Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pittsfield Manor during CMS and state inspections, most recent first.
A resident experienced a delay in treatment due to the facility's failure to promptly obtain and act on x-ray results, despite a noted decline in condition, including cough, wheezing, and decreased mobility. The resident was eventually admitted to the hospital with community-acquired pneumonia and respiratory failure. The facility did not adhere to its policy requiring timely notification of changes in condition and prompt diagnostic services.
The facility failed to properly store and label medications, with an unlocked medication cart and an undated Tuberculin vial found in the fridge. The medication cart was left unattended, and the Tuberculin vial lacked an open date, violating the facility's pharmaceutical procedures policy.
The facility failed to maintain proper food storage and hygiene practices, affecting all 80 residents. Observations included uncovered flour, improper storage of measuring utensils, and stacked meat boxes without drip trays. Dietary aides were seen neglecting hand hygiene and glove use, and the facility lacked policies on these practices. These deficiencies highlight significant lapses in food safety and hygiene protocols.
The facility failed to provide adequate incontinence care and maintain proper hygiene practices for several residents. Observations revealed incomplete cleaning procedures, lack of hand hygiene, and failure to follow the facility's perineal care policy. These deficiencies were noted in residents with varying medical conditions, including those with a history of urinary tract infections.
The facility failed to follow proper infection control protocols, with CNAs neglecting hand hygiene during glove changes and mishandling soiled linens. Observations showed CNAs did not sanitize hands between glove changes or after removing gloves, and soiled linens were improperly placed on the floor. These actions violated the facility's infection control policies, posing a risk of infection spread.
A resident with dementia was hit twice by another resident, also with dementia, in her room. CNAs intervened but did not report the incident to the administrator, violating the facility's abuse prevention and reporting policy.
A resident with dementia was observed hitting his wife, another resident, during an argument. Despite documentation in the nurse's notes, the facility administrator was not informed, and no abuse investigation was initiated. Interviews revealed communication breakdowns among staff, with the Director of Memory Care and LPN assuming others had reported the incident. The facility's policy requires immediate reporting and investigation of abuse allegations, which was not followed, leading to a deficiency.
A facility failed to investigate an alleged abuse incident where a resident with dementia was reportedly slapped by her husband, another resident. Despite documentation and staff awareness, the administrator was not informed, and no investigation was initiated. The facility's policy requires immediate reporting and investigation of abuse, but this protocol was not followed, leading to a deficiency.
The facility failed to provide two residents with written documentation explaining their hospital transfers. One resident, with severe cognitive impairment, returned from the ER without new orders, and the LPN did not recall providing written reasons for the visit. Another resident, frequently hospitalized, also did not receive written information. The DON confirmed that the facility's policy does not include giving residents written transfer reasons, only notifying family and hospital staff.
A facility failed to initiate a Level 2 PASARR for a resident who was diagnosed with schizoaffective disorder and pervasive developmental disorder after admission. Initially, the resident's PASARR Level 1 report showed no evidence of a serious behavioral health condition. However, when the physician added new diagnoses, a Level 2 PASARR was not conducted. The facility lacked a policy on PASARR and was expected to follow state guidelines.
Three residents with various medical conditions were not provided adequate feeding assistance in an LTC facility. Despite care plans indicating the need for adaptive equipment and supplements, residents struggled to eat due to severe shaking and lack of staff intervention. Family members had to assist with feeding, and the facility lacked a specific feeding policy.
A resident with a history of significant weight loss and medical conditions did not receive prescribed supplemental shakes with meals, as ordered by a physician. Despite being cognitively intact, the resident struggled to eat due to shaking hands, and observations showed the absence of the supplements during meals. The facility's policies on special needs and nursing rehabilitation were not adequately followed, resulting in a deficiency in providing necessary nutritional support.
A facility failed to maintain communication with a dialysis center and check the patency of a dialysis shunt for a resident requiring dialysis. The resident reported that the dialysis center does not use his right arm shunt due to pain, and staff do not check it. There was no written communication between the facility and the dialysis center, and the facility's electronic medical record did not document the condition of the resident's shunt. The facility's policy emphasizes communication with outside providers, which was not followed in this case.
A facility failed to administer the correct doses of fluticasone propionate nasal spray and psyllium husk to a resident, resulting in a medication error rate of 7.14%. An RN administered only one spray per nostril instead of two and initially measured an incorrect dose of psyllium husk. The errors were confirmed by an LPN against the physician's orders, which were not followed.
The facility failed to secure narcotics, specifically Tylenol with codeine, upon delivery from the pharmacy. A nurse signed off on the delivery without verifying the contents, and the medications were not loaded into the STAT safe due to an agency nurse lacking login access. The discrepancy was discovered when the pharmacy notified the facility, and the missing medication was not found during an audit. The nurse was terminated for not following policy, and the facility's procedures lacked documentation for accepting and securing medication deliveries.
A resident with severe cognitive impairment and multiple diagnoses was subjected to verbal and physical abuse by a CNA. The incident was witnessed by another CNA who intervened and reported it. The facility's investigation confirmed the abuse, violating their policy on abuse prohibition.
A resident with a history of cerebral infarction and hemiplegia fell from their wheelchair while reaching for a napkin. The facility did not investigate the fall or implement new prevention measures. The administrator acknowledged the lack of documentation and intervention, and the facility's policy did not address fall investigations.
The facility failed to follow proper PPE protocols for two COVID-19 positive residents. A CNA entered a resident's room without eye protection, and an RN entered another resident's room wearing only a surgical mask, despite signage requiring a N95 mask, gown, gloves, and eye protection. The Infection Prevention Nurse confirmed the necessity of these precautions.
The facility failed to supervise and prevent an altercation between two residents, resulting in one resident being sent to the emergency department with multiple contusions. Despite documented escalating behaviors and severe cognitive impairment, the aggressive resident was not adequately supervised, leading to the incident.
The facility failed to protect private health information by allowing a staff member to use a personal cell phone to take pictures of a resident's bruise. Despite a policy prohibiting such actions, the Infection Control Nurse took pictures and sent them to the Administrator, who was away in a meeting. The resident involved had severe cognitive impairment and unspecified dementia with agitation.
A resident with severe cognitive impairment and dementia was physically restrained by a CNA, resulting in a bruise. The CNA admitted to using physical restraint to prevent the resident from standing, and other staff members reported similar observations. The facility's policy prohibits such actions, leading to the noted deficiency.
A facility failed to report an allegation of abuse in a timely manner for a resident with severe cognitive impairment. Staff observed a CNA restraining the resident and reported it to an LPN, but no investigation was initiated at that time. The administrator later stated the CNA was using a tactile touch approach to prevent falls, but the facility's policy requires immediate reporting and investigation of such incidents.
The facility failed to conduct a thorough investigation into allegations of abuse concerning a resident. The administrator did not collect written statements from all involved parties, and the investigation packet lacked documentation of interviews with staff or residents, except for one CNA. Despite reports from other CNAs who observed the incident, their statements were not included, and they were not interviewed further.
Delay in Treatment Leads to Hospital Admission
Penalty
Summary
The facility failed to provide timely treatment for a resident who experienced a change in condition, resulting in a delay in treatment and subsequent hospital admission. The resident, who was experiencing a decline in physical mobility, cough with yellow sputum, and wheezing, was initially seen on 12/01/2024. Despite attempts to contact radiology for x-ray results and the nurse practitioner for further guidance, the facility did not obtain the necessary x-ray results until the following day. The resident's condition continued to decline, with increased weakness, cough, congestion, and wheezing noted, and a drop in oxygen saturation levels. The resident was eventually placed in isolation due to their symptoms and was admitted to the hospital with a diagnosis of community-acquired pneumonia and respiratory failure. The facility's policy on changes in a resident's condition requires prompt notification of the resident's physician and representative, as well as timely diagnostic services. However, the facility did not adhere to these policies, as evidenced by the delay in obtaining and acting upon the x-ray results, which contributed to the resident's worsening condition and need for hospital care.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store and label medications, as well as maintain medication carts locked, which could potentially affect all 80 residents. During an observation, a medication cart on Memory Lane was found unlocked and unattended while two nurses were sitting at the nurse's station with their backs to the cart. The Director of Nursing later confirmed that medication carts are expected to be locked when not in use. Additionally, a Registered Nurse was observed leaving her medication cart unlocked and her computer screen open to resident information. The nurse was unable to access the medication fridge due to a missing key, which led to the Director of Nursing using keys from her office to open it. Inside the fridge, a vial of Tuberculin was found without an open date, despite being used for both staff and residents. The facility's policy requires that medications be properly labeled with an open date, as Tuberculin is only good for 30 days after opening. The failure to label the vial correctly and secure the medication carts represents a breach of the facility's pharmaceutical procedures policy.
Food Safety and Hygiene Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to adhere to proper food storage and hygiene practices, which could potentially affect all 80 residents. During an initial tour of the kitchen, it was observed that a large plastic storage container of flour was left uncovered. Additionally, containers of rolled oats and thickener had measuring cups with handles submerged in the product, and a bag of brown sugar had a measuring spoon resting on top. In the walk-in refrigerator, boxes of beef and pork were stacked without drip trays to prevent cross-contamination. These observations indicate a lack of adherence to food safety standards. Further observations revealed improper hand hygiene and glove use by dietary aides. One dietary aide donned gloves without washing hands, handled food, and then removed gloves before washing hands. Another aide was seen touching their nose with a bare hand, handling food trays, and serving food without proper hand hygiene. The kitchen manager acknowledged the improper storage practices, and the facility administrator admitted the absence of policies regarding meat defrosting, hand hygiene, and glove use. These lapses in protocol highlight significant deficiencies in the facility's food safety and hygiene practices.
Inadequate Incontinence Care and Hygiene Practices
Penalty
Summary
The facility failed to provide timely and complete incontinence care for five residents, as observed during interviews and record reviews. The deficiencies included improper hand hygiene and glove changes, as well as incomplete cleaning procedures. For instance, one resident was not properly cleaned or dried during incontinence care, and the staff did not perform hand hygiene after removing gloves. Another resident's foreskin was not retracted for proper cleaning, and no cleansing product was used during the care. In another case, a resident with a history of multiple urinary tract infections did not receive adequate perineal care, as the staff did not separate the labia during cleaning or dry the area afterward. Additionally, a resident who was assisted to the toilet after being incontinent did not receive the expected incontinence care, as the staff did not cleanse all areas that urine would have touched. The facility's perineal care policy outlines specific procedures for cleaning, which were not followed in these instances. The facility's handwashing procedure, which emphasizes the importance of hand hygiene to prevent infection, was also not adhered to. Staff members were observed not washing their hands after removing gloves or engaging in activities that could contaminate their hands. These lapses in care and hygiene practices contributed to the deficiencies identified during the survey.
Infection Control Deficiencies in Hand Hygiene and Linen Handling
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the areas of hand hygiene, glove changing, and the handling of soiled linens. Multiple instances were observed where Certified Nurse Aides (CNAs) did not perform hand hygiene before donning gloves, between glove changes, or after removing gloves. This was evident during the provision of incontinent care to several residents, including those with dementia and other significant health conditions. For example, CNAs were observed changing gloves without sanitizing their hands in between, which is a critical step in preventing the spread of infection. In addition to hand hygiene lapses, the facility staff also mishandled soiled linens. In one instance, a CNA was observed throwing soiled sheets and bed pads on the floor before placing them in a bag, which is against the facility's infection control policy. This improper handling of soiled materials poses a risk of contamination and infection spread within the facility. The Director of Nursing acknowledged that soiled linens should not be placed on the floor, indicating a breach in protocol. The facility's Perineal Care Policy and Proper Hand Washing Procedure were not followed during the care of residents. The policy outlines specific steps for cleansing the perineal area and emphasizes the importance of hand hygiene. However, observations revealed that CNAs did not consistently use soap or perineal cleansers, and failed to dry residents after cleansing. These deficiencies in following established procedures highlight significant gaps in the facility's infection control practices, potentially compromising resident safety.
Failure to Prevent and Report Resident Abuse
Penalty
Summary
The facility failed to prevent abuse for a resident diagnosed with dementia, who was severely cognitively impaired. The incident involved another resident, also diagnosed with dementia and severely cognitively impaired, who entered the first resident's room, argued with her, and then hit her in the face twice. This incident was observed by Certified Nurse Aides (CNAs) who intervened to separate the residents and redirect the aggressor back to his room. However, the CNA did not report the incident to the facility administrator. The facility's policy on Abuse Prohibition and Reporting, dated 11/28/19, mandates the active prohibition of resident abuse, including neglect and corporal punishment. Despite this policy, the incident was not reported to the administrator, indicating a failure in the facility's abuse prevention and reporting procedures. The CNA involved was unsure if the incident was reported to the nurse on duty, highlighting a gap in communication and adherence to the facility's abuse reporting policy.
Failure to Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the Illinois Department of Public Health involving a resident with dementia. The incident involved a resident who was observed by CNAs to have hit his wife, another resident, in the face twice during an argument. Despite the incident being documented in the resident's nurse's notes, the facility administrator was not informed of the event until later, and no abuse investigation was initiated at that time. Interviews with facility staff revealed a breakdown in communication and reporting procedures. The Director of Memory Care was informed of the incident by a CNA but assumed the nursing staff had already notified the administrator. The LPN on duty was informed by a CNA about the incident and took steps to inform the family and doctor but did not notify the administrator. The CNA who witnessed the incident was unsure which nurse she informed and did not report the incident to the administrator. The facility's policy on abuse prohibition and reporting requires immediate reporting of abuse allegations to the administrator or designee and mandates that the Illinois Department of Public Health be notified within specific timeframes. The policy also outlines steps for protecting residents and conducting investigations, which were not followed in this case. The failure to report and investigate the abuse allegation represents a deficiency in the facility's adherence to its own policies and regulatory requirements.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with dementia, who was reportedly slapped by her husband, another resident with dementia and psychotic disturbance. The incident was documented in the nurse's notes, where it was noted that the husband was observed hitting his wife twice in the face during an argument. Despite this documentation, the facility's administrator was not informed of the incident until later, and no formal investigation was initiated at that time. Interviews with staff revealed a breakdown in communication and reporting procedures. The Director of Memory Care was informed of the incident by a CNA but did not follow up with the administrator, assuming it was the administrator's responsibility to investigate. Similarly, a Licensed Practical Nurse was informed by a CNA about the incident and notified the family and doctor but failed to inform the administrator. Another CNA witnessed the incident but was unsure who to report it to and did not inform the administrator. The facility's policy on abuse prohibition and reporting requires immediate reporting of alleged abuse to the administrator or designee and mandates an investigation. However, this protocol was not followed, resulting in a failure to protect the residents and ensure a thorough investigation. The lack of communication and adherence to policy led to the deficiency in addressing the abuse allegation appropriately.
Failure to Provide Written Transfer Documentation to Residents
Penalty
Summary
The facility failed to provide timely written documentation to two residents regarding their transfer to the hospital, which is a requirement for ensuring residents and their representatives are informed of the reasons for such transfers. One resident, who was severely cognitively impaired and diagnosed with dementia with psychotic disturbance, was returned from a local emergency room without any new orders or changes in condition. The hospital records indicated no acute concerns, and the resident was cleared to return to the facility. However, the Licensed Practical Nurse (LPN) stated that she did not remember providing any written documentation to the resident explaining the reason for the hospital visit. Another resident, who had been to the hospital several times in the past year, also did not receive any written information regarding the reason for their transfer. The LPN and the Director of Nursing (DON) confirmed that the facility does not provide residents with written documentation about the reason for their transfer, instead, the information is given to emergency medical staff. The facility's policy on resident transfers requires that the family and/or representative and hospital be notified, but it does not specify that the resident should receive written documentation, leading to this deficiency.
Failure to Initiate Level 2 PASARR for Resident with New Diagnoses
Penalty
Summary
The facility failed to initiate a Level 2 Preadmission Screening and Resident Review (PASARR) for a resident who was reviewed for PASARR. The resident's face sheet, which was undated, documented diagnoses of schizoaffective disorder, depressive type, and pervasive developmental disorder, unspecified. The resident's PASARR Level 1 report, dated May 25, 2023, indicated no evidence of an intellectual/developmental disability or a serious behavioral health condition. However, it was noted that if changes occurred or new information refuted these findings, a new screen must be submitted. On December 5, 2024, the Social Services staff member stated that upon admission, the resident did not have a diagnosis of schizoaffective or pervasive personality disorder. When the physician added these diagnoses on October 10, 2024, a Level 2 PASARR was not conducted. The Social Services staff member acknowledged that a Level 2 PASARR should have been done with the change in diagnosis. Additionally, the facility administrator stated that the facility did not have a policy on PASARR and expected the facility to follow the Illinois Department of Public Health guidelines on PASARR requirements.
Failure to Provide Adequate Feeding Assistance
Penalty
Summary
The facility failed to provide adequate feeding assistance to three residents, R8, R41, and R52, who were reviewed for nutrition and feeding assistance. R41, who has a history of generalized muscle weakness, hemiplegia, and other conditions, was observed struggling to eat due to severe hand tremors. Despite being on a regular diet with a recommendation for supplemental shakes, R41 was not provided with the necessary assistance or supplements during meals. Observations showed R41 attempting to eat with regular utensils, resulting in food falling off the fork due to her shaking, and no staff intervened to assist her. R8, diagnosed with cerebral infarction, morbid obesity, and other conditions, also experienced difficulties during meals. R8 was observed trying to eat with a fork, but due to significant shaking, food fell off the utensil. Despite having a care plan that included the use of adaptive equipment like scoop plates and Kennedy cups, these were not provided, and no staff assisted R8 during meals. R8's family members had to bring in finger foods and assist with feeding, as the facility did not provide the necessary support. R52, with diagnoses of Parkinsonism and neurocognitive disorder, required setup and clean-up assistance with dining. However, during observations, R52 was left without assistance, struggling to cut and eat her food. Staff did not offer help until R52 explicitly asked for it, and even then, assistance was minimal and inadequate. The facility lacked a specific feeding policy, and the administrator acknowledged that staff were expected to assist residents who needed help with eating, which was not consistently done in these cases.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to provide supplemental shakes as ordered for a resident, identified as R41, who was reviewed for nutrition and feeding assistance. R41 had a history of significant weight loss, with a 9% decrease over 90 days, and was on a regular diet with a physician's order for a house supplement of 4oz with breakfast and lunch. Despite this order, observations on multiple occasions revealed that R41 did not receive the supplemental shakes with her meals. This oversight was noted during meal times when R41 was seen struggling to eat due to shaking hands, which caused her food to fall off her fork. R41's medical history included generalized muscle weakness, hemiplegia, chronic kidney disease, and prediabetes, among other conditions. The resident was cognitively intact and independent in eating, but her physical limitations, such as shaking hands, made it difficult for her to consume meals effectively. Despite the presence of family members and staff, R41 did not receive the necessary assistance or the prescribed nutritional supplements to support her dietary needs. The facility's policies on addressing special needs and providing nursing rehabilitation were not adequately followed in R41's case. The lack of adherence to the care plan and physician orders resulted in the resident not receiving the necessary nutritional support, as evidenced by the absence of supplemental shakes during meals. This deficiency highlights a failure in the facility's systematic approach to managing the resident's nutritional needs and ensuring compliance with prescribed dietary interventions.
Failure to Maintain Communication and Check Dialysis Shunt
Penalty
Summary
The facility failed to maintain proper communication with the dialysis center and ensure the patency of a dialysis shunt for a resident requiring dialysis services. The resident, who is cognitively intact and dependent on renal dialysis, reported that the dialysis center does not use his right arm shunt due to pain, opting instead for a chest access. The resident also mentioned that the facility staff do not check his shunt. Interviews with facility staff revealed a lack of written communication between the facility and the dialysis center, with no paperwork being exchanged regarding the resident's dialysis treatment. The Director of Nursing was uncertain if nurses documented on dialysis fistulas, and a Licensed Practical Nurse admitted to usually checking the resident's fistula but was unsure about other nurses' practices. The facility's electronic medical record did not document the condition of the resident's right arm dialysis shunt. The facility's policy on special needs emphasizes the importance of communication with outside providers to ensure safe and continuous care, yet this was not adhered to in the case of the resident's dialysis care.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer the correct dose of medication, resulting in a medication error rate of 7.14%, which exceeds the acceptable threshold of 5%. During a medication administration observation, a Registered Nurse (RN) incorrectly administered fluticasone propionate nasal spray to a resident, providing only one spray per nostril instead of the prescribed two sprays. Additionally, the RN initially measured an incorrect dose of psyllium husk, pouring 30 milliliters instead of the prescribed 30 grams, before correcting the dose to one teaspoon in water. A Licensed Practical Nurse (LPN) later confirmed the correct dosages as per the physician's orders, which were not followed during the administration. The resident involved, identified as R41, has a diagnosis of constipation and was prescribed fluticasone propionate nasal spray and psyllium husk powder. The physician's orders specified two sprays of fluticasone per nostril and 30 grams of psyllium husk daily, which were not adhered to during the observed medication administration. The facility's medication administration policy requires all medications to be administered as prescribed by the physician, which was not followed in this instance.
Failure to Secure Narcotics Upon Delivery
Penalty
Summary
The facility failed to secure narcotics upon delivery from the pharmacy, specifically Tylenol with codeine, which was intended for stock medication. The incident involved a nurse who signed off on the delivery of medications but did not verify the contents of the order. The medications were delivered between midnight and 1 AM, and although there were two nurses present, one was an agency nurse without a login to access the STAT safe. The agency nurse did not contact the Director of Nurses to obtain a login, resulting in the medications being locked in the medication room instead of being loaded into the STAT safe. The discrepancy was discovered when the pharmacy notified the facility that the Tylenol with codeine had not been loaded, leading to the realization that the medication was missing. The facility conducted a full audit of the STAT-Safe Inventory and inspected all medication carts and rooms, but the missing medication was not located. The nurse involved was terminated for not following the facility's policy on accepting and securing medication deliveries. The facility's pharmaceutical procedures did not document the procedure for accepting medication deliveries and loading the STAT safe, contributing to the deficiency. The report also notes that none of the residents reviewed for pharmacy storage had documented allergies to Tylenol or codeine, and the facility's codeine allergy list did not include these residents.
Failure to Prevent Abuse of a Resident
Penalty
Summary
The facility failed to prevent abuse of a resident, identified as R4, who was severely cognitively impaired and required substantial assistance for daily activities. R4 was admitted with diagnoses including spastic hemiplegic cerebral palsy, major depressive disorder, moderate intellectual disabilities, and anxiety disorder. An incident occurred where a Certified Nurses Aide (CNA), identified as V7, was found to be verbally abusive and physically handling R4 inappropriately. The abuse was witnessed by another CNA, V4, who intervened and reported the incident. The facility's investigation confirmed the allegations of abuse. The incident was reported to the police, and the agency employing the CNA was notified. The facility's policy on abuse prohibition and reporting, dated November 28, 2019, outlines the prohibition of various forms of abuse, including verbal and physical abuse, which was violated in this case. The report highlights the failure to protect R4 from abuse, as required by the facility's policy.
Failure to Investigate and Prevent Falls
Penalty
Summary
The facility failed to investigate a fall and implement a new fall prevention intervention for a resident who experienced a fall. The resident, who has a history of cerebral infarction and hemiplegia, was found lying on the floor after sliding out of his wheelchair while reaching for a napkin. Despite being assessed by a nurse and found to have no injuries, the incident was not documented as a fall event, and no investigation was conducted to determine the cause or to develop a strategy to prevent future falls. The facility's administrator confirmed that the fall was not reported to management, and no progressive intervention was put in place. The facility's Emergency Care Procedure policy, which should guide staff in such situations, does not include instructions for conducting a fall investigation or implementing new fall prevention measures. This oversight indicates a gap in the facility's procedures for managing and preventing falls, potentially compromising resident safety.
Failure to Adhere to PPE Protocols for COVID-19 Positive Residents
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols for two residents who tested positive for COVID-19. In the first instance, a Certified Nurse Aide (CNA) entered the room of a COVID-19 positive resident without wearing the required eye protection, despite signage indicating the necessity of a N95 mask, gown, gloves, and eye protection. The CNA admitted to forgetting to wear the eye protection, rationalizing the omission by noting the resident was not coughing. In the second instance, a Registered Nurse (RN) was observed entering the room of another COVID-19 positive resident wearing only a surgical mask, contrary to the posted requirements of a N95 mask, gown, gloves, and eye protection. When questioned, the RN claimed to have removed the protective equipment. The facility's Infection Prevention Nurse confirmed that all staff should wear the specified protective gear when caring for COVID-19 positive residents. The facility's policies on COVID-19 and infection control emphasize the importance of using appropriate personal protective equipment to prevent the spread of infection.
Failure to Supervise Residents Leading to Altercation
Penalty
Summary
The facility failed to supervise and prevent an altercation between two residents, R3 and R4, resulting in R4 being sent to the local emergency department with multiple contusions. R3, who has severe cognitive impairment and a history of physical behavioral symptoms, was documented to have increasing agitation and aggressive behaviors over several days. Despite these documented behaviors, R3 was not adequately supervised, leading to the incident where he hit R4 with a lamp and a cup, causing injuries to R4's face, forearms, and shoulder. R3's medical records indicate a history of severe dementia with agitation and anxiety, and he was undergoing a medication change at the time of the incident. Multiple progress notes documented R3's escalating behaviors, including verbal and physical aggression towards staff and other residents. On the day of the incident, R3 was noted to be very aggressive, hallucinating, and difficult to redirect. Despite these signs, R3 was left unsupervised long enough to enter R4's room and cause harm. Interviews with staff revealed that they were aware of R3's behaviors but did not implement sufficient interventions to prevent the altercation. The CNAs on duty at the time of the incident were not adequately informed about R3's increased behavioral issues, and there was a lack of specific policies related to dementia care or supervision of residents. The facility's failure to provide adequate supervision and implement effective interventions for R3's behaviors directly led to the altercation and subsequent injuries to R4.
Breach of Resident Privacy Through Unauthorized Use of Personal Cell Phone
Penalty
Summary
The facility failed to protect private health information by allowing a staff member to use a personal cell phone to take pictures of a resident's bruise. The resident, who has severe cognitive impairment and a diagnosis of unspecified dementia with agitation, had bruises on their arm. The Infection Control Nurse took pictures of the bruises with her personal cell phone and sent them to the Administrator, who was three hours away in a meeting. The Administrator stated that she needed the pictures to start an investigation as the resident was leaving the facility. The pictures were later deleted. The facility's policy on cell phone and electronic handheld device usage, revised in 2019, explicitly prohibits the use of personal cell phones for taking pictures that could violate resident privacy and confidentiality. Despite this policy, the Infection Control Nurse used her personal cell phone to document the resident's bruises, and the Administrator deemed this action acceptable. This breach of policy and resident privacy was confirmed through interviews with the Administrator, the Infection Control Nurse, and a Certified Nursing Assistant who witnessed the incident.
Failure to Prevent Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse to a resident diagnosed with unspecified dementia and severe cognitive impairment. The resident, who was assigned a 1:1 CNA, was observed with a purplish-black bruise on his arm. The CNA assigned to the resident admitted to laying his hand across the resident's chest to prevent him from standing up. Another CNA witnessed the same CNA restraining the resident by holding his upper extremity/chest and reported it to an LPN. Additionally, another CNA observed the same CNA cradling the resident's feet and pushing him in a wheelchair, and later restraining the resident's forearms to prevent him from getting out of a chair. These actions were reported to the same LPN by the observing CNA. The facility's administrator acknowledged the bruise on the resident's arm and concluded that the CNA was using a tactile touch approach to prevent falls, as the resident was a fall risk. However, the facility's policy on Abuse Prohibition and Reporting explicitly prohibits any form of resident abuse, including the use of physical restraints not required to treat resident symptoms. The actions of the CNA were in direct violation of this policy, leading to the deficiency noted in the report.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for a resident diagnosed with unspecified dementia and severe cognitive impairment. The resident was observed with a purplish-black bruise on their arm, and multiple staff members reported witnessing a CNA restraining the resident by placing hands on the resident's chest and forearms to prevent them from standing up. These observations were reported to a Licensed Practical Nurse (LPN) on the same day, but there was no documentation that an investigation was initiated at that time. The facility's administrator later stated that the CNA was using a tactile touch approach to prevent the resident from falling, as the resident was a fall risk. However, the facility's policy requires that any alleged abuse or neglect be reported immediately to the administrator or designee. The facility did not provide evidence that the incident was reported or investigated promptly, as required by their policy.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to initiate a timely and thorough investigation in response to allegations of abuse concerning a resident. The administrator, V1, did not collect written statements from all involved parties, including the alleged abuser and other staff members who witnessed the incident. The investigation packet for the resident, R4, lacked documentation of interviews with staff or residents, except for one CNA, V14. Despite reports from other CNAs, V15 and V16, who observed V14 restraining R4, their statements were not included in the investigation, and they were not interviewed further. V1 concluded there was no abuse based solely on a conversation with V14, without obtaining necessary written statements or conducting comprehensive interviews as required by the facility's policy. The facility's policy on abuse prohibition and reporting mandates that interviews with all involved parties or potential witnesses be completed, with at least two interviewers present and notes taken. Signed statements from those who saw or heard information pertinent to the incident should be obtained. However, the administrator did not follow these procedures, resulting in an incomplete investigation. The failure to adhere to the policy and thoroughly investigate the allegations of abuse led to the deficiency cited by the surveyors.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pittsfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eastside Health And Rehabilitation Center | 1.5 mi | — | 0 | 0 |
| Barry Healthcare & Sr Living | 13.2 mi | — | 5 | 0 |
| Avenir At Maple Grove | 17.4 mi | — | 2 | 0 |
| Scott County Nursing Center | 18.1 mi | — | 1 | 0 |
| Evervella Of White Hall | 24 mi | — | 3 | 0 |
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