Pleasant View Luther Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Ottawa, Illinois.
- Location
- 505 College Avenue, Ottawa, Illinois 61350
- CMS Provider Number
- 145801
- Inspections on file
- 26
- Latest survey
- November 15, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pleasant View Luther Home during CMS and state inspections, most recent first.
A resident with impaired mobility and poor balance, assessed as a moderate fall risk, was left unsupported on the toilet during personal hygiene care after being transferred with a sit-to-stand lift. The CNA removed the lift sling and raised the enabler bar, leaving the resident unable to maintain balance, which resulted in a fall to the floor.
A resident experiencing depression and emotional distress following a separation and impending divorce did not receive psychosocial service interventions. The Social Service Director confirmed that the resident was not assessed for his feelings, was not included in any psychosocial programming, and that no such programs were available, with residents only attending general activities.
Two residents experienced improper handling of a bed bug infestation, with staff failing to consistently bag and remove all clothing and personal items, provide showers before room transfers, or document the incident and treatment. Staff interviews revealed confusion about procedures, and observations showed unbagged items left in affected rooms, contrary to facility policy and pest control recommendations.
A resident with a history of falls and cognitive impairment sustained a C1 fracture after tripping over another resident's wheelchair in a crowded dining area. Staff confirmed that the space was too narrow for safe ambulation and the resident's walker was not accessible, despite care plan interventions requiring its use. The facility did not identify or address environmental hazards or update fall prevention strategies after previous incidents.
A resident with dementia and major depressive disorder had her Zoloft dose reduced without her POA's knowledge or consent. The POA discovered the change after noticing the resident's emotional state and reviewing medication records. Facility documentation did not show consent for the dose reduction, and staff confirmed that notification and consent should have been obtained.
A resident's representative filed a grievance after finding the resident in bed, soaked in urine and not provided breakfast. Despite communicating concerns to a Resource Nurse and Social Service, the representative did not receive any follow-up or notification regarding the investigation or resolution of the grievance, contrary to facility policy requiring timely communication of grievance outcomes.
A resident who was frequently incontinent and required extensive ADL assistance did not receive timely incontinence care, resulting in the resident being found soaked in urine by a family member. Staff interviews confirmed that the resident was not checked or changed for an extended period, despite care plan interventions to keep the resident dry and prevent skin breakdown.
The facility failed to comply with its policies on hair restraints, food storage, and chemical storage, potentially affecting 76 residents. Kitchen staff did not fully cover their hair, and several food items were found unlabeled and undated. A Sanitizer chemical was improperly stored in the Dry Food Storage Room.
The facility did not ensure that its staff were trained in Hospice and End of Life Care for residents receiving hospice services. A RN and an LPN lacked the necessary education, and the administrator admitted the training was not assigned or completed. The RN confirmed she had not received such training since her hire.
A facility failed to follow proper infection control practices during a pressure ulcer dressing change for a resident. An RN did not perform hand hygiene or change gloves appropriately, using the same soiled gloves to cleanse the wound, apply ointment, and handle personal items and surfaces. The RN also disposed of garbage and moved an overbed table without sanitizing hands, contrary to the facility's infection control protocols.
The facility failed to follow its policy for changing and labeling oxygen tubing and humidifier bottles weekly for two residents. One resident had a humidifier bottle dated over a week old and undated tubing, while another had both the humidifier bottle and nasal cannula undated. The DON confirmed the policy requirement.
A facility failed to obtain written physician orders from Hospice providers for a resident with a terminal prognosis. Hospice orders were often given verbally, and facility nurses entered them into the EHR without written documentation. This led to confusion among staff, as one nurse was unaware of the correct method to administer Ativan. The lack of written orders and clear communication contributed to the deficiency in care.
A facility failed to document a clinical rationale for extending a PRN psychotropic medication order for a resident. The policy requires PRN orders to be limited to 14 days unless a rationale is documented. A resident had an order for Alprazolam for 30 days without a documented rationale. An LPN confirmed the extension was made without written justification.
The facility failed to ensure proper coordination and documentation of hospice services for residents, affecting three individuals with Alzheimer's Disease. Necessary hospice care plans, prescribers' orders, and clinical notes were missing from medical records. Communication between hospice and facility staff was primarily verbal, leading to insufficient documentation.
The facility failed to post Ombudsman contact information on resident floors, affecting all 77 residents. Residents were unaware of how to contact the Ombudsman, and the only poster was located on the first floor, where no residents reside. The Community Ombudsman had not visited in over a year and had difficulty reaching the Activity Director.
The facility failed to make the Survey Binder, containing prior survey results, accessible to residents. Residents were unaware of the binder's existence and location, which was found placed out of reach and view behind picture frames on a high ledge. Additionally, the binder lacked recent survey results, affecting all 77 residents.
The facility failed to provide written notifications to residents or their representatives regarding hospital transfers, affecting six residents. The administrator confirmed reliance on verbal notifications, contrary to policy requirements for written communication. This deficiency could impact all 77 residents.
The facility failed to provide the Bed Hold Policy to residents or their representatives during emergency hospital transfers, affecting six residents. The policy requires notification before hospitalization and at the time of transfer, but documentation showed no evidence of compliance. The Social Security Director confirmed that notifications were not provided as required.
A resident with dementia was sexually abused by another resident with a history of problematic behaviors in an LTC facility. The incident involved inappropriate touching and resulted in the victim feeling frightened and requiring hospital examination. Despite known risks, the facility failed to prevent the incident, leading to an Immediate Jeopardy situation.
A facility failed to implement its abuse prevention program, resulting in incidents of inappropriate sexual behavior between two residents. Despite policies requiring abuse screenings and reporting, these were not conducted or escalated, leaving residents vulnerable. The facility's inaction and lack of communication led to a deficiency in protecting residents' safety and rights.
A facility failed to report and investigate potential resident-to-resident sexual abuse involving two cognitively impaired residents. A CNA observed inappropriate behavior and reported it to an RN, who did not escalate the issue to the Abuse Coordinator, believing the residents could consent. The facility's policy on immediate reporting was not followed, and the administrator later confirmed the residents could not consent due to dementia.
A resident with Alzheimer's and other health issues, requiring assistance for ambulation, fell and fractured her femur due to a CNA's failure to use a gait belt as per facility policy. The incident led to a decline in the resident's condition and subsequent death. The CNA admitted to not using the gait belt, which was required for safety.
A facility failed to immediately report an allegation of physical abuse by a CNA towards a resident. The incident was reported the next morning, violating the facility's policy requiring immediate notification to the Administrator or Abuse Coordinator.
Failure to Implement Safety Interventions During Toileting Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to implement appropriate safety interventions for a resident identified as being at moderate risk for falls. The resident, who had impaired mobility and poor sitting/standing balance, was transferred to the toilet using a sit-to-stand mechanical lift. During personal hygiene care, the Certified Nursing Assistant (CNA) removed the lift sling and raised the enabler bar to provide more room, leaving the resident unassisted on the toilet. The resident was unable to maintain posture and balance, resulting in a fall to the floor. The facility's policies required that the harness safety strap be securely fastened and that the resident be properly supported during transfers and toileting. However, the CNA unhooked the resident from the lift and did not reapply the top harness before attempting to move the resident's feet onto the sit-to-stand lift. The CNA confirmed that the resident was unable to balance or stand without assistance, and that the enabler bars were intended for residents who could stand independently. The lack of proper support and supervision directly led to the resident's fall.
Failure to Provide Psychosocial Services for Resident in Emotional Distress
Penalty
Summary
The facility failed to provide psychosocial service interventions for a resident who was experiencing significant emotional distress due to a recent separation and impending divorce after more than 40 years of marriage. The resident reported feeling very depressed and stated that he would act out at times because he did not know how to handle his personal situation. He also indicated that the only interactions he had with the Social Service Director or other staff were when he was in trouble, and that no one had asked him about his feelings or what he was going through. The Social Service Director confirmed that the resident was not included in any psychosocial programming, had not been assessed regarding his feelings about the divorce, and that there were no psychosocial programs available in the facility, with residents only participating in general activities.
Failure to Follow Bed Bug Infection Control Protocols
Penalty
Summary
The facility failed to follow recommended guidelines for infection prevention and control in response to the presence of bed bugs in the rooms of two residents. Staff discovered bed bugs in one resident's room, and although clothing was bagged and removed on one occasion, there were inconsistencies in the handling of personal items and the timing of room treatment. On a previous occasion, not all clothing or items in drawers were removed, and staff questioned whether proper treatment was performed, as another live bed bug was found later. The pest exterminator did not arrive until several days after the initial report, and during this period, one resident was isolated in the room while the other was moved to a different room. Observations revealed that personal items such as shoes, socks, and toiletries were left unbagged in the affected rooms, contrary to the facility's own policy and the pest exterminator's recommendations. Staff interviews indicated a lack of consistent education and communication regarding the proper procedures for handling bed bug infestations. Some staff were unaware of the need to shower residents before moving them out of infested rooms, and there was confusion about the appropriate steps to take when bed bugs were found. Additionally, there was no documentation in the residents' medical records regarding the discovery of bed bugs or the treatment provided. The facility's policy required that all clothing and personal items be bagged, residents be showered and dressed in clean clothing from outside the room, and that personal belongings not leave the room until deemed bed bug free. However, these procedures were not consistently followed, as evidenced by staff and resident reports, lack of documentation, and direct observation of unbagged items remaining in the rooms. The failure to adhere to established protocols contributed to the ongoing presence of bed bugs and inadequate infection control practices.
Failure to Prevent Fall Due to Environmental Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to identify and address environmental hazards and did not implement effective fall prevention interventions for a resident with a known history of falls. The resident, who was assessed as a high fall risk due to Alzheimer's, vascular dementia, muscle weakness, and other conditions, required assistance with activities of daily living and was supposed to use a walker for support. On the day of the incident, the resident attempted to leave the dining room table, but the space was too narrow due to the placement of another resident's large wheelchair and a water cooler. The resident's walker was not accessible, and he attempted to step over the wheelchair, resulting in a fall that caused a head injury and a C1 (neck) fracture. Multiple staff interviews confirmed that the dining room layout did not provide adequate space for safe ambulation, especially for residents with mobility aids. The resident had a documented history of previous falls, and the care plan included interventions such as ensuring the use of a walker and anticipating the resident's needs. However, the care plan had not been updated with new interventions following recent falls, and environmental hazards in the dining area were not addressed. The facility's fall prevention policy required identification and mitigation of environmental risk factors, but these measures were not effectively implemented, directly contributing to the resident's accident.
Failure to Notify POA of Antidepressant Dose Change
Penalty
Summary
The facility failed to notify a resident's power of attorney (POA) regarding a change in the resident's antidepressant medication. The resident, who has diagnoses of dementia and major depressive disorder, had her Zoloft dose decreased from 75 mg to 50 mg without the knowledge or consent of her POA, who is also her daughter. The POA discovered the change after returning from vacation and noticing the resident was tearful and emotional. Upon reviewing the medication record, the POA found the dose reduction and stated she had not consented to it. The medication was later returned to the original dose at the POA's request, and subsequently increased with her consent. Review of the resident's psychotropic consent forms showed that the dose reduction to 50 mg was not documented, nor was there any record of the POA's consent for this change. The facility's resource nurse confirmed that the POA should be notified and consent obtained for any medication changes. The lack of notification and consent for the medication adjustment constituted a failure to follow required procedures for informing a resident's representative of significant changes.
Failure to Notify Resident Representative of Grievance Resolution
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's representative of the resolution of a grievance. The resident's daughter and Power of Attorney (POA) arrived at the facility and found the resident in bed, soaked in urine, with a strong urine odor in the room, and the resident had not been gotten up or fed breakfast. The POA communicated her concerns to the Resource Nurse via text and in person, expressing her desire to file a grievance and requesting follow-up. Despite this, the POA reported that she did not receive any communication from the facility regarding the findings or resolution of her grievance for nearly a month. The Resource Nurse confirmed receiving the grievance and acknowledged that an update should have been provided within 24 hours, but no follow-up communication was made to the POA. The Social Service staff completed a grievance form and documented the concern, but also did not notify the POA of the facility's response or findings. The facility's grievance policy requires that the resident or their representative be informed of the investigation's findings and corrective actions within seven working days, which was not done in this case.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was frequently incontinent of urine and required extensive assistance with activities of daily living did not receive timely incontinence care. The resident's facility assessment indicated a need for assistance with toileting and transfers. On the morning in question, the resident's daughter arrived to find the resident still in bed, soaked with urine, and attempting to get out of bed. The room had a strong urine odor, and the daughter was upset that the resident had not been toileted. Interviews with staff revealed that the night shift CNA last offered toileting at 2:30 AM, which the resident refused, and did not check on the resident again before the end of the shift. The day shift CNA reported only peeking into the resident's room at intervals without checking if the resident was wet or offering toileting assistance. The resident was not checked or changed until the daughter arrived and found the resident in a soiled state. The care plan for the resident included interventions to keep the resident dry and prevent skin breakdown, but these were not followed as documented.
Non-compliance with Food Safety and Storage Policies
Penalty
Summary
The facility failed to adhere to its policies regarding hair restraints, food storage, and chemical storage, which could potentially affect the safety and quality of food consumed by 76 of the 77 residents. Observations revealed that several kitchen staff members, including the Culinary Services Director, did not have their hair completely covered while in the kitchen, contrary to the facility's Use of Hair Restraints Policy. Staff members were seen with hairnets or caps that did not fully cover their hair, with tendrils, bangs, and beards left exposed. Interviews with the staff confirmed that they were aware of the requirement to cover all hair while in the kitchen. Additionally, the facility did not comply with its Storage Procedures and Date Marking Policies. Several food items in the Freezer, Walk-in Cooler, and Bakery Freezer were found without labels or dates, including individually wrapped meatloaf portions, a bag of rice, a pitcher of lemonade, sliced potatoes, sub sandwiches, and bags of cookies. Furthermore, a container of Sanitizer chemical was improperly stored in the Dry Food Storage Room, which is against the facility's policy that prohibits storing chemicals in food storage areas. The Kitchen Manager acknowledged the misplacement of the Sanitizer and the lack of labeling on the cookies.
Lack of Hospice and End of Life Training for Staff
Penalty
Summary
The facility failed to ensure that its staff were educated and competent in providing Hospice and End of Life Care for nine residents receiving hospice services. The Hospice Agreement for Nursing Facility, Inpatient and Inpatient Respite Care Services required that employees be familiar with the needs of hospice patients and competent in their care. However, training transcripts for a Registered Nurse and a Licensed Practical Nurse did not indicate that they had completed the necessary Hospice or End of Life education. The facility administrator acknowledged that the training was not assigned or completed for these staff members upon their hiring. Additionally, the Registered Nurse confirmed that she had not received any Hospice or End of Life training since her date of hire.
Inadequate Infection Control During Pressure Ulcer Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during the care of a resident with a pressure ulcer. Specifically, a Registered Nurse (RN) did not perform hand hygiene or change gloves appropriately during a dressing change for a resident with a pressure ulcer located in the coccyx area. The RN used the same soiled gloves to cleanse the wound and apply ointment and dressings, and then proceeded to handle personal items and other surfaces without performing hand hygiene. This included retrieving a marker from her pocket, signing and dating the dressing, and placing the marker back into her pocket without changing gloves or sanitizing hands. Furthermore, the RN continued to handle various items and surfaces with soiled gloves, including gathering treatment supplies, wiping scissors, and cleaning the overbed table. The RN also disposed of the garbage and moved an overbed table into another resident's room without performing hand hygiene. The Director of Nursing confirmed that hand hygiene should be performed between soiled and clean tasks and after removing gloves, which was not adhered to in this instance.
Failure to Change and Label Oxygen Equipment
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, R25 and R127, by not adhering to the policy of changing and labeling oxygen tubing and humidifier bottles weekly. For R25, the physician's orders required oxygen to be administered at 1-3 liters per minute via nasal cannula, with the tubing and humidifier bottle to be changed and labeled every Sunday night shift. However, on February 25, 2025, the humidifier bottle was dated February 16, 2025, and the oxygen tubing was not dated. Similarly, for R127, the orders specified oxygen at 2 liters per minute with the same weekly change and labeling requirement. On the same day, the humidifier bottle and nasal cannula for R127 were found undated. The Director of Nursing confirmed that the facility's policy mandates weekly dating and changing of these items.
Failure to Obtain Written Hospice Orders
Penalty
Summary
The facility failed to ensure that Hospice providers supplied written physician orders for a resident receiving Hospice services. The Hospice's agreement allowed nurses to receive and transcribe physician orders, which were to be countersigned by the facility's Director of Nursing or another nurse. However, for the resident in question, the facility did not have written documentation of medication order changes, aspiration risk orders, or instructions for administering medications. The resident's care plan indicated they were admitted to Hospice services with a terminal prognosis related to Alzheimer's Disease and Severe Protein Malnutrition, and they expired without the facility having complete Hospice documentation. Interviews with facility staff revealed that Hospice orders were often given verbally, and it was the responsibility of the facility nurses to enter these orders into the Electronic Health Record. The facility's Director of Nursing and Registered Nurses acknowledged that verbal orders were taken without written documentation, and the Hospice nurses did not leave progress notes or plans of care at the facility. This lack of written documentation led to confusion among the nursing staff, as one nurse admitted to not knowing the correct method of administering Ativan to the resident. The absence of written orders and clear communication between the Hospice and facility staff contributed to the deficiency in care provided to the resident.
Lack of Documentation for Extended PRN Psychotropic Medication
Penalty
Summary
The facility failed to document a clinical rationale for extending a PRN psychotropic medication order for a resident. The facility's policy requires that PRN orders for psychotropic medications be limited to 14 days unless the prescriber provides a documented rationale for extending the order. In this case, a resident had an order for Alprazolam, a psychotropic medication, to be administered as needed for anxiety for 30 days, three times per day. However, the clinical record did not include a documented rationale for extending the order beyond the standard 14 days. A Licensed Practical Nurse confirmed that the order was extended to 30 days without a written rationale, suggesting it was done to prevent the order from dropping off after 14 days.
Deficiency in Hospice Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure that hospice services were properly coordinated and documented for residents receiving hospice care. Specifically, the facility did not have the necessary hospice care plans, prescribers' orders, or clinical/progress notes available in the medical records for three residents under hospice care. This deficiency was identified during a review of hospice care management for a sample of 38 residents, affecting three residents with Alzheimer's Disease, one of whom had a terminal prognosis and expired during the review period. Interviews with facility staff and hospice personnel revealed that communication between the hospice and the facility was primarily verbal, with hospice nurses not leaving their notes at the facility. The Director of Nursing acknowledged that hospice orders were sometimes given verbally, and the Administrator admitted to having insufficient information in the facility's records. The hospice registered nurse confirmed that new orders or changes in care needs were communicated verbally, and there was uncertainty about whether the hospice office provided the facility with the necessary records.
Ombudsman Contact Information Not Visible to Residents
Penalty
Summary
The facility failed to ensure that the Ombudsman contact information was visible to residents on the second, third, and fourth floors. This deficiency was identified through observations, interviews, and record reviews. Residents from these floors attended a Resident Group meeting and expressed their unawareness of who the facility Ombudsman is, how to contact them, and reported not seeing any Ombudsman postings on their respective floors. The only Ombudsman poster was found at the entrance on the first floor, where no residents reside. Additionally, the Community Ombudsman reported not having visited the facility for over a year and mentioned unsuccessful attempts to contact the Activity Director, who did not return calls. The Activity Director claimed that the Community Ombudsman visits periodically but has not attended Resident Council Meetings. This lack of visibility and communication regarding the Ombudsman potentially affects all 77 residents residing in the facility.
Inaccessible Survey Binder and Missing Records
Penalty
Summary
The facility failed to ensure that the Survey Binder, which includes all prior survey results conducted by the State Agency, was easily accessible to residents. This deficiency was identified during a Resident Group meeting where several residents expressed their unawareness of the existence of such records and their location. The facility's policy states that residents have the right to see reports of all inspections from the last five years, but the residents reported not having seen this information or knowing where to find it. Upon investigation, it was found that the Survey Binder was placed on the upper level of the receptionist desk, approximately four and a half feet from the floor, and obscured behind two picture frames. This placement made it difficult, if not impossible, for residents, particularly those in wheelchairs, to see or reach the binder. Additionally, the binder was missing several recent survey results, including complaint or facility-reported incidents from the past year. The administrator confirmed the binder's location and acknowledged its inaccessibility to residents.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification to residents or their representatives regarding the reasons for their transfer to a hospital. This deficiency was identified for six residents who were transferred to the hospital for various reasons, including falls, changes in condition, and medical emergencies. The facility's policy requires that residents and their representatives be notified in writing and in a language they understand before a transfer or discharge occurs. However, in these cases, there was no documentation indicating that such written notifications were provided. The administrator confirmed that the facility does not provide written transfer forms to residents or their representatives, relying instead on verbal notifications. This practice was found to be inconsistent with the facility's own policy and regulatory requirements. The lack of written notification has the potential to affect all 77 residents residing in the facility, as it does not comply with the necessary procedures for informing residents and their representatives about transfers or discharges.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide a copy of the Bed Hold Policy to residents or their representatives during emergency hospital transfers, as required by their own policy. This deficiency was identified for six residents who were transferred to the hospital for various reasons, including falls, changes in condition, and passing a large clot. The facility's policy, dated December 4, 2020, mandates that a Notice of Bed Hold and Readmission Policy be provided before hospitalization or leave, with a second notice given at the time of transfer or within 24 hours of an emergency. However, documentation for residents R1, R5, R6, R11, R31, and R127 showed no evidence that such notices were provided during their respective hospital transfers. Interviews and record reviews revealed that the facility's Social Security Director acknowledged that residents only sign a bed hold contract upon admission and not with each hospital transfer or discharge. This practice contradicts the facility's stated policy and was confirmed by the inability to produce any bed hold notifications for the affected residents. The facility's CMS 671 Form indicated that 77 residents currently reside in the facility, suggesting that the failure to provide bed hold notifications could potentially affect all residents in the facility.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with dementia from sexual abuse by another resident, who also had dementia and a known history of problematic behaviors such as pacing, wandering, disrobing, and aggression. This incident occurred when the second resident placed his hand down the first resident's pants and performed aggressive sexual motions, resulting in the first resident feeling frightened and requiring a hospital examination where a minor tear near her vagina was noted. The incident was observed by a CNA during routine room checks, who then separated the residents and reported the incident. The first resident, who was severely cognitively impaired, had diagnoses including Alzheimer's Disease, Anxiety Disorder, Depression, and Unspecified Dementia with Agitation. The second resident, who was moderately cognitively impaired, had diagnoses including Vascular Dementia, Unspecified Dementia, Anxiety Disorder, and Major Depression Disorder. The second resident's care plan included monitoring for behaviors such as pacing, wandering, disrobing, and aggression. Despite these known risks, the facility did not adequately prevent the incident from occurring. The facility's policy on abuse and neglect emphasized the residents' right to be free from abuse, including sexual abuse, and required steps to be taken to ensure residents' protection when there is a suspicion of incapacity to consent to sexual activity. However, the facility failed to implement these policies effectively, as evidenced by the incident and the lack of prior intervention despite previous similar occurrences. The facility's failure to protect the resident from abuse resulted in an Immediate Jeopardy situation.
Removal Plan
- A head-to-toe assessment was completed on R1 and 1:1 monitoring was initiated for R2.
- Local police were contacted.
- R1 was sent out to the local hospital for evaluation and returned from the hospital with findings of a vaginal abrasion.
- R2 was maintained on 1:1 monitoring.
- Head-to-toe assessments were completed for each female resident residing on the memory care unit with no findings.
- Further staff interviews conducted with those who worked on the memory care unit with no findings of sexual abuse between R1 or R2 or any other residents.
- R1 was moved to a new room on a different floor.
- Care plan training for IDT for care planning requirements for actual/potential resident to resident abuse completed.
- Care plan updates completed on R1 and R2.
- Head to toe assessments conducted on all residents for signs and symptoms of abuse.
- Completion of the trauma abuse screening assessments on all residents to assess for signs and symptoms of abuse.
- Training took place on utilizing the Abuse and Neglect of a resident policy which includes exploitation and the prevention, detection and reporting expectations for all types of abuse. Training of all staff to be completed in person, or a call to that team member. Administrator was in-serviced by Regional Operations Director. Any team member who has not completed the training will not be able to work until training is completed.
- Administrator or designee will randomly interview four residents for any potential abuse allegations.
- Administrator or designee will interview four staff members to verify their understanding of the identification and reporting of abuse requirements.
- Results from the interviews will be reviewed by the QAPI Committee for any additional recommendations.
Failure to Implement Abuse Prevention Program
Penalty
Summary
The facility failed to implement its abuse prevention program effectively, leading to a deficiency in protecting residents from sexual abuse. Two residents, R1 and R2, were involved in incidents where R2 was observed engaging in inappropriate sexual behavior towards R1. Despite R1 being severely cognitively impaired and R2 being moderately cognitively impaired, the facility did not conduct the required abuse and neglect screenings since their admissions. The facility's policy mandates such screenings upon admission and quarterly, but these were not performed, leaving the residents vulnerable. The incidents included R2 attempting to lay in bed with R1 and being found in a compromising position with R1, which was witnessed by a CNA. The CNA reported these incidents to a nurse, but the nurse did not escalate the reports to the Abuse Coordinator as required by the facility's policy. This lack of reporting and follow-up allowed the situation to persist without appropriate intervention or preventive measures, such as room changes or increased supervision. Furthermore, the facility's staff, including the Social Service Director and the Administrator, were not informed of the incidents in a timely manner, which hindered their ability to take corrective actions. The facility's failure to adhere to its own policies and procedures for abuse prevention and reporting resulted in a deficiency, as the residents' safety and rights were compromised. The facility did not take adequate steps to protect the residents during the investigation, and the lack of communication and documentation contributed to the ongoing risk of abuse.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to identify and report a potential allegation of resident-to-resident sexual abuse involving two residents, R1 and R2, both of whom have cognitive impairments. The incident was first observed by a Certified Nursing Assistant (CNA), V4, who witnessed R2 attempting to undress R1. This was reported to the Registered Nurse (RN), V5, on duty, but no further action was taken to report the incident to the Abuse Coordinator or to investigate the matter further. The facility's policy requires immediate reporting of such allegations to the Abuse Coordinator, which was not followed in this case. A subsequent incident occurred where V4 observed R2 with his hand down the front of R1's pants, which was again reported to V5. Despite this, V5 did not report the incident to the Social Service Director/Abuse Coordinator, V3, and instead believed that the residents could consent to the interaction due to their perceived enjoyment. V5's personal beliefs about the residents' ability to consent, despite their cognitive impairments, led to a failure to follow the facility's policy on reporting and investigating potential abuse. The facility's administrator, V1, confirmed that the incidents were not reported as required and acknowledged that the residents were not capable of consenting due to their dementia. The facility's final report stated that consent could not be determined due to the residents' cognitive conditions, and the facility decided to act as if abuse had been substantiated. However, the lack of immediate reporting and investigation of the incidents represents a significant deficiency in the facility's handling of potential abuse cases.
Failure to Ensure Resident Safety During Assisted Ambulation
Penalty
Summary
The facility failed to ensure resident safety during assisted ambulation, resulting in a serious incident involving a resident who was at moderate risk for falls. The resident, diagnosed with Alzheimer's Disease, General Anxiety Disorder, Chronic Kidney Disease, Muscle Weakness, and a Displaced Intertrochanteric Fracture of the Left Femur, required partial to maximum assistance for ambulation. During an incident, the resident was being assisted by a CNA without the use of a gait belt, which was against the facility's policy. The resident tripped over a threshold and fell, leading to a fractured femur. The CNA admitted to not using a gait belt, acknowledging that it should have been used. Following the fall, the resident was taken to the emergency room and diagnosed with a left hip fracture. The resident underwent surgery and returned to the facility with increased confusion and required cueing, indicating a decline in condition. The resident was later admitted to hospice care and subsequently passed away. The death certificate listed aspiration pneumonia due to congestive hypertensive cardiovascular disease as the cause of death, with the femur fracture due to the fall and chronic kidney disease as significant contributing conditions. The resident's physician confirmed that the fall and fracture exacerbated the resident's decline and contributed to the subsequent death.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
The facility failed to immediately report allegations of employee-to-resident physical abuse to the Administrator/Abuse Coordinator for one resident. The incident involved a Certified Nursing Assistant (CNA) who allegedly punched a resident in the stomach. The CNA who witnessed the conversation about the abuse did not report it immediately to the appropriate authorities. Instead, she texted the Clinical Scheduler's phone after her shift ended, which was not checked until the following morning. This delay in reporting violated the facility's policy, which mandates immediate notification of abuse allegations to the Administrator or Abuse Coordinator. The incident occurred during mealtime when one CNA mentioned to another that she had punched a resident in the stomach to stop the resident's aggressive behavior. The CNA who heard this did not report it immediately due to fear and being new on the job. The Clinical Scheduler, who received the text message the next morning, then informed the Director of Nursing (DON) and the Administrator. The facility's policy clearly states that any team member who receives a complaint of abuse must notify their direct supervisor and the Coordinator of Abuse Prevention immediately, which did not happen in this case.
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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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