Oakwood Rehab And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Westmont, Illinois.
- Location
- 512 East Ogden Avenue, Westmont, Illinois 60559
- CMS Provider Number
- 145338
- Inspections on file
- 42
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Oakwood Rehab And Nursing Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, moderate cognitive impairment, and a documented high fall risk was care planned to be observed frequently and kept in supervised areas when out of bed. After being assisted to the toilet, a CNA left the resident alone in her room in a wheelchair at the resident’s request, even though staff acknowledged the room was not a supervised area and that close monitoring near the nurse’s station or in activities was a key fall-prevention measure. The resident attempted to bend forward to fix her slip-on shoes, fell from the wheelchair onto her right side, and was later diagnosed with a right clavicle fracture and a closed head injury. There was no documentation of the resident’s preference to stay in her room or of any discussions with her representative about alternative fall-prevention strategies, despite facility policy requiring identification, communication, and consistent implementation of safety interventions.
A nurse left her assigned unit for several hours during an overnight shift, resulting in multiple residents’ needs going unmet, including a resident with complex cardiac and psychiatric conditions who could not obtain requested anxiety medication, and another resident with COPD and CHF who experienced anxiety and breathing problems without timely nursing intervention. A CNA reported that a needed wound dressing change was not performed despite repeated calls, and paramedics later responded to a male resident’s 911 call stating he was on the floor and could not find the nurse. Staff and residents described prior issues with the same LPN, including wrong medication administration and refusal to provide ordered pain medication, and stated that this LPN was not to pass medications to certain residents. Documentation and grievance records did not reflect these concerns, and there were discrepancies between staff notes and police dispatch times about when the LPN was actually on break and contacted by law enforcement.
The facility failed to follow menu-specified portion sizes for mechanical soft meals, resulting in multiple residents receiving smaller portions than planned. A resident who eats in her room reported consistently small portions, another resident described portions as sometimes very small, and the Resident Council President reported frequent complaints of hunger, including receiving minimal meat on a jerk chicken sandwich and cereal served in a dessert bowl despite an order for double protein. During an observed lunch service, a dietary aide used a small black #30 scoop (about 1.07 oz) for ground hamburger for several residents on mechanical soft diets, did not know the scoop size, and did not reference the menu spreadsheet. The food service manager confirmed that a larger scoop should have been used, while the dietitian and facility recipes specified that a #10 scoop plus 1 oz broth was required to meet planned caloric and protein needs.
Surveyors found that the facility failed to maintain hot food at palatable temperatures and did not follow its own tray line temperature policy. Several residents who primarily eat in their rooms reported that meals were frequently cold or only lukewarm, and one resident returning from dialysis stated a CNA would not reheat his meal. The Resident Council President reported that food often arrived cold, sometimes covered only with plastic wrap, that warming pellets had been eliminated, and that some CNAs limited reheating assistance despite many residents using wheelchairs. During an observed meal service, a dietary aide admitted not taking food temperatures, unheated plastic plates were used for some residents, plate warmers and pellets were not used, and the facility ran out of insulated domes. Test tray temperatures for a hamburger and sides were below the 120°F minimum specified by the dietitian and facility policy, which requires measuring and recording food temperatures at every meal.
The facility failed to maintain routine housekeeping, resulting in multiple residents reporting that their rooms were not cleaned daily, trash was not emptied regularly, and floors remained sticky or soiled for extended periods. One resident’s bathroom toilet remained filled with toilet paper and stool for weeks, while others had overflowing garbage cans, missing trash liners, and visible splatter marks on floors that had not been cleaned for about a month. Staff, including a CNA and the receptionist, confirmed that not all rooms were cleaned daily and described room cleaning as a “lottery,” while the administrator acknowledged that rooms were supposed to be cleaned every day. Resident Council minutes over several months documented ongoing concerns about sticky floors, inadequate cleaning of the dining room after meals and activities, and requests for additional garbage bins.
Staff failed to follow the facility’s COVID-19 PPE and isolation policies for multiple COVID-19 positive residents. A receptionist exited a COVID isolation room still wearing PPE and discarded it in a housekeeping cart in the hallway. A COVID-positive resident received dialysis while a dialysis tech wore only a surgical mask and gloves, and another COVID-positive resident was dialyzed in the same room as two other residents without wearing a mask, while dialysis staff used only partial PPE and regular glasses for eye protection. Two COVID-positive residents did not have contact/droplet isolation signs on their door, and a CNA entered their room wearing only a surgical mask and reported uncertainty about their isolation status, despite facility policies requiring 10 days of contact/droplet isolation, door signage, and use of N95, eye protection, gown, and gloves.
The facility failed to maintain an adequate supply of clean, usable linens for all residents, as multiple linen carts on both floors were found with no or very few washcloths and bath towels, and some available items were stained, frayed, or appeared dirty. Several residents reported that linens placed on their beds or provided for personal care were stained, sometimes with feces or strong odors, and described having to cut towels into washcloths, use paper towels for bathing, or purchase their own disposable wipes and towels. Staff, including CNAs and an LPN, confirmed that linens were frequently unavailable or “disgusting,” leading some staff to bring in personal washcloths and wipes or resort to using tissue to dry residents during incontinence care. Laundry staff reported no backup stock of face cloths, delays in receiving new orders, late delivery of soiled linens from units, and difficulty removing stains despite multiple wash cycles, while Resident Council minutes documented ongoing resident complaints about linen frequency, quality, and variety.
Surveyors found that the facility failed to administer medications within one hour of scheduled times as required by its policy, affecting multiple cognitively intact and cognitively impaired residents. Several residents reported that medications, including insulin, psychotropics, pain meds, and other scheduled treatments, were routinely late, and documentation confirmed repeated delays of one to several hours for blood glucose checks and medication passes on multiple shifts. One LPN reported being the only nurse for 32 residents and described being constantly busy and unable to take breaks. Resident council minutes also reflected ongoing concerns about delayed responses to call lights and inconsistent follow-up by staff.
The facility failed to provide enough nursing staff to meet residents’ incontinence and medication needs, resulting in missed and delayed care. A resident with a pressure injury and incontinence was left in soiled briefs from morning until midday and was routinely double-briefed by a CNA who reported having too many residents to provide timely care, leading to excoriated and bleeding skin. Another resident with bowel and bladder incontinence was found in two saturated briefs with a reddened scrotum, despite care plan directions for pericare with each episode and a DON statement that double-briefing should not occur except by care-planned preference. Multiple cognitively intact residents reported frequent late medications and long waits for call light responses, and MAR audits showed routine, diabetic, and PRN medications, as well as blood glucose checks and insulin, were repeatedly administered one to several hours after scheduled times, contrary to facility policy requiring administration within one hour. Staff and resident council documentation described one nurse caring for over 30 residents and only two CNAs for that unit, with staff stating they were at bare minimum staffing and unable to complete all required care.
The facility failed to provide timely incontinence care and improperly used double incontinence briefs for two residents who were dependent on staff for ADLs. One resident, with a care plan noting a stage 2 pressure sore and risk for further skin breakdown related to incontinence and comorbidities, reported not being changed since morning and was found wearing two briefs, with excoriated and bleeding skin; the CNA stated she routinely used two briefs due to workload and delayed care. Another resident was found with two saturated briefs, urine and stool present, and a large reddened scrotum, and a CNA confirmed double briefs had been applied by the prior shift and should not be used because of skin concerns. Resident council minutes documented ongoing concerns about delayed and inconsistent call light response and staff turning off call lights without providing requested assistance, while the DON and facility policy specified that residents should not routinely wear double briefs and should be checked for incontinence every two hours and as needed.
Staff failed to follow facility incontinence care protocols when providing perineal hygiene to three residents who were incontinent of bowel and bladder. CNAs repeatedly used the same washcloth or towel to clean residents’ groin, perineal, and feces-contaminated perianal areas instead of using clean linens for single swipes as required. One resident had a saturated brief and a large, reddened scrotum, yet only one washcloth was used for all areas; another resident’s groin and perianal area were cleaned with a single washcloth; and a third resident’s groin, perineal, and stool-contaminated perianal areas were wiped with one towel, followed by a wet paper towel to remove soap. The DON acknowledged staff concerns about insufficient linens, confirmed that disposable wipes were not used, and stated that the facility’s expectation of single-use swipes with clean washcloths could not be met without adequate linen, despite care plans and policy requiring proper perineal care to help prevent UTIs.
Several residents received cold foods and beverages, such as milk and orange juice, at temperatures above facility policy standards, with some items served warm and sandwiches showing signs of poor quality. Staff confirmed that equipment was not maintaining proper temperatures, and temperature checks revealed that cold items were not kept at the required 41°F, resulting in a failure to provide palatable and safe meals.
Multiple residents were served smaller-than-required portions of protein and juice, with some receiving only one slice of ham or a turkey sandwich with insufficient protein, and breakfast juice served in half-filled, watered-down cups. Staff confirmed that menu requirements for portion sizes were not met, and residents reported ongoing hunger and the need for families to supplement their meals.
The facility did not consistently serve palatable meals at appropriate temperatures, as required by its policy. Observations showed that hot foods were often below the minimum temperature standard, and the plate warming equipment was only partially functional. Staff had stopped using warming pellets, and some were unaware of their availability. Multiple residents reported that their meals were served cold or unappetizing, with some refusing to eat facility-provided food. Food quality issues were also noted, including bland and improperly prepared meals.
A resident with multiple documented food allergies was repeatedly served meals containing allergens such as melons and cucumbers, despite informing staff and having her allergies listed in her care plan. Staff interviews revealed confusion and lack of awareness about the resident's allergies, and meal tickets showed inconsistent documentation, leading to continued exposure to foods she could not safely consume.
A resident in a long-term care facility experienced verbal and physical abuse by a CNA, leading to trauma and insomnia. The incident began when the resident requested assistance, resulting in a verbal altercation and the CNA striking the resident's hand. Despite video evidence and police involvement, the facility's investigation was inadequate, and staff failed to provide immediate support to the resident.
The facility failed to monitor refrigerator temperatures, label and date food items, and prevent cross-contamination in the kitchen. Additionally, the Dietary Manager was observed without a beard covering while handling food, violating the facility's hygiene policy. These actions affected all residents receiving food from the facility.
The facility failed to follow its grievance policy, affecting several residents who were unaware of the grievance process and did not receive feedback on their concerns. Issues such as missing personal items and staff using cell phones during care were not documented or resolved. The Resident Council raised concerns about staff cell phone use, but the problem persisted despite staff training.
The facility failed to provide adequate assistance with ADLs for several residents, leading to deficiencies in personal hygiene and care. Residents with various medical conditions were observed in unkempt states, wearing soiled clothing, and exhibiting poor personal hygiene. Despite requests for assistance with grooming and hygiene, staff did not provide the necessary care, resulting in compromised resident dignity.
The facility failed to provide adequate incontinence and catheter care, risking UTIs for several residents. A CNA did not properly clean a resident with a suprapubic catheter, and another CNA used the same cloth for different areas, risking cross-contamination. The facility's guidelines emphasize thorough cleaning to prevent infections, but these were not followed.
The facility failed to provide bedtime snacks as per their menu, affecting several residents who reported only receiving stale peanut butter sandwiches. The menu listed various snack options, but the Food Service Supervisor confirmed that only peanut butter sandwiches were prepared, with no beverages served. A review of the kitchen stock revealed a lack of several items listed on the always available menu.
The facility failed to implement proper infection control measures, including inadequate transmission-based precautions and improper hand hygiene. Residents with symptoms of infections were not placed on appropriate precautions, and staff did not perform hand hygiene or change gloves between tasks, leading to potential cross-contamination.
A resident's privacy was compromised during a shower when a CNA left the door open while assisting the resident, who was unclothed. The resident, who requires moderate assistance and is cognitively intact, was observed by a surveyor in this state. The Director of Nursing confirmed that this was a privacy issue, as the facility's guidelines emphasize the right to dignity and respect.
A resident reported being verbally and physically assaulted by a CNA, but the facility failed to conduct a thorough investigation. The facility did not review available video footage or request the police report, and the investigation lacked documentation of an interview with a nurse present during the incident. The police report indicated the CNA was arrested for battery.
A resident with a vascular wound on the left leg did not receive timely dressing changes, resulting in a heavily soiled dressing with urine, which overflowed onto the wound. The wound care nurse confirmed that dressings should be changed daily and as needed to prevent infection, but this protocol was not followed. The DON acknowledged the increased risk of infection due to the soiled dressing.
A resident with multiple diagnoses, including hemiplegia and contractures, was not provided with necessary braces to prevent further reduction in ROM, despite a care plan indicating their use. Observations and interviews confirmed the absence of braces, and an occupational therapist recommended their use to maintain joint integrity. The facility did not implement these interventions, as acknowledged by the DON.
A facility failed to document the necessary post-dialysis assessments for a resident with end-stage renal disease. The resident required in-facility hemodialysis four days per week, but the facility nurses did not complete the after-dialysis portion of the communication form on several occasions. This failure to document assessments, such as checking the fistula and monitoring vital signs, was contrary to the facility's policy for post-dialysis monitoring.
A resident with dementia and multiple medical conditions was not provided with meaningful activities, despite being bed-bound and dependent on staff. The resident frequently called out for attention, but staff often ignored her calls, failing to provide the necessary engagement. Although the facility's policy requires tailored activities, there was no evidence of such activities being provided, leading to a deficiency.
A resident with a pelvic fracture developed a Stage 3 pressure injury due to the facility's failure to perform adequate skin assessments. Despite having a low air loss mattress and being able to reposition himself, the resident's skin was not properly checked during showers, and the injury was not identified until it reached an advanced stage. Documentation inconsistencies and lack of adherence to skin assessment protocols contributed to the deficiency.
A resident was physically assaulted by another resident over the volume of a TV, resulting in multiple facial injuries and the need for emergency medical treatment. The facility failed to protect the resident from abuse, despite having an abuse prevention policy in place.
Failure to Supervise High-Risk Resident Resulting in Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent a fall for a resident with known fall risk factors. The resident had multiple diagnoses, including COPD, type 2 diabetes, heart failure, depression, muscle wasting and atrophy, and osteoporosis, and was assessed as having moderate cognitive impairment. Her care plan identified her as at risk for falls related to general weakness, overestimating her abilities, poor coordination, unsteady gait, use of narcotics, decreased safety awareness, and impulsiveness with attempts to stand or self-transfer without assistance despite repeated education. The care plan interventions included observing her frequently, placing her in supervised areas when out of bed, and promptly toileting and laying her down after meals. On the day of the incident, a CNA assisted the resident to the toilet after lunch and, at the resident’s request, left her in her room sitting up in her wheelchair so she could watch TV. Staff interviews indicated that the resident was often kept near the nurse’s station or in activities for closer monitoring due to her fall risk, and that her room was not considered a supervised area because staff were not always present in that hallway. Despite this, the CNA left her alone in her room, and the RN later found her on the floor in front of her wheelchair. The resident reported that she had bent down to fix her slip-on shoes, lost control, and fell forward onto her right side. Nursing notes documented that the resident was found on the floor on her right side, with a bump on her right temple and complaints of right shoulder pain, and that she was later diagnosed at the hospital with a traumatic closed fracture of the distal right clavicle and a closed head injury. The DON and nursing staff acknowledged that monitoring and keeping the resident in high-supervision areas were key fall prevention measures for her, and that her room did not meet this standard. The CNA who left her in the room stated she was not fully familiar with the resident’s specific care needs and relied on shift report for information. There was no documentation in the care plan or nursing notes of the resident’s preference to stay in her room, nor any documented discussions with her power of attorney or family about alternative fall prevention measures, despite the facility’s policy requiring identification of accident risks, communication of specific interventions to staff, and consistent implementation and monitoring of those interventions.
Nurse Leaving Unit Causes Unsupervised Residents and Unmet Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to ensure consistent nursing supervision and provision of care when the assigned nurse left the unit for an extended period during an overnight shift. One cognitively intact resident with multiple complex diagnoses, including congestive heart failure, asthma, morbid obesity, type II diabetes, chronic kidney disease, and various psychiatric conditions, reported activating the call light late at night for anxiety medication. A CNA responded and attempted to locate the assigned LPN but was unable to find her. The resident later observed the LPN asleep in a car in the parking lot and, after continued absence of the nurse and ongoing unmet needs among several residents, called the local police nonemergency line. The resident reported that after the police officer awakened the LPN in the car, the LPN eventually returned to the building but later left the floor again to buy coffee. Another resident with significant cardiopulmonary and neurologic conditions, including COPD, asthma, congestive heart failure, cerebral infarction with hemiplegia/hemiparesis, and a care plan requiring bronchodilators as ordered and head-of-bed elevation during episodes of breathing difficulty, was reported by staff to have been anxious and experiencing breathing problems during the time the LPN was off the unit. A CNA stated that the LPN had been informed at the beginning of the shift that a resident needed a wound dressing change, but the dressing was not changed, and the resident continued to call throughout the night while the LPN was in the car. During this same period, paramedics arrived in response to a male resident’s 911 call reporting that he was on the floor and could not find the nurse; the LPN was reportedly unaware of the situation and attempted to dismiss the resident’s report to paramedics. A third cognitively intact resident with multiple diagnoses including heart failure, asthma, respiratory failure, morbid obesity, chronic pain, and major depressive disorder reported being asleep during the incident but stated that she had heard about it from several residents and that the LPN was not allowed to administer her medications due to a prior refusal to provide ordered pain medication. Both this resident and the first resident reported prior issues with the same LPN, including wrong medication administration and refusal to administer pain medication, and stated that the LPN was not to pass medications to them. A CNA corroborated that the LPN left the floor for several hours, could not be reached by calls or texts, and that this was not the first time the LPN had left the floor for extended periods. Review of grievances, employee files, and investigation materials showed no contemporaneous documentation of concerns or disciplinary actions related to the incident, and there were discrepancies between staff progress notes and the police dispatch times regarding when the LPN was actually on break and contacted by law enforcement.
Failure to Follow Menu-Specified Portion Sizes for Mechanical Soft Meals
Penalty
Summary
The facility failed to serve menu-specified portion sizes for a lunch meal, resulting in residents receiving smaller portions than required to meet their nutritional needs. The facility’s week-at-a-glance menu for a specific Tuesday listed hamburger with seasoned pinto beans and seasoned corn, and the corresponding menu spreadsheet directed that mechanical soft diets receive a #10 scoop plus 1 oz broth of ground hamburger. During interviews, one resident who received room trays reported that the food was horrible and that portions were small, while another resident stated that portions were sometimes so small that they were only enough to feed grandchildren. The Resident Council President reported frequent complaints from residents about small portions, residents going to vending machines due to hunger, personal experiences of being hungry despite an order for double protein, receiving jerk chicken with hardly any meat to cover the bun, and being served cereal in a dessert bowl. During an observed meal service at the kitchen steam table for second-floor residents on mechanical soft diets, a dietary aide plated food using a small black scoop for ground hamburger for four residents on mechanical soft consistency diets. When questioned, the aide did not know the scoop size, reported not looking at the menu spreadsheet, and no spreadsheet was present at the steam table. The food service manager, who stated that both she and the aide were new and still in training, identified that the aide should have used a #12 green scoop and confirmed that the black scoop in use was a #30 scoop providing approximately 1.07 oz. The facility’s recipe for Ground Hamburger with Broth specified a serving size of a #10 scoop plus 1 oz broth, with instructions to serve 2 oz ground protein with a #10 scoop plus 1 oz hot broth, and the facility’s scoop chart showed that a #10 scoop equals 3.33 oz and a #12 scoop equals 2.90 oz. The dietitian stated that recipes indicate serving sizes to ensure meals meet caloric and protein needs and that using the wrong scoop affects meal planning.
Failure to Maintain Hot Food Temperatures and Follow Tray Line Temperature Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide hot, palatable food at safe and appetizing temperatures, particularly for residents receiving room trays. Multiple residents reported that their meals were frequently cold or only lukewarm. One resident who routinely eats in her room stated that the food is horrible and most of the time cold. Another resident reported that food is sometimes hot but often cold, noting that most residents eat in their rooms. A resident who returns from dialysis stated that his food is lukewarm at best and complained that a CNA refused to reheat his meal after dialysis. The Resident Council President reported that residents frequently receive cold food, sometimes covered only with plastic wrap instead of insulated covers, and that warming pellets had been eliminated. He also stated that some CNAs tell residents they will reheat food only once and then residents are on their own, which is problematic for residents who use wheelchairs. Surveyors observed the meal service and found that required food temperature checks were not performed at the start of service. A dietary aide acknowledged not taking food temperatures that day. The facility used a mix of unheated plastic plates for dementia unit residents and China plates warmed in an oven, while plate warmers and warming pellets were not in use. Plated meals were covered with insulated domes and transported in carts, but the facility ran out of domed covers toward the end of service, and some food was placed on a small metal cart. When a CNA took temperatures from a test tray after a resident’s tray was passed, the hamburger and side dishes measured between 103.6°F and 114.6°F, below the facility policy and dietitian’s stated acceptable range of at least 120°F for hot foods. The facility’s written policy required that all food temperatures on the serving line be measured and recorded at every meal and that hot foods not be served below 120°F, which was not followed during the observed meal service.
Failure to Maintain Routine Housekeeping and Clean Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with a safe, clean, comfortable, and homelike environment by not routinely cleaning resident rooms and bathrooms and not consistently emptying trash. On the survey date, no housekeepers were observed on the first floor, and the receptionist was seen entering resident rooms to empty garbage cans due to the absence of housekeeping staff. One resident’s bathroom toilet was filled with toilet paper and stool and had a strong stool odor, and a CNA reported that the toilet had been in that condition for at least three weeks. Another resident’s room and bathroom trash bins had no liners, and the room floor was sticky with splatter marks of an unknown substance that the resident stated had been present for at least a month. Multiple residents reported that their rooms were not cleaned daily and that trash was not emptied regularly, with one resident stating that her bathroom garbage, containing incontinence briefs from a former roommate, had been full since Sunday and was only removed after she asked an aide on Thursday. Additional resident interviews and staff statements confirmed inconsistent housekeeping practices. One resident stated that housekeeping had deteriorated from daily cleaning to sometimes going a week without cleaning. Another resident reported that her garbage can often became very full because it was not emptied regularly and that it had been a long time since her room was cleaned. The administrator acknowledged that he was managing housekeeping due to the lack of a housekeeping manager and stated that resident rooms should be cleaned daily. The receptionist, who had prior housekeeping experience, described that daily room cleaning should include emptying garbage, cleaning high-touch surfaces, sweeping and mopping floors, and cleaning bathrooms, but noted she could only help with spot cleaning before returning to reception duties. A CNA reported that not all rooms were cleaned daily and relayed that the housekeeper described room cleaning as “more of a lottery” as to which rooms were cleaned each day. Resident Council minutes from three consecutive months documented resident concerns about sticky floors after mopping, the dining room not being cleaned after meals and activities, and requests for additional garbage bins. A routine resident room housekeeping policy was requested by surveyors but was not provided.
Failure to Use Required PPE and Isolation Precautions for COVID-19 Positive Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently used appropriate personal protective equipment (PPE) and isolation practices for residents who were COVID-19 positive. Surveyors observed that a receptionist entered the room of a resident on contact/droplet isolation for COVID-19 wearing gloves, gown, and a surgical mask, then exited the room still wearing the PPE and disposed of the gown and gloves in a housekeeping cart in the hallway. Another resident who was COVID-19 positive was in the dialysis room while a dialysis technician provided care wearing only a surgical mask and gloves, without full PPE as required by facility policy. In addition, a COVID-19 positive resident was in the dialysis room without a mask, in the same space as two other residents who were not listed on the COVID isolation list, while dialysis staff wore only partial PPE (surgical masks, with one staff member also wearing a gown and using regular glasses as eye protection). Further observations showed that two residents who were COVID-19 positive did not have contact/droplet isolation signs on their door, only a general PPE instruction sign, and a CNA entered their room wearing only a surgical mask. The CNA stated she did not know whether these residents were on isolation, reporting conflicting information from others. The DON stated that residents who test positive for COVID-19 are to be placed on contact/droplet isolation for 10 days, with a sign on the door and staff required to wear gloves, gown, N95 mask, and face shield, and that COVID-positive residents may leave their rooms for dialysis only if they wear a surgical mask. Facility policies, including the PPE and Source Control Policy, Acute Respiratory Illness Management Policy, and Viral Respiratory Pathogens Toolkit, require appropriate transmission-based precautions, including N95 respirator, eye protection, gown, gloves, room restriction except for medically necessary purposes, and contact/droplet isolation for 10 days for residents with COVID-19. These documented requirements were not followed in the observed instances.
Facility Fails to Provide Adequate Supply of Clean Linens for Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to provide clean linens in sufficient quantity to meet the care needs of all 98 residents. Surveyors observed multiple linen carts on both floors with either no washcloths or bath towels, or only a few items available, some of which were stained or visibly worn and frayed. On several occasions, linen carts contained only a small number of bed sheets, pillowcases, blankets, or gowns, but lacked basic items such as washcloths and towels needed for bathing and incontinence care. The Director of Nursing (DON) acknowledged that a stained towel on a cart was not acceptable for use and reported that CNAs had voiced concerns about not having enough linen to provide resident care. Residents reported ongoing problems with both the quantity and condition of linens. One resident stated she could not find a usable washcloth because some appeared soiled even after laundering and that some linens were so stained she did not want them on her body; she reported throwing some linens away and cutting up towels to make washcloths. Another resident, who served as Resident Council President, reported that on one day there were no towels available on either floor for her shower, leading her to wash with a paper towel, and that her fitted sheet had a large brown stain present when it was placed on her bed. This resident also stated that towels were not clean, were often stained, had feces on them, and had an odor, and that residents, families, and staff had been purchasing their own disposable wipes due to concerns about facility linens. Additional residents reported days when no washcloths were available, having to cut towels into pieces to use as washcloths, and purchasing their own disposable wipes because facility washcloths were stained and dirty. Staff interviews corroborated the lack of adequate, clean linens. CNAs described the linen supply situation as “horrible,” stating there were no washcloths or towels available for resident care and that they had personally purchased washcloths and wipes from home to use on residents, discarding them after use. One CNA reported using tissue to pat residents dry during incontinence care when linens were unavailable. An LPN stated that linens were “disgusting” and that she had seen linens come from the cart improperly cleaned. The laundry staff member reported having no backup face cloths, waiting on an order for more, and stated that soiled linens were often sent down late in her shift, limiting her ability to clean them in time. She also acknowledged that some washcloths and towels remained stained even after being washed twice. Resident Council meeting minutes over several months documented resident requests for more frequent linen changes, a greater variety of linens, and stronger or different facial washcloth materials.
Widespread Failure to Administer Medications Within Policy Timeframes
Penalty
Summary
The deficiency involves the facility’s failure to administer medications within one hour of the prescribed times as required by its own medication administration policy. The electronic medical record (EMR) and Medication Admin Audit Reports showed repeated late administration of scheduled medications for multiple cognitively intact residents, including psychotropic medications, diabetic medications, pain medications, and topical treatments. For one resident who served as Resident Council President, multiple medications scheduled for late afternoon and evening (such as Buspirone, Lamotrigine, Dicyclomine, Trazodone, Ezetimibe, Mirtazapine, Lomotil, Gabapentin, Propranolol, and topical creams) were consistently given more than an hour late over several days. Another cognitively intact resident reported that nurses stated they were busy and that residents would receive medications when the nurses could get to them; this resident’s Buspirone, Metformin, probiotic, buprenorphine/naloxone, Omeprazole, blood glucose checks, and multiple evening medications (including Lipitor, Gabapentin, insulin glargine, Trazodone, and Amitriptyline) were documented as administered significantly later than scheduled. Additional residents reported and demonstrated similar patterns of delayed medication administration, particularly related to diabetic care and insulin timing. One cognitively intact resident stated her blood glucose check was not completed as scheduled because the nurse was out of testing strips and had to obtain them from another area; this resident’s insulin glargine and insulin lispro doses, as well as Dicyclomine, were administered well after their scheduled times. Another cognitively intact resident reported that afternoon-shift nurses passed medications late and described an instance where diabetic medications due at 6:00 PM were not received until 9:00 PM; documentation showed late administration of Atorvastatin, Humalog insulin, and Metformin. A further cognitively intact resident reported there were not enough nursing staff, and records showed her Carvedilol and blood glucose monitoring scheduled for 5:00 PM were not completed until 8:36 PM. The pattern of late medication administration extended to residents with cognitive impairment and to other scheduled treatments. A severely cognitively impaired resident had ophthalmic solutions, topical cream, and blood glucose monitoring scheduled for early evening but administered more than two hours late, and on subsequent days had blood glucose checks and evening insulin and Terazosin given beyond the one-hour window. Another cognitively intact resident’s morning and noon medications, including insulin lispro, insulin glargine, Pregabalin, Buspirone, multiple oral medications, and buprenorphine, were administered significantly later than scheduled. One resident reported waiting more than two hours for medications and a CNA stated this resident complained that nurses might not give her medications because her room was at the far end of the hallway. Resident Council meeting minutes over several months documented resident concerns about call light response times, inconsistent follow-up, and staff turning off call lights before addressing residents’ requests. A nurse (LPN) reported being the only nurse for 32 residents, described being nonstop busy, unable to take breaks, and “just surviving every shift, ” in the context of the facility policy requiring medications to be administered within one hour of prescribed times.
Insufficient Nursing Staff Leading to Missed Incontinence Care and Delayed Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ incontinence care and medication administration needs, resulting in missed or delayed care for multiple residents. One resident with a care plan identifying a stage 2 pressure sore on the left buttock and risk for further skin breakdown due to incontinence, impaired mobility, diabetes, and comorbidities reported not receiving incontinence care since getting out of bed in the morning. When a CNA provided care around midday, the resident was found wearing two incontinence briefs with a small amount of thick feces and blood in the brief, and excoriation of the buttocks, sacrum, scrotum, and a bleeding left abdominal fold. The CNA stated she routinely placed two briefs on this resident because she was responsible for many residents, could not always get back to him, and believed the extra brief would keep his clothes dry when he sat in a wet brief for extended periods. Another resident with a care plan for bowel and bladder incontinence, including an intervention to clean the perineal area with each incontinence episode, was observed during incontinence care wearing two briefs that were saturated with urine and stool, with a large, reddened scrotum. The CNA providing care stated the double briefs had been applied by the previous shift and acknowledged that residents should not wear two disposable briefs at the same time because it was bad for their skin. The DON later stated that residents should not have two briefs on unless this was a care-planned preference and that double-briefing could lead to skin breakdown and UTIs if not changed, while facility policy required residents to be checked periodically for incontinence and provided appropriate perineal/genital care. Multiple cognitively intact residents reported that medications, including routine and PRN pain medications, were often late and that nurses told them they were busy and would give medications when they could. Medication administration records showed repeated delays beyond the facility’s policy requirement that medications be administered within one hour of prescribed times. One resident council president reported complaints from residents about late medications, long call light response times, and insufficient staff; their MAR showed numerous medications scheduled for late afternoon and evening being given more than an hour late on several days. Other residents reported late blood glucose checks and insulin administration, with documentation showing insulin and other medications given one to several hours after scheduled times. One resident stated their blood glucose check was delayed because the nurse lacked testing strips and had to obtain them from another area, and that insulin ordered for early evening was not given until later at night. Additional residents described waiting more than two hours for medications and feeling there were not enough nurses to pass medications when needed. MAR reviews for several cognitively intact and severely cognitively impaired residents showed repeated late administration of ophthalmic medications, creams, oral medications, blood glucose monitoring, and insulin, often one to two hours after scheduled times. Resident council minutes over several months documented ongoing concerns about call light response times, inconsistent follow-up, and staff turning off call lights before providing requested assistance. Staff interviews revealed that one LPN was responsible for 32 residents on a floor that previously had 25 residents, and CNAs reported working with only two CNAs for 30 residents, including many with mechanical lifts, feeding needs, and dialysis schedules. The DON confirmed that the first floor, with about 30 residents, was staffed with two CNAs and one nurse on all shifts, despite the facility assessment and staffing policy stating staffing should be based on census and acuity to ensure sufficient staff to meet residents’ care needs.
Failure to Provide Timely Incontinence Care and Improper Use of Double Briefs
Penalty
Summary
The facility failed to provide timely incontinence care and improperly used double incontinence briefs for residents dependent on staff for ADLs. One resident reported not receiving incontinence care since getting out of bed in the morning and was found wearing two incontinence briefs, with a small amount of thick feces and blood in the brief. His buttocks, sacrum, scrotum, and left abdominal fold were excoriated, with the abdominal fold bleeding. The CNA caring for him stated she usually placed two briefs on him because she was unable to get to him promptly due to having many residents to care for, and that she checked residents every two hours and used the extra brief as a liner to keep his clothes dry. She reported he had last been changed at about 7:30 AM and acknowledged he had excoriation from sitting in a wet brief all day. The resident’s care plan documented a stage 2 pressure sore on the left buttock and risk for additional or worsening skin integrity issues related to incontinence, impaired mobility, diabetes, and comorbidities, with interventions including checking for incontinence as needed and providing peri care. Another resident was observed receiving incontinence care while wearing two incontinence briefs, with the brief saturated with urine and stool and his scrotum large and reddened. The CNA providing care stated the double briefs had been applied by the previous shift and acknowledged residents should not have two disposable briefs on at the same time because it was bad for their skin. This resident’s care plan indicated bowel and bladder incontinence with an intervention to clean the peri area with each incontinence episode. Resident council meeting minutes over several months documented resident concerns about call light response times, variability in staff follow-up, and staff turning off call lights before providing requested assistance. The DON stated residents should not have two incontinence briefs on unless this was a care-planned preference and acknowledged that double briefs may lead to skin breakdown and UTIs if not changed, and that incontinent residents were to be checked every two hours and as needed per facility policy, which required periodic checks and perineal/genital care to prevent infection and improve quality of care.
Improper Incontinence Care and Inadequate Linen Use During Perineal Hygiene
Penalty
Summary
The deficiency involves staff failing to provide incontinence and perineal care according to facility policy and protocols, primarily due to inadequate use of clean linens and improper wiping techniques. For one resident with bowel and bladder incontinence, a CNA opened a saturated brief and observed a large, reddened scrotum, then used a single washcloth multiple times to wipe the penis, scrotum, buttocks smeared with feces, and rectal area. The CNA stated that disposable wipes were no longer used, that towels usually ran out, and that only one towel was available for the incontinence care provided. The resident’s care plan required cleaning the perineal area after each incontinence episode. Another resident with bowel and bladder incontinence received perineal care from the same CNA, who reported finding only one washcloth on the linen cart. The CNA used that single washcloth to wipe the groin from right to left and then down the perineal area, and then used the same cloth to clean the perianal area. A third resident, also incontinent of bowel and bladder, received care from a different CNA who had only one washcloth and one towel. The CNA wet the bath towel and used it to wipe the groin, perineal, and perianal areas, including an area with stool, and then used a wet paper towel to remove soap from the perineal area. The DON confirmed that CNAs had voiced concerns about not having enough linen, that the facility used washcloths and bath towels instead of disposable wipes, and that staff were expected to swipe only once with each clean washcloth during perineal care, which could not be met if linens were insufficient. The facility’s incontinence care policy required perineal and genital care to prevent infection and ensure appropriate care and services to prevent urinary tract infections.
Failure to Serve Cold Foods and Beverages at Safe Temperatures
Penalty
Summary
The facility failed to provide cold foods and beverages at acceptable palatable temperatures for five residents reviewed for food preparation and quality. Multiple residents reported that items intended to be served cold, such as orange juice and milk, were instead served warm. One resident received a breakfast tray with milk and orange juice at 9:37 AM but did not return from dialysis until 11:30 AM, by which time the items were no longer at a safe temperature. Other residents also stated that their cold foods and drinks were served warm, and the quality was poor. Observations during tray line service revealed that deli sandwiches were placed next to the steam table, and a ham sandwich tested at 70 degrees Fahrenheit. Sandwiches also showed signs of poor quality, such as wilted lettuce and melting cheese. Temperature checks conducted by facility staff confirmed that cold beverages were not maintained at appropriate temperatures, with orange juice and milk measuring above the required 41 degrees Fahrenheit. The dietary manager acknowledged that the juice dispenser was not keeping juices cold, and the dietitian confirmed that cold items should be at 40 degrees Fahrenheit at the serving station and at least 45 degrees at point of service. Facility policy requires cold foods to be maintained at 41 degrees Fahrenheit and served at 40-45 degrees for palatability, but these standards were not met during the survey period.
Failure to Provide Adequate Protein and Juice Portions as Specified in Menu
Penalty
Summary
The facility failed to provide residents with the appropriate portion sizes of protein and juice as specified in the facility's menu and as required to meet residents' nutritional needs. Observations and interviews revealed that multiple residents received less than the required 3 ounces of ham for lunch, with some receiving only one slice weighing 2.3 ounces, and substitute turkey sandwiches containing only 2 slices of deli meat and one slice of cheese, which did not provide an equivalent amount of protein. Additionally, breakfast trays included only half-filled cups of orange juice, and residents reported that the juice was watered down. Staff confirmed that ice was added to juice containers before serving, further diluting the juice. Residents expressed dissatisfaction with the portion sizes, stating they were still hungry and that their families had to bring additional food. The facility's dietitian confirmed that the menu required 3 ounces of ham and 6 ounces of orange juice to meet dietary requirements, and that substitute items should be nutritionally comparable to the main entree. The dietary aide and interim dietary manager acknowledged inconsistencies in portion sizes and preparation, with pre-sliced ham of varying thickness and sandwiches prepared the day before. Facility policy required menus to be developed according to national guidelines and reviewed by a dietitian to ensure residents' nutritional needs were met, but these standards were not followed, resulting in insufficient food portions for the majority of residents reviewed.
Failure to Serve Palatable Meals at Required Temperatures
Penalty
Summary
The facility failed to serve palatable meals at appropriate temperatures in accordance with its own policy, affecting all residents receiving oral diets. During multiple meal services, observations revealed that hot foods were not maintained at the required temperatures, with measured temperatures for items such as pork, rice, and green beans falling below the facility's minimum standard of 120 degrees Fahrenheit. The plate warmer was only partially functional, with hot plates available on one side and only slightly warm plates on the other. Staff attempted to compensate by transferring plates between sides during service, but this did not ensure consistent hot food delivery. Additionally, the use of warming pellets under meal plates had been discontinued about a week prior to the survey, and some staff were unaware of their availability. Resident interviews consistently described dissatisfaction with the temperature and palatability of meals. Several residents reported that their food was served cold or unappetizing, with some choosing not to eat the facility-provided meals or opting to order food from outside. Specific complaints included cold breakfasts, tough and dry meats, undercooked or overcooked vegetables, and sandwiches that were either burnt or not toasted. The Resident Council President confirmed that the discontinuation of warming pellets had negatively impacted food temperature, and multiple residents stated that hot foods were not consistently served hot. Further observations during meal service found that food quality was also lacking, with meals such as macaroni and cheese with beef described as bland, lacking seasoning, and missing cheese sauce. Vegetables were found to be mushy or overcooked, and some meals were served with large blocks of margarine rather than being properly prepared. Facility recipes indicated that certain preparation standards, such as not overcooking vegetables, were not followed. Staff interviews corroborated that the use of warming equipment had changed recently and that there were issues with the plate warmer's effectiveness.
Failure to Accommodate Resident Food Allergies and Preferences
Penalty
Summary
A resident with documented allergies to shellfish, squash, all melons, bananas, and cucumbers repeatedly received meals containing these allergens despite informing facility staff of her allergies. The resident reported being served a salad with cucumber and a tray with melons on multiple occasions, and provided photographic evidence of the meals. Interviews with staff, including a CNA and the Dietary Manager, confirmed that the resident had been served foods she was allergic to. The Dietary Manager was unaware of all the resident's allergies, and there was confusion regarding whether cucumber was an allergy or a dislike, as reflected by handwritten changes on the resident's meal ticket. The Registered Dietitian also did not confirm the cucumber allergy directly with the resident, relying instead on information from the resident's daughter. The resident's care plan and medical records clearly listed her allergies, and the facility's policy required identification and accommodation of food allergies. Despite this, the resident continued to receive meals containing allergens, and staff interviews revealed a lack of consistent understanding and communication regarding her dietary restrictions. The facility had previously documented the need to double-check the resident's trays and ensure unwanted items were not served, but these measures were not effectively implemented, resulting in repeated exposure to allergens.
Resident Suffers Abuse by CNA, Facility Fails to Protect
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a Certified Nursing Assistant (CNA), resulting in the resident feeling traumatized and unsafe. The incident involved a male resident who was cognitively intact and had a history of severe medical conditions. The altercation began when the resident requested assistance from the CNA to empty his urinal, which led to a verbal confrontation. The CNA responded with yelling and cursing, and when the resident began recording the interaction, the CNA physically struck the resident's hand, causing his phone to fall. The resident reported feeling unsafe and traumatized by the incident, which was corroborated by video evidence showing the CNA's aggressive behavior. The resident expressed fear and insomnia following the event, indicating a significant impact on his mental well-being. Despite the presence of other staff members during the altercation, there was a lack of intervention to de-escalate the situation or provide immediate support to the resident. The facility's investigation into the incident was inadequate, as it failed to document key witness interviews and did not review available video footage. The police were involved, and the CNA was arrested for battery. The facility's response to the resident's distress was insufficient, as staff did not inquire about his well-being or offer immediate medical evaluation following the incident.
Deficiencies in Food Safety and Staff Hygiene Practices
Penalty
Summary
The facility failed to properly monitor and maintain food safety standards in their kitchen, affecting all residents receiving food from the facility. During an inspection, it was observed that the reach-in refrigerator containing milk and cheeses lacked a functional thermometer, and the temperature logbook for several days was blank, indicating a failure to monitor refrigerator temperatures. Additionally, a tray of partially covered shredded pork in the walk-in refrigerator was not properly labeled, and pork chops in the walk-in freezer were not sealed correctly, leading to freezer burn and ice accumulation. The pork chops were stored under a leaking fan, which was acknowledged by the Dietary Manager, who stated the fan was in the process of being fixed. Furthermore, the facility did not ensure that dietary staff adhered to personal hygiene policies, as the Dietary Manager was repeatedly observed without a beard covering while preparing and serving food. This was in violation of the facility's policy requiring facial hair to be covered in the kitchen. Other staff members confirmed the requirement for hair coverings, yet the policy was not consistently enforced. These deficiencies in food storage, labeling, and staff hygiene practices were contrary to the facility's own policies and professional standards, potentially compromising food safety for the residents.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adhere to its grievance policy, impacting eight residents who were reviewed for grievances. During a resident interview meeting, several residents expressed that they were unaware of the facility's grievance process and had not received feedback on their concerns. The Ombudsman provided a grievance form to the residents, who stated they had never seen it before. Specific grievances, such as missing personal items and concerns about staff using cell phones during care, were not documented or addressed according to the facility's records. Additionally, the Resident Council had raised issues about staff cell phone use in multiple meetings, but the problem persisted despite an in-service training provided to staff. Several residents reported specific grievances that were not filed or addressed. One resident mentioned missing clothing and a phone charger, while another reported a missing razor and coat. These grievances were not found in the facility's records. Another resident expressed concerns about untimely incontinence care, which was also not documented. The facility's grievance policy requires that grievances be filed and resolved promptly, but the facility did not comply with this policy, as evidenced by the lack of documentation and resolution of the residents' concerns.
Deficiencies in ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for nine residents, leading to deficiencies in personal hygiene and care. Residents with various medical conditions, including hemiplegia, dementia, and osteoarthritis, were observed in unkempt states, wearing soiled clothing, and exhibiting poor personal hygiene. For instance, one resident with hemiplegia was found in the same hospital gown for several days, with stringy hair and a foul odor, indicating a lack of assistance with bathing and grooming. Another resident, who was incontinent and required substantial assistance, was found with a saturated incontinence brief and excoriation in the groin area, suggesting neglect in timely incontinence care. This resident also had long, jagged nails and facial hair, despite requesting assistance from staff. Similarly, a resident with severe cognitive impairment was observed wearing the same clothes for multiple days, with long nose hair and facial whiskers, indicating a lack of grooming and hygiene care. Additional residents expressed the need for assistance with nail care and shaving, which was not provided despite their requests and the acknowledgment of staff. The facility's policy on ADL care, which includes hygiene, grooming, and toileting, was not adhered to, as evidenced by the observations and resident interviews. The Director of Nursing confirmed that residents should receive assistance with ADLs, but the report highlights a systemic failure to meet these care standards, resulting in compromised resident hygiene and dignity.
Inadequate Incontinence and Catheter Care Leading to UTI Risks
Penalty
Summary
The facility failed to provide adequate incontinence and catheter care, leading to potential risks of urinary tract infections (UTIs) for several residents. One resident, who had a history of traumatic brain injury and other urological issues, was not properly cleaned by a CNA during incontinence care, as the CNA did not ensure the penile and scrotal area were cleaned before changing the incontinence brief. Another resident with vascular dementia and a stage 4 pressure ulcer was also inadequately cleaned, as the CNA failed to clean the front perineum after a bowel movement before placing a new incontinence brief. Additionally, a resident with multiple sclerosis and a suprapubic catheter was observed with a leaking catheter, and the CNA did not clean the abdominal folds or catheter tube properly. The facility's Director of Nursing confirmed that the staff should clean the entire peri-area from front to back to prevent skin breakdown and UTIs. Another resident, who was cognitively intact but required maximum assistance, was not properly cleaned during incontinence care, as the CNA used the same disposable cloth for different areas, risking cross-contamination. The facility's guidelines and policies emphasize the importance of thorough cleaning to prevent infections, but these were not followed in the observed cases.
Failure to Provide Adequate Bedtime Snacks
Penalty
Summary
The facility failed to provide bedtime snacks in accordance with their menu, affecting five residents who attended a resident council meeting. During the meeting, residents expressed concerns about the availability and quality of bedtime snacks. They reported that only peanut butter sandwiches were served, and not all residents received them. Some residents mentioned that the sandwiches were stale, and only those who could reach the nurses' station were able to obtain them. This issue was consistent across different floors, as noted by residents residing on both the first and second floors. The facility's menu listed various snack items, including sugar-free fruited gelatin, peanut butter and jelly sandwiches, oatmeal raisin cookies, graham crackers, fruited yogurt, applesauce, and assorted beverages. However, the Food Service Supervisor confirmed that only peanut butter and jelly sandwiches were prepared daily, with no beverages served. Upon reviewing the kitchen stock, it was found that several items listed on the always available menu were not in stock, including gelatin mix, fruited yogurt, oatmeal raisin cookies, graham crackers, and prepared applesauce. The facility had a census of 74 residents, but the supervisor was unsure of the number of sandwiches prepared daily.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by multiple instances of inadequate transmission-based precautions and improper hand hygiene practices. Several residents, including those with symptoms of diarrhea, bacterial wound infections, and pneumonia, were not placed on appropriate transmission-based precautions. For instance, a resident with suspected C-difficile infection was not on contact precautions, and another resident with a draining wound was not on contact transmission-based precautions. Additionally, staff members were observed failing to perform hand hygiene before and during the provision of care. In one instance, three CNAs provided incontinence care to a resident without performing hand hygiene before donning gloves, and they continued to use the same gloves throughout the care process, even when handling clean linens. This practice was repeated in several other cases, where CNAs did not change gloves or perform hand hygiene between tasks, leading to potential cross-contamination. The facility's policies on hand hygiene and transmission-based precautions were not adhered to, as staff members were observed placing soiled linen on the floor and not using full PPE when required. These actions were contrary to the facility's own guidelines, which emphasize the importance of hand hygiene and the use of appropriate precautions to prevent the spread of infections among residents, staff, and visitors.
Privacy Violation During Resident Shower
Penalty
Summary
The facility failed to maintain privacy for a resident during a shower, which is a violation of resident rights. The incident involved a male resident who is cognitively intact and requires partial/moderate assistance with showering. During a surveyor's observation, the resident was found sitting unclothed in a small shower room while being assisted by a Certified Nursing Assistant (CNA). The CNA was holding the door open with one hand while using the other hand to spray water on the resident with a handheld shower head. This action compromised the resident's privacy, as confirmed by the Director of Nursing, who acknowledged that showering residents with the door open is a privacy issue. The facility's Resident Rights Guidelines emphasize the right of residents to be treated with respect and dignity, which was not upheld in this instance.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving a resident and a Certified Nursing Assistant (CNA). The resident, who was cognitively intact and had a history of severe medical conditions, reported being verbally and physically assaulted by the CNA. The facility's investigation did not include a review of available video footage from the facility's camera at the nurse's station, nor did it request the police report related to the incident. The facility's final report concluded the allegation was unsubstantiated without these critical pieces of evidence. Additionally, the investigation lacked documentation of an interview with a Registered Nurse who was present during the incident. Although the Administrator/Abuse Coordinator viewed a video recorded by the resident, he did not review the facility's video footage, which could have provided a clearer view of the incident. The police report, which was not considered in the facility's investigation, documented that the CNA was arrested and cited for battery. This oversight in the investigation process highlights significant gaps in the facility's response to abuse allegations.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to provide appropriate wound care for a resident with a vascular wound on the left leg. On December 10, 2024, the resident was observed with a stained tubi-grip covering the wound dressing, which was not changed by the following day. On December 11, 2024, the dressing was found to be heavily soiled with a brown substance and had a strong urine odor. The wound care nurse confirmed that the dressing should be changed daily and as needed, especially if soiled, to prevent infection. Despite this protocol, the dressing was not changed in a timely manner, leading to the dressing being heavily soiled with urine, which overflowed onto the wound. The Director of Nursing acknowledged the increased risk of infection when a soiled dressing is left in place. The resident's care plan indicated the need for changing the dressing as needed and ensuring the skin remains dry to prevent further breakdown.
Failure to Provide Necessary Braces for Resident with Contractures
Penalty
Summary
The facility failed to assess and provide necessary braces to a resident, identified as R41, to prevent further reduction in range of motion (ROM) and maintain proper positioning. R41, who has multiple diagnoses including hemiplegia, hemiparesis, and contractures of both hands, was observed without any brace or splint on his hands despite having a care plan that indicated the use of such devices. The resident was cognitively intact and required total assistance with activities of daily living (ADLs). Observations and interviews revealed that R41 did not have any braces or splints applied to his hands, contrary to the care plan that specified their use during nighttime. The care plan for R41, initiated in February 2023, included the application of a soft brace to the left hand and a resting hand splint to the right hand from 7:00 PM to 7:00 AM. However, there were no active physician orders for these devices as of December 2024. An occupational therapist screened R41 and confirmed the need for bilateral distal upper extremity braces to maintain joint integrity. Despite this recommendation, the facility did not implement the necessary interventions, as confirmed by the Director of Nursing, who acknowledged the need to follow the resident's plan of care to prevent further contractures.
Failure to Document Post-Dialysis Assessment
Penalty
Summary
The facility failed to document the necessary dialysis communication and assessment for a resident, identified as R64, who required dialysis services. R64 was admitted with multiple diagnoses, including end-stage renal disease, type 2 diabetes, hemiplegia, hemiparesis following cerebral infarction, and hypotension of hemodialysis. The resident had an order for in-facility hemodialysis four days per week and a left arm A-V fistula. The deficiency was identified when it was found that the facility nurses did not complete the after-dialysis portion of the dialysis communication form on several occasions, specifically on November 25, 26, 27, and 29, 2024, and December 2 and 6, 2024. The facility's policy required that the dialysis communication form be completed with any information requested by the certified dialysis facility, including an assessment of the fistula for bruit and thrill, checking the dressing for bleeding, and monitoring the resident's blood pressure and pulse. However, the review of R64's dialysis communication forms showed that these assessments were not documented by the facility nurses on the specified dates. This lack of documentation indicates a failure to adhere to the facility's policy for post-dialysis monitoring and observation, which is crucial for ensuring the resident's safety and well-being after dialysis treatment.
Failure to Provide Meaningful Activities for Bed-Bound Resident with Dementia
Penalty
Summary
The facility failed to provide meaningful activities to a resident diagnosed with dementia, who is bed-bound and dependent on staff for daily living activities. The resident, who has multiple medical conditions including dementia, major depressive disorder, and anxiety disorder, was observed repeatedly yelling for staff assistance over several days. Despite being alert and oriented, the resident expressed a preference to stay in bed rather than participate in group activities. Staff acknowledged the resident's behavior of calling out for attention but did not consistently provide the necessary engagement or activities to address her needs. Observations revealed that the resident's calls for assistance were often ignored by staff, who were seen sitting at the nurses' station instead of attending to her. Although the resident was prescribed medication for her behavior, the staff did not adequately respond to her calls or provide the one-on-one interaction she desired. The resident reported that she did not receive the daily pop-in visits or newsletters as claimed by the staff, and her television remote was out of reach, preventing her from changing the channel to something she wanted to watch. The facility's activity policy mandates providing activities tailored to residents' needs and interests, including those unable to leave their rooms. However, there was no evidence of an activity assessment or documentation showing that meaningful activities were being provided for the resident. The care plans in place for the resident highlighted the need for social interaction and diversional activities to manage her behavioral symptoms, but these interventions were not effectively implemented, leading to the deficiency.
Failure to Perform Adequate Skin Assessments Leads to Stage 3 Pressure Injury
Penalty
Summary
The facility failed to perform adequate skin assessments to prevent pressure injuries for a resident who was admitted with intact skin. The resident, who had a pelvic fracture and used a walker, developed a Stage 3 pressure injury on the sacral area that was not identified until it reached this advanced stage. The resident had a low air loss mattress and was able to reposition himself but required reminders due to pain from his fractures. Despite being alert and oriented, the resident was not informed of any open areas during his showers, and the nurses did not perform skin checks during these times. The facility's documentation showed inconsistencies and lack of proper skin assessments. The Bath and Skin Report Sheet indicated that the resident received showers on specific dates, with a check mark for an open area on one occasion, but the body diagram was not marked consistently. The nurse's initials on the shower sheets were indecipherable, and it was unclear if agency staff were involved. The Wound Licensed Nurse Practitioner discovered the Stage 3 pressure injury upon returning from vacation, indicating that the Certified Nursing Assistants and nurses did not follow the facility's protocol for skin assessments during bathing and care.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse by another resident. Resident 1 (R1) was attacked by Resident 2 (R2) over the volume of a TV, resulting in R1 sustaining multiple facial injuries, including a large hematoma, lacerations, and abrasions. R1 required evaluation and treatment in the emergency room. The incident occurred on the evening of 4/18/24, when R2 entered R1's room and hit him with a TV remote. R1's injuries were extensive, including bruising and swelling to his face, a laceration on his nose, and abrasions on his ear and finger. R1's medical history includes stroke with left side weakness, major depressive disorder, and other significant conditions, making him vulnerable and dependent on staff assistance for activities of daily living (ADLs). The facility's records and interviews with staff confirmed the sequence of events. On the night of the incident, a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) responded to R1's cries for help and found him with significant facial injuries. R1 reported that R2 had attacked him because of the TV volume. The facility's timeline showed that R2 entered R1's room at 8:55 PM and left at 8:56 PM. The police were called, and R2 was taken to the police station in handcuffs. R1 was transported to the hospital for treatment. Interviews with various staff members, including the Director of Nursing (DON), Nursing Supervisor, and Wound Care Nurse, corroborated R1's account of the assault and detailed the extent of his injuries. R2 admitted to the assault, stating that he hit R1 because R1 refused to lower the TV volume. R2's care plan was updated to include interventions for behavior distress and ineffective coping mechanisms. The facility's abuse prevention policy affirms the right of residents to be free from abuse and outlines measures to prevent such occurrences. However, the facility failed to protect R1 from physical abuse by R2, resulting in significant injuries and the need for emergency medical treatment.
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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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