care was provided. Staff interviews and documentation revealed significant staffing shortages and a failure to follow the resident's care plan and facility policy, resulting in neglect.
Two residents with significant cognitive and physical impairments were not adequately supervised or protected from accident hazards. One resident, left unsupervised and agitated in the dining room, fell from a wheelchair and sustained a clavicle fracture. Another high-risk resident, dependent on staff for bed mobility, experienced two unwitnessed falls from bed despite interventions, resulting in a closed head injury and other injuries. Staff were unable to identify who was responsible for monitoring, and interventions in place were ineffective in preventing these incidents.
A resident with multiple complex medical conditions experienced a 34.8% unplanned weight loss over six months due to the facility's failure to monitor and implement effective interventions. Despite documented high risk for malnutrition and changes in enteral feeding orders that reduced caloric intake, staff did not adjust the care plan or provide additional nutritional support, and there was a lack of clear monitoring or follow-up as required by facility policy.
Two residents at high risk for skin breakdown, including one with a tracheostomy and another with multiple comorbidities and impaired mobility, developed or sustained pressure injuries due to the facility's failure to implement and document individualized interventions as required by policy. Device-related wounds and multiple pressure ulcers were observed, with care plans lacking specific measures such as repositioning frequency and use of prescribed support devices.
Surveyors found expired IV fluids, supplements, and medications, as well as opened multi-dose vials lacking required labeling, in multiple medication storage areas. Food items used for medication administration were also unlabeled and stored with medications. Staff interviews confirmed that nurses were responsible for checking and removing expired medications, but these procedures were not followed according to facility policy.
Staff failed to consistently follow infection control protocols, including proper use of PPE and hand hygiene when entering isolation rooms, and did not clean glucometers between resident uses. Several residents with multidrug resistant organisms or C. difficile were not promptly placed on appropriate isolation, and care plans were not updated to reflect infection status. Staff and visitors were observed entering isolation rooms without required precautions, and there was confusion among staff regarding isolation procedures.
A resident with chronic respiratory failure and a tracheostomy developed white and yellow patches in the mouth, which were observed by a surveyor and confirmed by a nurse. The resident reported not receiving oral care for two weeks. The physician and nurse practitioner were not notified of the change in condition until days after the initial observation, contrary to facility policy requiring immediate notification.
Two residents with documented serious mental illness were not referred for required PASRR Level 2 assessments, despite facility policy and confirmation by social services that referrals should have been made. Only PASRR Level 1 screenings were available, and the necessary follow-up for further evaluation was not completed.
A resident with obstructive sleep apnea and chronic respiratory failure did not receive prescribed BIPAP therapy for five days due to the machine being stored and not set up after a hospital stay. Staff did not verify the machine's status or ensure its availability, and the resident's care plan lacked interventions for sleep apnea or BIPAP use. There was no assessment or documentation regarding the resident's use or refusal of the device, resulting in failure to follow physician orders.
A resident with hemiplegia and hemiparesis was repeatedly found with a power strip resting in their bed, plugged in and powering multiple items, despite being unable to reach it. Staff acknowledged that the power strip should not have been in the bed and identified it as a safety hazard, in violation of facility policy requiring minimization of environmental hazards.
Two residents did not receive required ADL support, including regular showers and effective oral care. One resident with a tracheostomy was found with significant oral debris and reported no oral care for two weeks, while another resident had not been offered a shower and had no documentation of refusal or preferences. Staff interviews revealed inconsistent practices and lack of proper documentation, contrary to facility policy.
A resident with left hemiparesis and limited mobility, requiring extensive assistance with hygiene, was repeatedly observed with an unshaved beard and unclean nails. The resident reported being unable to perform these tasks independently and stated that staff were too busy to help. Staff interviews indicated a lack of awareness of the resident's hygiene needs, and facility policies for maintaining self-image and following care plans were not followed.
Surveyors found that the facility submitted inaccurate MDS assessments, including incorrect discharge destinations and failure to properly identify residents with serious mental illness or intellectual disabilities for PASRR purposes. Several residents with documented mental health diagnoses were not correctly coded in the MDS, resulting in discrepancies between medical records and assessment documentation.
A resident with multiple chronic conditions did not receive several scheduled medications within the required time frame, as confirmed by staff and the electronic MAR. Additionally, the resident's bed linens were visibly soiled and had not been changed as needed, contrary to facility policy. These deficiencies were also reflected in prior resident council concerns about medication timeliness and linen changes.
A resident with a tracheostomy and frequent drooling developed skin breakdown due to inadequate moisture management. Despite being at high risk for skin issues, the facility did not implement effective interventions to keep the resident's neck area dry, leading to moisture-associated skin damage. The resident's care plan lacked specific measures to address the frequent drooling, contributing to the development of open wounds.
The facility failed to promptly respond to resident call lights, affecting three residents. One resident waited 52 minutes for assistance after activating her call light, despite staff being present nearby. Other residents also reported delays in receiving help, particularly at night. The facility's policy requires call lights to be answered promptly, but staff actions did not align with this, resulting in a deficiency.
A facility failed to follow transmission-based isolation precautions for a resident with C. Auris. An LPN administered medication via a gastric tube without wearing a gown, despite the requirement for gowns and gloves. The resident had a complex medical history, including encephalopathy and gastrostomy status. The facility's infection prevention nurse confirmed the need for enhanced barrier precautions, but the necessary PPE was not utilized, leading to the deficiency.
A resident admitted with healed scar tissue and at moderate risk for skin breakdown developed a facility-acquired pressure ulcer within three days. Despite being incontinent and needing assistance with repositioning, the resident was left soiled with stool, contributing to the wound's development. The facility's policy on skin care prevention was not adequately followed, as the wound was later deemed avoidable.
The facility did not report the final results of an abuse investigation within the required timeframe. A resident alleged that a CNA hit him with a bed remote control. The administrator could not provide documentation that the final report was sent to the Illinois Department of Public Health within five working days, as required by the facility's abuse policy.
A resident with hemiplegia and hemiparesis was injured during a transfer when a CNA failed to follow the facility's mechanical lift policy, which requires two staff members. The CNA attempted the transfer alone, resulting in the resident hitting his head on the lift and sustaining facial swelling.
A facility failed to obtain informed consent for psychotropic medication for a resident with a known allergy to bupropion. The resident's allergy was documented, but the nurse practitioner did not evaluate the allergy or discuss the risks with the resident. Additionally, the consent form signature did not match the resident's, and memantine was administered without proper consent. The facility's policy requires informed consent for psychotropic medications, which was not followed, impacting the resident's care.
A facility failed to follow its medication administration policy, resulting in a resident missing doses of tolvaptan for hyponatremia. The medication was not delivered by the pharmacy, and the nurse did not notify the physician or document the missed doses in the MAR. The DON confirmed the medication was not in the convenience box, and the physician was not informed about the need for an alternative medication.
A resident was moved to a new room without consent, causing sleep disruption due to cognitively impaired roommates. The facility also delayed signing a death certificate, causing distress to a deceased resident's family. Both incidents highlight failures in communication and adherence to policies.
The facility failed to prevent accidental decannulation for a ventilator-dependent resident, who was found without a pulse due to lack of supervision and interventions. Additionally, the facility did not follow hypoglycemia protocols, leading to the resident's death. Another resident did not receive prescribed IV antibiotics due to transcription errors, and a third resident experienced prolonged seizures before emergency services were called.
A resident dependent on a ventilator experienced cardiac arrest when left unsupervised due to both assigned nurses taking breaks outside the facility. The resident was found decannulated and without a pulse by a respiratory therapist, who initiated emergency procedures. The delay in obtaining help was due to the absence of nurses on the unit. Interviews revealed that the nurses were unaware of the requirement to inform others when leaving for breaks, leaving the unit unsupervised.
A facility failed to investigate and report an allegation of mental abuse involving a resident, where an agency nurse questioned the resident's ethnicity inappropriately. Despite the family member's concerns being reported, the administrator did not conduct an abuse investigation, considering it a grievance instead. The resident has a complex medical history, and the facility's policy requires such incidents to be investigated and reported.
A resident with a complex medical history did not receive prescribed IV antibiotics on multiple occasions, as discovered by the Infection Coordinator during an audit. The facility failed to complete a medication error incident report for this omission, contrary to its policy. Additionally, another medication was not administered as ordered, and no incident report was filed.
A resident with a moderate risk for skin breakdown was left in a dialysis chair for over eight hours, despite requests to be repositioned due to pain. The facility failed to follow prescribed treatment orders and care plans, including not replacing a soiled dressing promptly and leaving the resident on a mechanical lift sling, which could disrupt the air mattress's effectiveness.
A high-risk resident developed an unstageable pressure ulcer due to the facility's failure to conduct weekly skin assessments as required. Despite being admitted with intact skin and a history of pressure sores, the resident's condition worsened due to inadequate monitoring and documentation, resulting in a significant wound within 12 days.
A high fall risk resident with dementia experienced two unwitnessed falls due to inadequate fall interventions. Despite being identified as a high risk, the interventions, such as ensuring the call light was within reach, were insufficient given the resident's cognitive limitations. The resident sustained a head injury requiring hospital care after the second fall. The facility's fall prevention policy was not effectively followed, as new interventions were not implemented after the first fall.
A resident with anxiety and depression was verbally and physically abused by a CNA, who used derogatory language and pushed the resident, causing him to hit his head. The incident began in the dining room and escalated in the resident's room. Witnesses confirmed the CNA's behavior was initially playful but became threatening. The facility's DON acknowledged the actions as verbal abuse.
A resident with multiple sclerosis and neuromuscular dysfunction of the bladder, who was dependent on staff for toileting, experienced a delay in receiving incontinence care. The resident activated the call light at 9:41 AM, but it remained unanswered for over two and a half hours. A nurse entered the room for medication administration but did not address the resident's request for care. When a CNA finally attended to the resident, the incontinence brief was saturated, and there was a strong urine odor, violating the facility's incontinence care and call light response policies.
Failure to Supervise High-Risk Resident Resulting in Elopement Through Unsecured Exits
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement of a resident who had been clearly identified as a high elopement risk and incapable of unsupervised outside pass privileges. The resident had diagnoses of unspecified mild dementia with behavioral disturbance and bipolar disorder with severe manic episode and psychotic features, with documented moderate cognitive impairment (BIMS score of 12) and mild deficits in memory, attention, and concentration. A community survival skills evaluation documented that the resident could not safely negotiate community streets, did not know the facility address or how to contact the facility in an emergency, could not reliably refrain from self-harm or socially inappropriate behavior in the community, did not know how to seek help in an emergency, and lacked knowledge of potentially dangerous situations. The same evaluation explicitly stated the resident was not capable of unsupervised outside pass privileges and that there would be no community pass. The facility’s own elopement evaluations dated 2/26 and 3/4 identified the resident as high risk for elopement, with multiple risk factors checked: hanging around exits and stairways, physical ability to leave the building, poor judgment and confusion, theme behavior (e.g., belief in responsibilities elsewhere), and responsiveness to environmental cues. Social service documentation on 3/4 described the resident as ambulating independently throughout the unit, intermittently attempting to access exit doors without authorization, and demonstrating poor safety awareness, impaired judgment, and memory deficits, with no successful elopement yet but clear elopement risk. Nursing and social service staff reported that the resident frequently packed bags, attempted to leave via the front door, stated that a son was coming to pick her up, took pictures of exit doors, and exhibited sundowning behavior in the evenings, packing bags and insisting on leaving. A nurse’s progress note on 3/18 documented the resident with packed bags headed to the front entrance in an attempt to leave, requiring redirection back to the room, after which the resident became very angry and screamed. On the evening of the elopement, the nurse supervisor administered the resident’s 6:00 p.m. medications and then continued medication administration for other residents. When he returned around 9:00 p.m. to give remaining medications, the resident was not in the room. The assigned CNA reported last seeing the resident around 8:00 p.m. sitting on the bed with items packed, stating she was leaving the facility. The CNA later stated she had not been informed the resident was an elopement risk and last saw the resident around 8:30–9:00 p.m. before going on break. A family member reported receiving a call from the resident around “7ish,” during which the resident said she did not know where she was but was trying to get to the family member, then became upset and disconnected when told to return to the facility. The family member was unable to reach the resident for several hours and later learned from a bus driver that the resident was at a distant, high-traffic intersection, and arranged for the resident to be transported by bus to a downtown location where the family member picked her up. The facility did not know how or when the resident exited the building, and staff, including the administrator and DON, were unable to determine which door was used. Multiple exit routes were identified that could be opened without a code, delay, or audible alarm, including double doors near the dialysis unit and double doors by the time clock leading directly to an alley behind the facility. Staff acknowledged that these doors were routinely left unarmed/open for staff entry and exit, and that some family members knew to use the employee-only exit after visiting hours. A police report documented that the nurse supervisor initially stated a search had been conducted but later retracted that statement, and that hallway cameras did not record. The report also documented that some residents knew exit passcodes even though they were not supposed to, and a cognitively intact resident was able to state the unit exit code and demonstrate its use. The facility’s elopement policy defined elopement as leaving the premises or safe area without authorization and/or necessary supervision, and excluded only alert and oriented residents who could handle themselves outside; however, the resident in question had been repeatedly documented as cognitively impaired, unsafe in the community, and at high risk for elopement, yet was able to leave the facility without staff awareness or supervision and travel a considerable distance before being located by family.
Failure to Timely Report Alleged Physical and Verbal Abuse
Penalty
Summary
The facility failed to follow its abuse policy by not reporting an alleged physical and verbal abuse incident within the required 2-hour timeframe. A resident who was assessed as alert and oriented to person, place, and time stated that a CNA struck him on the right posterior upper arm with an open hand and verbally abused him. The resident reported this alleged abuse to a nurse around midnight and later to the Administrator. A nursing note documented that the resident stated he had been hit and that he was calling the police, and that the DON and Administrator were notified. Despite this, there was no corresponding abuse allegation report submitted to the state agency on the date of the allegation, and the Regional office confirmed there was no facility reportable abuse allegation for this resident for that date. The Administrator stated that the nurse had called him when the incident occurred but he missed the call while asleep, and when he returned the call he believed it was already past the noncompliance window, so he did not submit the initial abuse allegation report as required by the facility’s Abuse Policy and Prevention Program, which mandates reporting any allegation of abuse to the state within 2 hours.
Failure to Ensure Dignified Response to Call Light and Dining Experience
Penalty
Summary
The deficiency involves the facility’s failure to provide a dignified environment and respect resident rights during dining and in response to call light use for one resident. The resident is an older female with multiple diagnoses including neuromyelitis optica, difficulty in walking, muscle disorder, lack of coordination, cognitive communication issues, depression, anxiety, aphasia, and moderate cognitive impairment as evidenced by a BIMS score of 12. On the survey date, she was observed in bed, alert, oriented, groomed, missing teeth, and able to make her needs known. She reported needing to be changed and stated she had been pressing the call light without response. When she pressed the call light in the surveyor’s presence, there was no light at the call panel, no audible sound, and no light above the door. She stated that when she presses the call light staff do not come, that this happens all the time, and that a CNA had said she would return but did not, leaving her needing incontinence care. Later that day, a CNA entered the room to provide incontinence care and then prepared to feed the resident. The resident’s meal was served on a Styrofoam plate with a plastic fork, and the CNA stood the entire time while feeding her. The CNA acknowledged that she was supposed to sit when feeding residents but stated she liked to stand sometimes so she did not get tired, and she did not know why the resident was being served on paper products. The DON and ADON both stated that staff should sit when feeding residents, that this is a dignity issue, and that residents should not feel rushed and should be engaged at eye level. The ADON also stated the resident had no restriction requiring use of paper products. Facility policies and the Resident’s Rights document require CNAs to treat residents with kindness, dignity, and respect, create and maintain an atmosphere of warmth and positive regard, and adhere to all facility policies and procedures, including those related to meals and resident rights.
Failure to Ensure Resident Had a Functioning Call Light
Penalty
Summary
The deficiency involves the facility’s failure to provide a working call light for a resident with multiple medical conditions and functional limitations. The resident is an older female with neuromyelitis optica, difficulty walking, muscle disorders, lack of coordination, aphasia, depression, anxiety, spinal stenosis, anemia, edema, and other comorbidities. Her BIMS score indicates moderate cognitive impairment, and her care plans document high fall risk, incontinence risk, extensive need for staff assistance with ADLs, and a communication problem related to aphasia. The care plans specifically require that the call light be placed within reach, that staff assess her ability to use it, and that a safe environment be ensured by having the call light in reach. On the survey date, the resident was observed in bed, alert and oriented, with the call light within reach. She reported that she needed to be changed, had been pressing the call light, and that no one had responded. The surveyor observed her pressing the call light and noted that the light at the call light panel did not come on, there was no audible sound, and the light above the door did not illuminate. The resident stated that when she presses the call light staff do not come and that this happens all the time. She also reported that a CNA had said she would return but did not, and that she remained wet and needed to be changed. When the CNA was informed by the resident that the call light was not working, the CNA confirmed that the call light did not activate and stated she would notify maintenance, also acknowledging she had not checked the call light that morning. The Maintenance Director later attempted multiple times to reset and test the call light in the resident’s bed space, confirming that the panel light sometimes came on but there was no audible sound and no light above the door, and at other times the call light did not work at all. The bathroom call light and the call light for the other bed space in the room were found to be functioning. Facility leadership and nursing staff stated that call lights are supposed to be checked every shift and that defective call lights are to be promptly reported and addressed, consistent with facility policies and job descriptions requiring equipment to be maintained in proper working order and hazardous conditions to be reported. Despite these policies, the resident’s primary call light was not functioning as required at the time of the surveyor’s observations and interviews.
Failure to Administer and Document Ordered Medications for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to administer and document medications as ordered for one resident. The resident is an adult female with multiple diagnoses including neuromyelitis optica, difficulty in walking, muscle disorder, lack of coordination, cognitive communication issues, depression, spinal stenosis, anemia, edema, hyperlipidemia, tremor, aphasia, anxiety, dysthymic disorder, and kidney/ureter disorder. Her BIMS score indicated moderate cognitive impairment, though she was observed to be alert, oriented, groomed, and able to make her needs known. On one day, the resident reported she had not received her medication and that the nurse had said she would return but did not. The following day, the resident again stated she had not received her morning medications the previous day as scheduled. Interviews with staff and review of the Medication Administration Record (MAR) and progress notes showed that multiple scheduled medications were not documented as given and no reasons were recorded for the omissions. The DON stated that medications are to be given within one hour before or after the scheduled time, and that if not given, the nurse must notify the provider and resident/family and document the reason on the MAR. One LPN reported she had given the resident’s 9:00 a.m. and 12:00 p.m. medications but likely forgot to document them due to being busy, while another LPN stated that blank MAR boxes indicate medications were not given. The MAR for the resident showed missed 9:00 a.m. doses of famotidine, hydrocodone-acetaminophen, nystatin powder, primidone, and buspirone, and a missed 12:00 p.m. dose of vitamin D3, with no documented reason for non-administration, contrary to the facility’s medication administration policy and nursing job description.
Failure to Perform Hand Hygiene and Change Gloves After Incontinence Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow infection prevention and control practices during incontinence care for one resident. The resident was an adult female with multiple medical conditions, including neuromyelitis optica, difficulty walking, muscle and coordination disorders, cognitive communication issues, depression, lung findings, cervical spinal stenosis, anemia, edema, hyperlipidemia, tremor, aphasia, anxiety, dysthymic disorder, and kidney/ureter disorder. Her BIMS score indicated moderate cognitive impairment, but she was alert, oriented, groomed, able to make her needs known, and observed lying in bed with the call light within reach. The resident reported that she had been pressing the call light for help to be changed, that a CNA had said she would return but did not, and that she still needed to be changed. The CNA later stated she had last changed the resident around 9:00 a.m. When the CNA entered the room to provide incontinence care, she donned gloves and proceeded with the care. After completing the incontinence care, she placed the soiled incontinence brief in a plastic bag and then, without changing gloves or performing hand hygiene, moved the bedside table over the resident and adjusted the resident’s clothing and bed. She then went to the glove box, removed the soiled gloves, and put on clean gloves without performing hand hygiene, and proceeded to adjust the resident in bed and prepare to feed her, again without completing hand hygiene. The CNA later acknowledged she should have removed gloves and washed her hands after incontinence care and should not have touched anything with dirty gloves. The facility’s infection prevention nurse and assistant DON both stated that incontinence care requires glove use and hand hygiene before and after care, and that staff should not touch resident items or equipment with soiled gloves. Facility policy and CDC hand hygiene guidance, as well as the CNA job description, require hand hygiene before and after resident care and emphasize that gloves are not a substitute for hand hygiene.
Failure to Prevent and Protect Resident From Alleged Sexual Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to prevent resident-to-employee sexual abuse and to ensure a resident’s right to be free from abuse. A resident with a cognitive communication deficit and depression reported that a CNA walked up behind her and kissed her on the cheek. She stated to nursing staff that this was not the first time the CNA had made this type of attempt and that his behavior made her feel uncomfortable. The resident’s family member reported that the resident was kissed on the cheek by the CNA and that the facility made her feel like it was acceptable, resulting in the resident feeling unsafe. The resident expressed a desire to contact the police, and a police report was made, which was later determined to be unfounded. Interviews with facility staff confirmed that the resident’s complaint was communicated through the nurse to the ADON, who then assessed the resident and notified the administrator, identified as the abuse coordinator. The DON stated she was not in the facility at the time of the complaint but expected all nursing staff to follow the abuse guidelines and noted that all staff receive abuse training upon hire. Facility records, including an admission record, abuse care plan, progress notes, a witness statement, and an incident report, documented the resident’s condition and the reported incident. The facility’s Abuse Policy and Prevention Program affirms residents’ rights to be free from abuse and outlines measures such as pre-employment screening, staff orientation and training on abuse recognition and reporting, and immediate protection of residents involved in possible abuse; however, despite these policies, the resident reported experiencing unwanted physical contact from a staff member and feeling unsafe.
Failure to Ensure Safe Discharge Planning for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a resident with end stage renal disease who was dependent on renal dialysis. The resident’s admission record showed a diagnosis of end stage renal disease and dependence on dialysis, with a care plan indicating dialysis on Monday, Wednesday, and Friday and a discharge planning focus that included dialysis. An order summary reflected a discharge home order, and a social service progress note documented on the day of discharge that the dialysis time was still pending. Despite the lack of a confirmed hemodialysis chair date and time, the resident’s family chose to proceed with discharge home at 1:00 p.m., and the assistant administrator and administrator were notified. The facility’s discharge policy required Social Services to assess discharge potential on admission, meet with the resident and/or family to set up outside services and equipment, and enter a discharge summary progress note into the EMR upon planned discharge. Interviews confirmed that the discharge occurred without a confirmed dialysis appointment. The administrator stated that the resident did not want to stay in the facility to ensure a dialysis date and time was set up and acknowledged that the resident and family were aware dialysis was not confirmed when they proceeded with discharge. The family member reported that the social worker said they would call with the dialysis date and time as soon as possible and that all paperwork was in, but the family never received a call and the resident was taken to the local hospital emergency room the following morning for dialysis treatment. The DON stated an expectation that social service staff set up all home health care services, including a confirmed dialysis date and time, and that if a resident insisted on leaving, the physician should be notified.
Failure to Ensure Safe Discharge and Correct Medications at Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe discharge and transfer, including providing the correct medications and required documentation or notification related to the resident’s needs, appeal rights, or bed-hold policies. A resident with end stage renal disease and dependence on renal dialysis was discharged home with the wrong medications. Interview with the resident’s family member indicated that the facility called their cell phone after discharge and asked them to bring the medications back, and the family confirmed that the medications they initially received were not theirs. The family reported that they returned the medications and that they were not used. An LPN reported that on the day of discharge she educated the resident’s family on the medications, and the family expressed understanding before leaving with the medications. About an hour later, the LPN noticed that the resident’s medications were still at the facility and realized the family had been discharged with the wrong medications, prompting a call to the family to return and exchange them. The DON stated that nurses are expected to use a two-nurse system to verify correct medication and dosage at discharge, and acknowledged that the resident had been discharged with the wrong medications. Record review showed a discharge home order, an order summary with the resident’s medications, a care plan to administer medications as ordered, a discharge summary progress note documenting medication education and discharge teaching, and an incident report for discharge of wrong medications. The facility’s discharge policy requires completion and review of discharge instructions and a medication list with the resident or representative, and that all appropriate medications be given per physician orders at the time of discharge.
Failure to Follow Physician Order for Nightly BiPAP Use
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for nightly BiPAP use for a resident requiring respiratory support. The resident, an older adult with multiple diagnoses including COPD with acute exacerbation, asthma, dependence on supplemental oxygen, hypertension, hyperlipidemia, benign prostatic hyperplasia, syncope and collapse, and prediabetes, had a physician order dated 2/12/26 for BiPAP settings of 20/7 with an oxygen blend of 25–30% FiO2 to maintain pulse oximetry at 92–94%, using a full face mask every night with staff assistance to apply the device. A nurse practitioner progress note dated 2/12/26 documented that the resident did not receive his BiPAP machine. Review of the Medication Administration Record for the month showed the BiPAP order as written but documented as not administered from 2/12/26 through 2/15/26, with the DON explaining that a “9” on the MAR indicates not given/not administered. During interview, the LPN unit manager confirmed the physician’s BiPAP order but stated she was unsure whether the resident actually received the BiPAP. The facility was unable to provide a policy on following physician orders and only produced a BiPAP policy stating that respiratory therapy/nurses oversee initiation and delivery of BiPAP and must verify the physician order and document appropriately, without evidence that these steps were carried out for this resident during the identified dates.
Failure to Post Daily Nurse Staffing Information at Front Desk
Penalty
Summary
Surveyors found that the facility failed to post the required daily nurse staffing information at the front desk. On 2/25/26 at 11:00 AM, surveyors observed that no daily staffing posting was available or visible at the front desk. At 11:30 AM, the Administrator (V1) stated that the daily staff posting should be in the receptionist area and that the staffing coordinator is responsible for it, and further acknowledged that if the posting is not found at the receptionist area, then it has not been posted. At 12:45 PM, the DON (V2) confirmed that the daily staff posting should be posted at the receptionist desk in the main lobby every day. At 1:04 PM, V1 stated there was no facility policy for daily staff posting, but acknowledged it is a requirement to have it daily, and the facility was unable to provide a policy. This failure had the potential to affect 164 residents receiving care in the facility. No additional resident-specific medical histories or conditions were described in the report beyond the statement that 164 residents were receiving care in the facility at the time of the deficiency.
Failure to Implement Planned Fall Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement fall care plan interventions for residents identified as being at risk for falls. One resident, an older female with intact cognition, had a documented fall and a care plan that required her bed to be kept in the lowest position and her call light to be within reach. During observation, her bed was found elevated to the highest position and her call light was on the floor, out of her reach. A Licensed Practical Nurse then lowered the bed and placed the call light within reach and acknowledged that the bed should be in the lowest position and the call light accessible to the resident. Another resident, an older male with mild cognitive impairment and assessed as high risk for falls, had two documented falls and a care plan intervention specifying the use of floor mats at the bedside. On two separate observations, no floor mat was in use or available in his room. A CNA stated they did not think this resident ever had floor mats as a fall intervention and did not see any in the room. The Unit Manager stated that the floor mat should be available as planned in the resident’s care. The facility’s fall prevention and management policy requires that residents at risk for falls have fall risk identified on the care plan with interventions implemented to minimize fall risk, which was not followed in these cases.
Failure to Maintain Ordered Inner Cannula for Tracheostomy Care
Penalty
Summary
The facility failed to provide an ordered inner cannula for the tracheostomy of one resident during tracheostomy care. The resident is an older adult with diagnoses including cardiac arrest with anoxic brain injury, chronic respiratory failure with hypoxia, tracheostomy and gastrostomy tube, and heart failure. The resident’s MDS showed severely impaired cognitive skills for daily decision making and total dependence on staff for care, requiring assistance of two or more helpers. A physician’s order dated 1/16/2026 directed that the inner cannula be changed twice daily on every day and night shift, and specified a Shiley size 8 FLEX tracheostomy tube. On the survey date at 9:40 AM, the surveyor observed the tracheostomy without an inner cannula in place. When asked to assess the tracheostomy, a respiratory therapist removed the tracheostomy mask, confirmed there was no inner cannula present, and stated the resident was supposed to have one. The therapist reported having rounded on the resident earlier that morning to provide a breathing treatment but could not explain why the inner cannula was missing. A second respiratory therapist later assessed the tracheostomy, also confirmed the absence of the inner cannula, and stated the resident should have one in place, describing that the inner cannula is changed twice a day and is a safety feature that allows quick removal of mucus plugs or obstructions. The Respiratory Therapist Director stated that staff are expected to change the inner cannula during tracheostomy care every shift or as needed and to ensure it is in place during initial rounds. The facility’s tracheostomy care policy, revised 10/2024, includes use and replacement of an inner cannula as part of routine tracheostomy care, but this was not followed for this resident at the time of observation.
Failure to Maintain Two-Person Assistance During High-Risk Resident Care Resulting in Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that two staff members remained at the bedside during incontinence care for a resident who was identified as high risk for falls and required two-person assistance for turning and repositioning. The resident, who had diagnoses including end stage renal disease, weakness, and difficulty walking, had a documented fall risk score of 10, indicating high risk according to the facility's fall prevention policy. During an episode of ADL care, one staff member (the DON) stepped away from the bedside to retrieve a garbage can while the other staff member (a CNA) continued with care. This resulted in the resident sliding out of bed and falling to the floor. The incident report and staff interviews confirmed that the resident required substantial or maximal assistance for hygiene and repositioning, with care plans specifying two-person assistance at all times. Despite this, the staff did not ensure all necessary items were at the bedside before starting care, leading to one staff member leaving the resident unattended. The fall resulted in the resident sustaining a scalp hematoma and requiring transfer to a hospital for evaluation and treatment.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident who was documented as fully dependent on staff for toileting and identified as always incontinent was not provided incontinence care for over four hours. The resident's care plan required staff to check for incontinence as needed, and facility policy stated that incontinence care should be provided to keep residents dry, comfortable, and odor-free. On the day of the incident, the resident was observed sitting in a wheelchair, urinating on the floor with wet clothing while attempting to eat lunch. Staff interviews confirmed that the last incontinence care provided to the resident was at 8:00 am, and that residents are supposed to be changed every two hours. The resident was found to be soiled and saturated with urine, indicating a failure to provide timely incontinence care as required by the care plan and facility policy.
Failure to Implement and Communicate Tracheostomy Restraint Orders Leads to Resident Death
Penalty
Summary
The facility failed to implement ordered respiratory care interventions for a resident with a tracheostomy, specifically neglecting to ensure the application and monitoring of hand mitten restraints as required by the care plan and physician orders. The resident had a documented history of pulling at her tracheostomy tube, and the care plan included the use of mittens to prevent self-decannulation. Multiple staff members, including the respiratory therapist and nursing supervisor, confirmed that the resident was supposed to have mittens applied at all times, but observations and interviews revealed that the mittens were not in place during the relevant shift. The agency nurse assigned to the resident was unaware of the mitten order and did not receive a proper handoff or information about the restraint requirement, and the facility's electronic medical records were inaccessible at the time, further impeding communication. The incident culminated when the resident was found unresponsive with her tracheostomy tube removed, and she was later pronounced deceased by paramedics. Staff interviews indicated that there was no visible evidence of the mittens being applied during the shift, and both the nurse and CNA assigned to the resident were not informed about the restraint order. The respiratory therapist reported that he had reminded the nurse about the need for mittens, but was unsure if any action was taken. Additionally, there was no documented incident report or completed progress note for the event, and the care plan binder at the nurse station was found to be incomplete. The resident's medical history included aphasia following cerebral infarction, acute respiratory failure with hypercapnia, tracheostomy status, and dependence on supplemental oxygen. The resident had previously attempted to remove her tracheostomy tube multiple times, and her daughter had requested the use of restraints, which was eventually ordered and consented to. Despite these clear directives, the facility failed to ensure that the required interventions were consistently implemented and communicated among staff, directly leading to the resident's self-decannulation and subsequent death.
Failure to Protect Resident Property and Prevent Misappropriation
Penalty
Summary
The facility failed to follow its abuse policy regarding the protection of resident property, resulting in the loss and misappropriation of personal items such as bank cards and state IDs for three residents. In one case, a resident's belongings were collected due to a bed bug issue, during which money and a state ID were found, but no bank cards. The resident's power of attorney instructed that the items be discarded, and the facility was unable to locate the state ID. Documentation also showed that the resident's purse was reported missing upon discharge, and the family could not locate it. Another resident reported missing bank cards from her room, which was communicated to her power of attorney, the administrator, and the police. One card was found in the facility laundry and returned, but two cards remained missing, with one being used for unauthorized transactions. In a third case, a resident's family discovered unauthorized ATM withdrawals totaling $3,809.50 during the resident's stay, with the resident known to keep her PIN with her debit card. The facility was unaware of the missing card until after discharge, and the family filed a police report. These incidents demonstrate the facility's failure to prevent misappropriation of resident property as required by its abuse policy.
Failure to Implement Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in its Fall Prevention and Management Guidelines for two residents identified as high risk for falls. One resident with severely impaired cognition, who had a documented history of falls, was observed in bed without the required floor padding in place. Additionally, this resident was unable to use the standard call light, and when tested, the call light was found to be nonfunctional until it was forcefully reconnected. The care plan for this resident specified the use of floor mats and an alternative call system, but these interventions were not in place at the time of observation. Another resident, also identified as high risk for falls, was observed in bed with the floor padding positioned two feet away from the bed rather than at the bedside as required. The care plan for this resident included the use of floor mats and maintaining the bed in the lowest position, but the observed placement of the floor mat did not align with these interventions. Staff interviews confirmed that both residents were considered high risk for falls and that the specified interventions should have been implemented according to facility policy.
Failure to Provide Timely Incontinence Care Resulting in Resident Neglect
Penalty
Summary
A resident with diagnoses including mixed/urinary incontinence, a vulvar malignancy, obesity, and a radiation-induced groin wound was identified as fully dependent on staff for toileting and incontinence care. The resident was assessed as cognitively intact and had a care plan indicating a self-care deficit in bed mobility, requiring staff assistance for repositioning and hygiene. The care plan also noted the resident was at risk for abuse and neglect. According to interviews and documentation, the resident was left soiled in feces for several hours during the night, despite using the call light and contacting family for help. The resident reported feeling exposed, uncomfortable, and emotionally distressed, and was not provided incontinence care until police arrived for a well-being check. Family members corroborated the resident's account, stating they received multiple distress calls from the resident throughout the night, attempted to contact the facility without success, and ultimately called the police. The police report confirmed the resident was found lying in bed without undergarments, with a significant amount of feces present, and a strong odor in the room. Police observed that staff were slow to respond to the resident's needs, and one staff member attempted to attribute the lack of care to alleged behavioral issues, which was contradicted by social services and the care plan, both of which indicated no such behaviors were present. Staff interviews revealed significant staffing shortages on the night in question, with only one nurse and one CNA present when two nurses and four CNAs were required for the unit. The nurse on duty reported being unable to provide care to the resident due to the lack of available assistance, and another CNA stated that care was provided but did not document it, while another CNA denied being assigned to the resident. The administrator acknowledged that failure to provide incontinence care as required constitutes neglect, and the facility's abuse policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or emotional distress.
Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to provide effective supervision and implement adequate interventions to prevent accidents for two residents with significant cognitive and physical impairments. One resident with right-side hemiplegia, lack of coordination, abnormal posture, and dementia was left unsupervised in the dining room while agitated, resulting in a fall from a wheelchair. Staff interviews revealed that the resident was placed in the dining room during a room cleaning, became agitated, and attempted to open the door, leading to the fall. There was confusion among staff regarding who was responsible for monitoring the dining room at the time, and the facility was unable to identify who was supervising the area when the incident occurred. The resident sustained a clavicle fracture and required hospital treatment. Another resident with dementia, a history of falls, and a healing left humerus fracture experienced two unwitnessed falls from bed. This resident was assessed as high risk for falls and was dependent on staff for repositioning in bed. Despite interventions such as placing the bed in the lowest position and using a floor mat, the resident continued to fall, sustaining injuries including a closed head injury, scalp abrasion, and swelling of the left upper extremity. Staff acknowledged that the interventions in place were ineffective in preventing the resident from falling out of bed, and it was unclear how the falls occurred given the resident's dependence on staff for mobility. The facility's fall prevention and management policies require identification and evaluation of residents at risk for falls, planning of preventive strategies, and ensuring a safe environment. However, in both cases, the facility did not provide adequate supervision or effective interventions, resulting in serious injuries to both residents. The lack of clear staff assignment and monitoring contributed to the deficiencies in resident safety and accident prevention.
Failure to Monitor and Intervene for Significant Weight Loss
Penalty
Summary
The facility failed to monitor and implement effective interventions for a resident at high risk for malnutrition, resulting in a 34.8% unplanned weight loss over less than six months. The resident had multiple diagnoses, including diabetes, muscle wasting, dysphagia, seizures, and gastrostomy status, and required substantial to maximal assistance with eating. Despite being on continuous enteral feeding with nothing by mouth status, the feeding order was changed in January to a twice-daily bolus, which provided only about half of the estimated caloric needs. Dietary notes repeatedly documented the resident's high risk for malnutrition, significant weight loss, and questioned the accuracy of some weight measurements, but no new interventions or adjustments to the feeding regimen were documented in response to the ongoing weight loss. Staff interviews revealed uncertainty regarding the accuracy of the resident's weight history and a lack of clear interventions or monitoring in response to the significant weight loss. The dietician acknowledged the weight loss and questioned the validity of previous weights but did not implement additional interventions, stating the resident's weight was stable at a lower level. The nurse practitioner was unaware of any concerns or interventions related to the weight loss. The facility's weight management policy required weekly weights and timely follow-up with dietary recommendations in cases of significant change, but there was no evidence these procedures were followed for this resident.
Failure to Prevent and Individualize Care for Pressure Ulcers in High-Risk Residents
Penalty
Summary
The facility failed to prevent the development of a wound in a resident with a tracheostomy who was identified as being at very high risk for skin breakdown and fully dependent on staff for care. This resident, who had diagnoses including respiratory failure, type II diabetes, and abnormal posture, was observed with a tracheostomy collar in place and was found to have an in-house acquired laceration on the left side of the neck. The wound was attributed to friction and moisture associated with the tracheostomy collar, and staff interviews confirmed that the collar and moisture contributed to the skin breakdown. Facility policy required individualized interventions for device-related pressure injuries, but the necessary preventive measures were not implemented to avoid this injury. Another resident, who was non-responsive and had multiple diagnoses including lumbar fracture, diabetes, and malnutrition, was found to have approximately 18 areas of impaired skin, including deep tissue injuries and pressure ulcers on both ears, elbows, sacrum, ischium, feet, and neck/head areas. Observations revealed that prescribed interventions such as a neck pillow for pressure relief were not in use, and the care plan did not include specific interventions for turning, repositioning, or the use of bolsters and neck pillows. Staff interviews indicated that while some interventions like heel boots and air mattresses were in place, individualized interventions for specific pressure areas, particularly the ears, were missing from the care plan. The facility's own policies required that skin and wound care interventions be individualized based on the resident's condition and that prevention protocols be implemented according to resident needs. However, the care plans for high-risk residents did not reflect all necessary or prescribed interventions, and staff did not consistently implement or document individualized measures to prevent pressure injuries. This lack of individualized care and failure to follow established protocols resulted in the development and worsening of pressure injuries in residents at high risk for skin breakdown.
Expired and Unlabeled Medications Found in Medication Storage Areas
Penalty
Summary
Surveyors identified multiple failures in medication storage and labeling across several nursing units. Expired intravenous fluids and catheter kits were found in the medication storage room, and the medication refrigerator contained expired medications, as well as food items such as pudding and applesauce that were not labeled or dated. Multi-dose vials of insulin and tuberculin solution were opened but lacked required labels indicating the date opened and expiration date. Additionally, expired house stock medications and resident-specific medications were found on the floor near the refrigerator, rather than being properly stored. In one instance, a resident's medication, atropine 1%, was found with an expiration date that had already passed. Further observations revealed that in other medication rooms and carts, expired supplements and medications were present, and opened containers of medication were not consistently labeled with the date opened. Staff interviews confirmed that nurses are responsible for checking for expired medications and ensuring proper labeling, but these procedures were not followed. The facility's own medication storage policy requires separation of medications from food, immediate removal of outdated drugs, and proper labeling, all of which were not adhered to during the survey.
Failure to Implement Infection Control Precautions and Equipment Cleaning
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, specifically regarding contact isolation precautions for residents with positive multidrug resistant organisms and the cleaning of shared medical equipment. Multiple staff members, including CNAs, LPNs, and restorative aides, were observed entering rooms of residents on contact or enhanced barrier precautions without performing hand hygiene or donning appropriate personal protective equipment (PPE) such as gowns and gloves. In several instances, staff entered isolation rooms, provided care, or handled resident equipment without following established protocols, and visitors were also seen entering isolation rooms without PPE or hand hygiene. Additionally, staff failed to clean and disinfect glucometers between resident uses during blood sugar checks, as observed with several residents. The facility's infection prevention nurse and interim director of nursing both confirmed that staff are expected to clean glucometers with disinfecting wipes between each use, and that PPE and hand hygiene are required when entering contact isolation rooms. However, observations showed that these practices were not consistently followed, and staff demonstrated confusion or lack of knowledge regarding when PPE was required and the reasons for resident isolation. The report also notes that some residents with confirmed infections, such as C. difficile, were not promptly placed on contact isolation, and care plans were not updated to reflect current infection status or required precautions. There were inconsistencies in the application of isolation signage and communication among staff regarding residents' isolation status. The facility's own policy requires contact precautions for residents with certain infections, use of dedicated or disinfected equipment, and proper PPE use, but these were not adhered to during the survey period.
Failure to Notify Physician of Change in Resident's Oral Condition
Penalty
Summary
The facility failed to follow its change of condition policy by not immediately notifying the physician or nurse practitioner when a resident developed white patches in the mouth and on the tongue. The resident, who had chronic respiratory failure, a tracheostomy, and required assistance with oral hygiene, was observed by a surveyor to have yellow mucous and raised white/yellow patches in the mouth. The resident reported not receiving oral care for two weeks. The nurse present at the time confirmed the observation. Despite the visible oral changes, the nurse practitioner was not notified until two days after the initial observation, and the medical doctor was not informed until the following day. Both practitioners stated they would have expected to be notified of such changes and would have initiated treatment sooner. The facility's policy requires prompt notification of the physician or nurse practitioner in the event of a significant change in a resident's condition, which was not followed in this case.
Failure to Refer Residents with Serious Mental Illness for PASRR Level 2 Assessment
Penalty
Summary
The facility failed to refer two residents with serious mental illness for a required Preadmission Screening and Resident Review (PASRR) Level 2 assessment. For one resident, documentation showed diagnoses of anxiety, depression, schizophrenia, and bipolar disorder, with the Minimum Data Set (MDS) confirming these conditions. However, the MDS section A1500 indicated that the resident was not considered by the state PASRR process to have a serious mental illness, and no PASRR Level 2 assessment was provided upon request. The social services staff confirmed that the resident should have been referred for a Level 2 PASRR due to their diagnoses. Similarly, another resident with diagnoses of anxiety and major depression was also not referred for a PASRR Level 2 assessment. The MDS and face sheet confirmed the diagnoses, but the PASRR Level 1 was the only documentation available, and section A1500 was marked as not having a serious mental illness. The facility's policy requires identification and evaluation of all residents with possible serious mental illness for appropriate PASRR screening, but this process was not followed for these two residents.
Failure to Provide Prescribed BIPAP Therapy and Care Planning for Obstructive Sleep Apnea
Penalty
Summary
A resident with diagnoses of obstructive sleep apnea and chronic respiratory failure did not receive their prescribed BIPAP therapy for five consecutive days. The resident reported to staff that her CPAP mask was broken and that she did not have her CPAP placed on the previous night. Upon investigation, staff did not verify the status of the machine or ensure its availability in the resident's room. The BIPAP machine, which was specific to the resident's physician orders, was found in storage after the resident's recent hospital stay, and had not been set up or used. The resident's care plan did not include interventions for obstructive sleep apnea or the use of the BIPAP machine, and there was no documentation of assessment regarding the resident's use or refusal of the device. Staff interviews revealed a lack of awareness regarding the resident's need for the BIPAP machine and the absence of a care plan addressing this need. The respiratory director confirmed that the machine had not been set up and that the resident had not refused its use. The care plan coordinator acknowledged that there was no individualized plan of care for the resident's obstructive sleep apnea or BIPAP use, and that she was unaware of the five-day period during which the resident did not have access to the prescribed therapy. Facility policy requires that physician orders be followed, but in this case, the order for nightly BIPAP use was not implemented.
Unsafe Placement of Power Strip in Resident's Bed
Penalty
Summary
The facility failed to provide a safe, home-like environment by allowing a power strip to rest in the bed of a resident diagnosed with hemiplegia and hemiparesis. On multiple occasions, the resident was observed lying in bed with a white power cord and power strip positioned at the foot of the bed, with several items plugged into it and the power strip in the 'on' position. The resident was unable to reach the power strip or the items plugged into it. Staff interviews confirmed that the power strip should not have been in the bed and acknowledged it as a safety hazard. The facility's policy requires a systematic approach to minimize environmental hazards, but this was not followed in this instance.
Failure to Provide Regular Showers and Effective Oral Care
Penalty
Summary
The facility failed to follow its policies regarding activities of daily living (ADLs), specifically in providing regular showers and effective oral care to residents. One resident with chronic respiratory failure, tracheostomy status, and weakness was observed with yellow mucus and raised white/yellow patches in the mouth, and reported not having received oral care in two weeks. Staff confirmed the presence of what appeared to be thrush and provided oral care only after the issue was identified by the surveyor. The infectious disease nurse noted that the resident was at higher risk for infections due to medications and tracheostomy and required prescription mouthwash for the infection. Another resident reported not having had a shower since before a recent hospital stay and expressed a desire for a shower, with no documentation of refusal. Staff interviews revealed confusion about shower responsibilities and documentation, with some staff equating bed baths to showers. The resident's care plan did not address bathing or shower preferences, and there was no evidence that showers were offered or refused as required by facility policy. The facility's own policies state that residents should be offered a bath or shower at least weekly, and assistance should be provided as needed, but these were not followed for the residents reviewed.
Failure to Provide Hygiene Assistance for Dependent Resident
Penalty
Summary
A deficiency was identified when staff failed to follow the care plan for a dependent resident requiring assistance with hygiene. The resident, who has a diagnosis of left hemiparesis, limited range of motion, hypertension, and COPD, was observed on multiple occasions with a long, unshaved beard and long, unclean nails. The resident reported being unable to shave or cut his nails independently and stated that staff were too busy to assist him. Despite being care planned for extensive assistance with hygiene and other activities of daily living, the resident's hygiene needs were not met as observed over several days. Interviews with staff revealed a lack of awareness regarding the resident's need for shaving, and documentation confirmed that the resident required substantial to maximal assistance with daily care. Facility policies require maintenance of resident self-image and adherence to person-centered care plans, but these were not followed in this instance, resulting in the resident's hygiene needs being neglected.
Inaccurate MDS Assessments and PASRR Identification
Penalty
Summary
The facility failed to ensure accurate completion and submission of Minimum Data Set (MDS) assessments for multiple residents. In one instance, a resident's MDS indicated discharge to a short-term general hospital, while progress notes documented that the resident was actually discharged home with family, resulting in conflicting records. Additionally, for several residents with documented diagnoses of anxiety, major depression, schizophrenia, and bipolar disorder, the MDS assessments did not accurately reflect their mental health status in Section A1500, which is used for PASRR (Preadmission Screening and Resident Review) identification. Specifically, the assessments indicated that these residents were not considered by the state Level II PASRR process to have serious mental illness or intellectual/developmental disabilities, despite their diagnoses. These inaccuracies were identified through interviews and review of medical records, affecting all five residents reviewed for assessment accuracy. The facility's own PASRR review policy requires identification and evaluation of all residents for serious mental illness or intellectual/developmental disabilities to ensure appropriate placement and services, but the assessments failed to meet these requirements. The deficiencies were limited to the documentation and coding of resident assessments and did not include any mention of corrective or follow-up actions.
Failure to Administer Medications Timely and Maintain Clean Linens
Penalty
Summary
A resident with multiple complex medical conditions, including end stage renal disease, diabetes, chronic obstructive pulmonary disease, and a history of coronary artery bypass graft, did not receive medications as ordered and experienced delays in medication administration. The resident's medication administration record (MAR) showed that several medications, including Cinacalcet, Atorvastatin, Gabapentin, Clopidogrel, Fluticasone inhaler, Lidocaine patch, renal vitamins, and Senna, were overdue and marked in red, indicating they were not given within the required time frame. The nurse responsible for medication administration confirmed that the resident had not received the scheduled morning medications, which were due at 9:00 AM, and acknowledged that the medications were late. The facility's policy requires medications to be administered within one hour before or after the scheduled time, which was not followed in this instance. Additionally, the same resident's bed linens were found to be visibly soiled with dried, dark-colored stains, and the resident reported that the sheets had not been changed for two days. Facility policy states that linens should be changed on shower or bath days and whenever they are wet or soiled. The assistant director of nursing confirmed the expectation that aides change sheets when visibly soiled. Resident council meeting minutes from previous months also documented ongoing concerns from residents about untimely medication administration and infrequent linen changes.
Failure to Prevent Skin Breakdown Due to Inadequate Moisture Management
Penalty
Summary
The facility failed to prevent skin breakdown for a resident, identified as R2, who was at high risk due to frequent drooling and a contracted neck position. R2, who is nonverbal and dependent on staff for all care, had a tracheostomy and was diagnosed with conditions including demyelinating disease of the Central Nervous System, quadriplegia, and dysphagia. The resident's care plan did not include interventions to manage the frequent drooling, which led to moisture being trapped around the neck and tracheostomy area, causing the skin to become fragile and open. On January 18, 2025, R2 was found to have new skin issues on the left side and front of the neck, which were identified as moisture-associated skin damage (MASD) rather than pressure ulcers. The wounds were attributed to the combination of drooling, the contracted neck position, and the trach ties rubbing against the skin. Despite the high risk for skin breakdown noted in R2's Braden Scale assessment, the facility did not implement adequate preventative measures to keep the area dry and protect the skin. Interviews with staff and family members revealed that R2's neck was frequently wet due to drooling, and the use of Velcro bibs provided by the family offered some help in managing the moisture. However, the facility's failure to consistently keep the area dry and implement effective interventions led to the development of open wounds. The facility's Skin Care Prevention Policy emphasized the importance of cleaning the skin at the time of soiling and at routine intervals, but this was not adequately followed for R2.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to adhere to its policy of promptly responding to resident call lights, which affected three residents. Specifically, one resident, identified as R8, experienced a significant delay in receiving assistance after activating her call light. The call light was initially activated at 12:44 PM, and although a CNA acknowledged the request at 1:07 PM, the resident did not receive the necessary assistance until 1:36 PM, resulting in a total wait time of 52 minutes. During this period, the resident expressed discomfort and the need to be changed due to being damp and having urinated. Despite the presence of staff in the vicinity, the call light was not promptly addressed, and the resident's request for assistance was not fulfilled in a timely manner. Additionally, other residents, R9 and R10, also reported delays in receiving assistance, particularly during nighttime hours. R9 mentioned that staff took a long time to respond to various needs, while R10 noted delays in receiving help for toileting needs. Observations during the survey revealed that staff were present in the hallway but did not prioritize responding to the call lights. The facility's policy, dated September 2023, mandates that call lights should be answered as soon as possible, and staff should listen to and fulfill residents' requests. However, the observed actions and inactions of the staff did not align with this policy, leading to the deficiency in care provided to the residents.
Failure to Follow Isolation Precautions for Resident with C. Auris
Penalty
Summary
The facility failed to adhere to transmission-based isolation precautions and enhanced barrier precautions for a resident diagnosed with a multidrug-resistant organism, specifically C. Auris. The deficiency was observed when a Licensed Practical Nurse (LPN) administered medication via a gastric tube to the resident without wearing a gown, despite the requirement for staff to don gowns and gloves when entering the room. The resident's door had a sign indicating the need for gown and gloves, but no gowns were available in the bin outside the room. The LPN prepared and administered the medication with the door open, further neglecting the necessary precautions. The resident involved had a complex medical history, including encephalopathy, moderate protein-calorie malnutrition, resistance to multiple antimicrobial drugs, gastrostomy status, and quadriplegia. The resident's care plan indicated active infection with C. Auris and the use of a tube feeding. The facility's infection prevention nurse confirmed that enhanced barrier precautions and isolation require staff to wear gowns and gloves, especially for high-contact activities such as device care. Despite these protocols, the facility's failure to provide and utilize the necessary personal protective equipment (PPE) led to the deficiency.
Failure to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The facility failed to prevent a resident, who was admitted with healed scar tissue on the sacrum and identified as at moderate risk for skin breakdown, from developing a facility-acquired pressure ulcer. Within three days of admission, the resident developed a pressure ulcer measuring 2 cm x 1.5 cm x 0.3 cm on the sacrum. The resident, who was cognitively intact and diagnosed with paraplegia, moderate protein-calorie malnutrition, diabetes, and osteomyelitis, reported being left soiled with stool on the overnight shift twice, which she believed led to the development of the wound. Upon admission, the resident was assessed by the wound team and noted to have healed scar tissue on the sacrum, with barrier cream applied. Despite being incontinent of bowel and bladder and needing assistance with turning and repositioning, the resident did not receive unavoidability charting upon admission. The wound was identified during rounds on 9/9/24 by the treatment nurse and wound doctor. The facility's policy on skin care prevention, revised in 9/2023, states that residents should receive appropriate care to decrease the risk of skin breakdown, including cleaning the skin at the time of soiling and at routine intervals. However, the resident's wound was later determined to be avoidable, indicating a failure in adhering to the facility's skin care prevention policy.
Failure to Report Final Abuse Investigation Results Timely
Penalty
Summary
The facility failed to adhere to its abuse policy by not reporting the final results of an abuse investigation within the required timeframe. A resident reported that a CNA hit him in the mouth with a bed remote control while being put back to bed. Despite the initial report being documented, the facility's administrator admitted to being unable to locate or provide documentation that the final investigation report was sent to the Illinois Department of Public Health within the mandated five working days. The facility's abuse policy, reviewed in September 2017, clearly states that the administrator or designee must forward a final written report of the investigation results to the Illinois Department of Public Health within this timeframe, which was not done in this case.
Failure to Follow Mechanical Lift Policy Results in Resident Injury
Penalty
Summary
The facility failed to adhere to its mechanical lift policy, which mandates the presence of two staff members during resident transfers using a mechanical lift. This policy is in place to ensure the safety of residents by having one caregiver focus on the resident's head and body positioning while the other operates the lift. On the evening of October 15, 2024, a certified nursing aide (CNA) attempted to transfer a resident with a mechanical lift without the assistance of a second staff member. During this transfer, the resident, who has a history of hemiplegia and hemiparesis affecting the right side, was struck on the head by the lift, resulting in facial swelling above the right eye. The resident involved in the incident was admitted to the facility with multiple diagnoses, including hemiplegia, hemiparesis, and contractures, requiring total assistance from two staff members for transfers and toileting. Despite the resident's request for a moment to adjust his power wheelchair, the CNA proceeded with the transfer alone, leading to the accident. The facility's investigation confirmed that the CNA violated the established transfer protocol, which requires two-person assistance, and this breach of policy was substantiated by the facility's reportable documents.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to adhere to its psychotropic medication policy by not obtaining informed consent from a resident or the resident's family before initiating a psychotropic medication. This deficiency affected one resident, identified as R4, who was prescribed bupropion despite having a documented allergy to the medication. The allergy was noted in R4's medical records from a previous admission and a pre-admission hospital record, but the reaction was unknown. The nurse practitioner, V15, was aware of the allergy but did not document any evaluation of the allergy or discussion with R4 about the risks of taking bupropion. Additionally, the signature on the psychotropic medication consent form did not match R4's signature on the admission contract, indicating that proper consent was not obtained. Furthermore, R4's medical records showed that memantine was administered without a signed consent form from either R4 or a family member until several weeks after the medication was first given. The facility's policy requires that the resident or their representative be informed of the risks and benefits of psychotropic medications and that informed consent be obtained. The failure to follow these procedures resulted in the administration of medications without proper consent and documentation, affecting the resident's care and safety.
Failure to Administer and Document Medication
Penalty
Summary
The facility failed to adhere to its medication administration policy, resulting in a resident missing scheduled doses of tolvaptan, a medication prescribed for hyponatremia. The Director of Nursing (DON) acknowledged that the medication was ordered but not delivered by the outside pharmacy, and the nurse did not notify the physician about the unavailability of the medication. Additionally, the nurse did not check the facility's convenience box for the medication or document the missed doses in the resident's Medication Administration Record (MAR) as required by the facility's policy. The resident's Physician Order Sheet (POS) indicated that tolvaptan was ordered for specific periods, but the MAR showed discrepancies in the administration of the medication. Despite the medication being marked as administered on certain dates, the facility's records and a photo of the medication delivery indicated that the resident did not receive all the doses. The DON confirmed that the medication was not stored in the convenience box and that the physician was not notified in a timely manner about the missed doses or the need for an alternative medication. This lack of communication and documentation led to the resident missing several doses of the prescribed medication.
Failure in Room Assignment and Death Certificate Signing
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by not appropriately managing room assignments and discharge planning. A cognitively intact resident was moved to the long-term care side of the facility without consent and placed in a room with two severely cognitively impaired residents, causing significant sleep disruption and mental distress. The resident expressed dissatisfaction with the room change and lack of communication with social workers, highlighting the facility's failure to consider the resident's preferences and needs. Additionally, the facility did not ensure timely signing of a death certificate for a deceased resident, resulting in mental anguish for the family and a delay in funeral services. The primary care physician and a pulmonology consultant both refused to sign the death certificate, citing they were not the primary physician. The funeral home and the family made several attempts to contact the facility for resolution, but their calls were not returned promptly, leading to a 30-day delay in obtaining the signed death certificate. The facility's policies on resident rights and room transfers were not adhered to, as evidenced by the lack of proper notification and explanation for the room change. The social services department experienced recent staffing changes, which may have contributed to the oversight in discharge planning and communication with the resident. The delay in signing the death certificate was eventually resolved after intervention by the Director of Nursing, but not before causing significant distress to the deceased resident's family.
Failure to Implement Interventions and Follow Protocols
Penalty
Summary
The facility failed to implement effective interventions to prevent the accidental removal of a tracheostomy cannula and accidental extubation for a ventilator-dependent resident. The resident, who had a history of fidgeting and pulling on the ventilator tubing, was found decannulated and without a pulse. Despite previous incidents of the resident disconnecting the ventilator tubing, no interventions such as a 1:1 sitter or a psych consult were implemented. Additionally, both nurses assigned to the unit were on break, leaving the unit without nursing supervision when the incident occurred. The facility also failed to follow their Hypoglycemia Policy and procedure for the same resident. After detecting low blood sugar, the nurse administered glucagon but did not establish intravenous access or call 911 when the intervention was not effective. The resident's blood sugar remained critically low, and the nurse did not seek further assistance or notify emergency services promptly. The resident was later found in cardiac arrest and pronounced deceased by paramedics. Furthermore, the facility failed to transcribe an IV antibiotic order for another resident, resulting in the resident not receiving the prescribed medication during their stay. The resident was admitted with a discharge summary indicating the need for IV antibiotics, but this was not reflected in the facility's physician order sheet. This oversight led to the resident developing drainage from a surgical site. Additionally, the facility delayed calling 911 for a resident experiencing active seizures, resulting in the resident having seizures for three hours before being transferred to the hospital.
Lack of Nursing Supervision Leads to Resident's Cardiac Arrest
Penalty
Summary
The facility failed to ensure uninterrupted nursing supervision in a ventilator care unit, leading to a critical incident involving a resident, R3. R3, who was admitted with severe cognitive impairment and dependence on a ventilator, experienced cardiac arrest when the tracheostomy cannula was found removed. At the time of the incident, both assigned nurses were on break outside the facility, leaving the unit under the care of unlicensed staff. The respiratory therapist, V24, discovered R3 without a pulse and initiated emergency procedures, but there was a delay in obtaining additional help as no nurses were present on the unit. The report details that V24 responded to an alarm and found R3 decannulated, without receiving oxygen or assisted breathing. V24 replaced the cannula and called a code blue, but it took time for help to arrive. V30, an LPN from a nearby unit, responded after being notified by a CNA and assisted in performing CPR with V24 until paramedics arrived. The paramedics found R3 unresponsive and without a pulse, and despite resuscitative efforts, R3 went into cardiac arrest again during transport to the hospital. Interviews with staff revealed that the nurses on duty, V31 and V32, were unaware of the requirement to inform others when leaving the unit for breaks. Both nurses left the facility without recording their absence, leaving the unit unsupervised. The Director of Nursing, V2, was unaware of the lack of supervision and emphasized the importance of communication among nurses to ensure coverage during breaks. The facility's employee handbook states that staff are not permitted to leave the facility grounds during breaks and must ensure adequate staffing at all times, which was not adhered to in this case.
Failure to Investigate and Report Allegation of Mental Abuse
Penalty
Summary
The facility failed to implement its abuse prevention protocol by not investigating and reporting an allegation of mental abuse involving a resident. The incident involved an agency nurse, V7, who questioned the ethnicity and last name of a resident, R1, in a manner perceived as inappropriate by the resident's family member, V4. This incident was initially reported to the facility's assistant administrator, V14, on 8/27/24, but the administrator, V1, did not conduct an abuse investigation, as she considered it a grievance rather than an abuse allegation. The family member, V4, had previously raised concerns about similar questions regarding R1's race/ethnicity by another employee, indicating a pattern of inappropriate inquiries. Despite these concerns being presented to the facility during an IDPH survey on 9/19/24, the administrator, V1, did not initiate an abuse investigation or report the incident to the Department of Public Health as required by the facility's policy. The facility's policy mandates that all allegations of abuse, neglect, or mistreatment be investigated and reported to the appropriate authorities. R1, the resident involved, has a complex medical history, including conditions such as enterocolitis, cerebral infarction, and chronic respiratory failure, among others. The failure to investigate and report the incident as potential mental abuse represents a significant deficiency in the facility's adherence to its abuse prevention and reporting protocols. The administrator acknowledged the lapse in procedure, noting that the agency nurse involved no longer works at the facility.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medication in accordance with the written orders of the attending physician, specifically omitting doses of antibiotics for a resident. The resident, who had a complex medical history including conditions such as Enterocolitis due to Clostridium Difficile, Chronic osteomyelitis, and Stage 4 pressure ulcers, experienced a delay in intravenous (IV) antibiotics treatment due to omitted doses. The omission was discovered by the Infection Coordinator during an antibiotics audit, who found extra IV antibiotics in the medication room. The Medication Administration Record (MAR) indicated that the medication was not given on specific dates, and a medication error incident report was completed by the Infection Coordinator. Additionally, the facility's policy on drug administration was not followed, as no medication error incident report was completed for another instance where Vancomycin HCl oral suspension was not administered as ordered. The Assistant Director of Nursing (ADON) confirmed that the medication was not given on certain dates and acknowledged that a medication error incident report should have been completed. The facility's policy requires that an incident report be completed immediately after an error is discovered to ensure proper resident follow-up.
Failure to Follow Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to follow prescribed treatment orders and care plans for a resident, identified as R5, who was at moderate risk for skin breakdown due to existing medical conditions, including cerebral infarction, diabetes, and amputations. R5 had a stage three pressure sore and an unstageable pressure sore, which required specific care interventions. On a particular day, R5 was left in a dialysis chair for over eight hours, despite repeatedly requesting to be placed back in bed due to pain. The staff, including a CNA and a nurse, were aware of R5's requests but did not reposition him or transfer him to bed, citing room maintenance and a pending room transfer as reasons. Additionally, R5 was observed lying on a mechanical lift sling for over two hours, which was against the facility's policy as it could disrupt the air mattress's effectiveness and contribute to skin breakdown. The facility's skin care prevention policy mandates appropriate care to reduce the risk of skin breakdown, which was not adhered to in this case. Furthermore, R5's dressing was found to be soiled and removed without being replaced promptly, contrary to physician orders that required the application of a new dressing if the previous one was soiled or removed.
Failure to Monitor High-Risk Resident Leads to Pressure Ulcer
Penalty
Summary
The facility failed to adequately monitor a resident who was at high risk for skin breakdown, leading to the development of an unstageable pressure ulcer. The resident, who was admitted with intact skin but a history of pressure sores, was noted to have blanchable redness on the sacrum shortly after admission. Despite being identified as high risk with a Braden score of 12, the facility did not conduct weekly skin assessments as required by the care plan. This lack of monitoring resulted in the resident developing a significant wound within 12 days of admission. The resident's medical history included severe protein calorie malnutrition, atrial fibrillation, and other conditions that increased the risk of skin complications. Although initial assessments noted the need for interventions such as barrier creams and turning protocols, there was a gap in documentation and follow-up assessments from 2/12/24 to 2/22/24. This oversight contributed to the progression of the skin condition to an unstageable wound, which was only documented after it had developed significantly.
Failure to Implement Effective Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement effective fall interventions for a high fall risk resident diagnosed with dementia and a history of falls. The resident, who had severe cognitive impairment and was at high risk for falls, experienced an unwitnessed fall that resulted in a hospital stay and required six staples to the head. Despite being identified as a high fall risk, the interventions in place, such as ensuring the call light was within reach, were insufficient given the resident's cognitive limitations. The resident was found on the floor on two separate occasions, with the first fall occurring when the resident attempted to get up without assistance, despite the call light being within reach. The nursing staff, including a nurse and the Director of Nursing, acknowledged that the resident was not likely to remember to use the call light due to cognitive impairment. After the first fall, the intervention was to ensure the call light was within reach, which was already part of the baseline care plan, indicating a lack of new and effective strategies. The second fall occurred when the resident attempted to exit the bed without assistance, leading to a head injury. The facility's fall prevention policy requires updating the care plan with new interventions based on root cause analysis after each fall, which was not effectively done in this case.
Staff-to-Resident Abuse Incident
Penalty
Summary
The facility failed to prevent an incident of staff-to-resident abuse involving a resident identified as being at risk for abuse. The incident involved a certified nursing assistant (CNA), V6, who verbally and physically abused a resident, R4, who had a diagnosis of anxiety and depression and was assessed to have moderately impaired cognitive patterns. The altercation began in the dining room when V6 attempted to make R4 interact with a new roommate, R12, which R4 refused. V6 became upset and used derogatory language towards R4, calling him a 'motherf**ker.' The situation escalated when V6 followed R4 to his room, where she pushed him onto the bed, causing R4 to hit his head on the wall. Witnesses, including another CNA, V5, confirmed the sequence of events, noting that V6's behavior was initially playful but turned serious and threatening. V5 observed V6 arguing with R4 and witnessed the physical altercation but did not intervene. The facility's Director of Nursing (DON), V2, acknowledged that V6's actions constituted verbal abuse and that V6 should have walked away when R4 became agitated. The facility's abuse policy emphasizes the residents' right to be free from abuse and outlines that abuse includes physical and verbal actions that cause harm or mental anguish to residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident identified as dependent on staff for toileting. The resident, who was admitted with multiple sclerosis and neuromuscular dysfunction of the bladder, was cognitively intact and required assistance for personal care. The resident's Minimum Data Set indicated complete dependence on staff for toileting hygiene and documented the resident as always incontinent. On the day of the incident, the resident activated the call light at 9:41 AM, requesting assistance for incontinence care, but the call light remained unanswered for over two and a half hours. During this period, a nurse entered the resident's room to administer medications but did not address the resident's request for incontinence care. When a CNA finally attended to the resident at 12:15 PM, the resident's incontinence brief was found to be saturated with urine, and there was a strong urine odor. The resident's gown was also wet. This incident was in violation of the facility's incontinence care policy, which emphasizes keeping residents dry and comfortable to prevent skin breakdown, and the call light response policy, which requires prompt response to call lights.
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A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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