Resthave Home-whiteside County
Inspection history, citations, penalties and survey trends for this long-term care facility in Morrison, Illinois.
- Location
- 408 Maple Avenue, Morrison, Illinois 61270
- CMS Provider Number
- 146177
- Inspections on file
- 26
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Resthave Home-whiteside County during CMS and state inspections, most recent first.
A resident with cerebral palsy, cognitively intact but dependent for all ADLs and using a wheelchair for mobility, was being unloaded from a facility van when the transportation driver, distracted by an outdoor event, pushed the wheelchair backward toward the rear door while the mechanical lift was still fully lowered and not in place at the door. The wheelchair fell about three feet to the ground, causing a forearm laceration and an acute fifth metatarsal fracture. Facility policy required the lift to be raised and in position before moving a wheelchair onto it, and observations of other drivers showed correct procedures included securing the lift, locking wheelchair brakes, and responding to the van’s door alarm and warning light when weight is present without the lift engaged.
A resident with myeloblastic leukemia, cognitively intact and requiring weekly CBC tests to monitor her condition, did not receive labs as ordered. After the resident’s daughter/POA notified staff that weekly CBCs were needed and the provider entered the order, labs were only drawn on three occasions with significant gaps between draws. The DON reported that a nurse’s order-entry error initially prevented weekly labs from being completed, and that even after correction, the lab technician failed to perform scheduled draws on multiple dates. The daughter reported that the lab technician was not showing up or was missing the resident, and the Administrator acknowledged there was no laboratory policy in place.
Two residents and their families reported that a pair of CNAs, known as "the twins," provided care in a manner that was rough, rushed, and lacking in dignity, including physically rough handling during transfers, moving a post–hip replacement resident too quickly, and contributing to residents’ refusal of care and preference to remain soiled rather than accept assistance from these aides. Another CNA confirmed that multiple residents had requested not to receive care from these CNAs, and facility leadership, including the DON and administrator, were aware of these complaints and a formal grievance but the CNAs continued to be regularly assigned to the same unit.
Surveyors found that multiple residents were maintained on prophylactic antibiotics such as Macrobid, Cephalexin, Bactrim, and Nitrofurantoin without evidence of an acute UTI, without urinalysis or culture obtained by the facility, and with orders lacking required stop dates and clear indications. The DON/IP reported that some antibiotics were continued because of past UTI history or resident/family preference, and acknowledged that reassessments of ongoing need were not performed and that communication with hospice and the NP about these prophylactic regimens had not occurred, despite a facility policy requiring complete antibiotic orders and adherence to an antibiotic stewardship program.
The facility failed to follow its Antibiotic Stewardship Program by not adequately monitoring prophylactic antibiotic use for four residents. The DON/IP, who shared infection prevention duties with a non-nurse administrator and reported limited experience in stewardship, allowed ongoing antibiotic orders without required elements such as stop dates and clear indications. Several residents were started or continued on Macrobid, Cephalexin, Bactrim, or Nitrofurantoin for UTI prevention based on history or preference rather than an acute UTI, without facility-obtained urinalyses, and without documented reassessment or consultation with the NP or hospice regarding the continued need for these medications.
A resident with esophageal dysphagia and malnutrition, ordered NPO with Jevity 1.5 cal bolus feeds of 240 ml via feeding tube five times daily, did not receive the prescribed tube feeding volume due to inaccurate measurement by an RN. Instead of using the provided syringe, the RN repeatedly poured formula into a 30 ml medicine cup without verifying the marked volume and transferred it into a 120 ml drinking cup that was not filled to the intended level before administering it through the feeding tube. Review of the 1,000 ml formula bottle and feeding schedule by the DON showed that, by the time of the observed feeding, the bottle should have been empty and an additional 200 ml from a new bottle required, but only about 60 ml from the new bottle was used, resulting in an under-delivery of approximately 140 ml compared to the physician’s order.
A resident with multiple comorbidities, a history of repeated falls, and impaired mobility was care planned as high risk for falls with use of a stand lift for transfers. An agency CNA, working alone and unaware that two staff were required for mechanical lift transfers per facility policy, used a mechanical stand lift without a second staff member and placed the sling under the resident’s armpits with the belt around the chest instead of around the waist. During the transfer, the resident’s legs gave out, the resident slipped from the sling, and fell to the floor, after which staff manually lifted the resident into a wheelchair before a nurse assessment, contrary to the facility’s stated practice.
A resident with Alzheimer's Disease and Down Syndrome, requiring moderate assistance, was subjected to physical and verbal abuse by an RN who, after becoming frustrated with the resident's presence and communication at the nursing station, yelled at and forcefully moved the resident in her wheelchair down the hall despite the resident's distress and resistance. Multiple CNAs witnessed the incident and intervened to protect the resident.
The facility failed to act on monthly medication reviews for four residents, with issues including lack of documented rationale for not reducing medication doses and unaddressed pharmacist recommendations. The DON was initially unaware of the procedures due to a sudden staff change, leading to delays in addressing medication review forms.
The facility did not adhere to the prescribed menu for residents on a pureed diet, affecting six residents. A cook prepared pureed chicken using incorrect portion sizes, serving it with a #10 scoop instead of the prescribed #8 scoop for chicken breast and #20 scoop for bread. The dietary manager confirmed that the diet spreadsheet should be followed to ensure nutritional adequacy.
A resident, who is cognitively intact and requires assistance with toileting, reported feeling disrespected after a CNA initially refused to change her soaked incontinence brief, citing she was not the assigned CNA. The CNA later returned to assist but was reportedly rude, leaving the resident feeling upset. The DON was informed and is investigating the incident, which violated the facility's policy on treating residents with dignity.
A resident with chronic obstructive pulmonary disease and other conditions was found to be self-administering an albuterol inhaler without a proper assessment or physician's order. The resident kept the inhaler at the bedside and used it as needed, contrary to the facility's policy requiring an interdisciplinary assessment and a physician's order for self-administration. The resident's care plan and medical records did not reflect authorization for this practice.
A resident with a low BMI and multiple health conditions was not consistently provided with prescribed nutritional supplements, such as health shakes and magic cups, leading to weight loss. Despite recommendations for weight gain, staff did not assist or encourage the resident to eat, and some supplements were withheld due to the resident's refusal. The facility's failure to implement effective nutritional interventions resulted in a decrease in the resident's weight.
A facility failed to administer medications at prescribed times, resulting in a 22.22% error rate. One resident with diabetes received insulin late, potentially affecting blood sugar accuracy, while another received pain medication outside the allowed time window. The DON confirmed the importance of timely administration and pre-meal blood sugar checks.
A resident with multiple diagnoses, including diabetes, experienced a significant medication error when an LPN checked their blood sugar after breakfast and administered insulin based on this reading. The facility's policy requires blood sugar checks before meals to ensure accuracy and prevent hypoglycemia. The Director of Nursing confirmed the importance of adhering to this protocol.
A facility failed to implement enhanced barrier precautions for a resident with a wound, as required by their infection control program. The resident had a foam dressing on the sacrum that was not intact, and two CNAs provided care without wearing gowns. The care plan required enhanced precautions, including gowns and gloves during high-contact activities, but these were not followed, leading to the deficiency.
The facility failed to administer the pneumococcal vaccine to two residents, despite their consent and the facility's policy to offer it upon admission. One resident, with multiple health conditions, consented to the vaccine, but records showed no administration. Another resident's records also lacked documentation of the vaccine. Interviews revealed that the facility's process involves social services reviewing immunizations upon admission, but this protocol was not followed for these residents.
A resident with cognitive and mobility impairments experienced a fall resulting in a skin tear, but the facility failed to promptly notify the resident's POA. The facility's policy allowed for notification by 10:00 AM if the event occurred overnight, but the POA expected immediate notification to make timely care decisions. The facility's Fall Management Policy did not address family notification, leading to a deficiency in communication.
A resident with a history of falls was not properly assessed or provided with adequate fall prevention measures, such as a bed alarm, after multiple incidents of rolling out of bed. Staff were not informed of the resident's fall tendencies, and the care plan lacked specific interventions. The facility's fall management policy was not followed, and the fall mat was not used correctly, leading to the resident falling between the mat and the bed.
A resident with severe cognitive impairment was observed inappropriately touching another resident in a common area. Despite staff intervention, the incident highlights a failure to prevent abuse, as the resident had a history of inappropriate behavior. The facility's policy against abuse was not effectively enforced.
A resident with severe cognitive impairment was verbally abused by a CNA during breakfast. The CNA was overheard by two other CNAs making inappropriate comments, including telling the resident she couldn't go home without eating and calling her 'fu**ing pathetic.' The incident was reported, and the CNA admitted to the comments, leading to her termination. The facility's policy against abuse was violated.
Failure to Safely Use Van Wheelchair Lift Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfer of a cognitively intact resident with cerebral palsy and bilateral upper and lower extremity impairment during unloading from a facility transport van. The resident, who was dependent on staff for all ADLs and used a wheelchair and motorized scooter for mobility, was being returned to the facility by a transportation driver. According to the facility incident report and interviews, the driver pushed the resident in his wheelchair backward toward the rear van door while the wheelchair lift remained fully lowered to the ground instead of being raised and in place at the door. The driver admitted he was distracted by an Easter egg hunt occurring on the facility grounds and was talking to someone, and stated he was not paying attention when he pushed the resident out of the van. As the resident was pushed backward out of the van without the lift in position, the wheelchair fell approximately three feet from the van to the ground, with the wheelchair handles striking the ground first. The resident’s wife, who was following the van in her car, witnessed the event and reported that the driver did not have the lift up and that the resident “just fell backwards out of the van.” She stated that the resident’s high-back wheelchair protected his neck and back. Following the fall, the resident was noted to have a small laceration on his left forearm and later an X-ray of the left ankle showed an acute fracture of the fifth metatarsal with adjacent soft tissue swelling. Facility policy for transportation requires that, when unloading, the lift be unfolded and left in the raised position at the back doors, and that the resident be wheeled from inside the van onto the raised lift with wheelchair brakes locked before lowering the lift to the ground. Observation of other drivers demonstrated that proper procedure included having the lift raised and in place before unlocking wheelchair wheels and moving the resident toward the door, and that the van used had an alarm and red light that activate when weight is at the door without the lift in place, which would have sounded during the incident.
Failure to Provide Ordered Weekly CBC Labs for Leukemia Monitoring
Penalty
Summary
The facility failed to provide ordered weekly laboratory services for a resident with myeloblastic leukemia. The resident was admitted with a diagnosis of myeloblastic leukemia, a condition associated with low hemoglobin and red blood cell counts, and was cognitively intact with a BIMS score of 13. On a documented date, the resident’s daughter and power of attorney informed the facility that the resident should be receiving weekly CBC tests, and the provider ordered weekly CBC labs accordingly. A subsequent health status note indicated that the resident would begin going to a local hospital for her weekly CBC draws due to past issues with the current lab services. The resident later stated that her daughter managed her labs but believed some had been missed, and the daughter reported that the lab technician was either not showing up or missing the resident, and that the facility had indicated it was not a big deal that the labs were not drawn. Laboratory records showed that the resident’s CBCs were drawn on three dates only, with no lab drawn on or shortly after the date the weekly order was initiated, and after a draw on a later date, there was nearly a three-week gap before the next lab was obtained. The DON stated that the initial failure to complete weekly labs after one of the draws was due to a nurse’s error when entering the order, and that after this error was corrected, the lab technician still failed to draw the resident’s labs on several occasions, specifically missing scheduled draws on two identified dates. The DON confirmed that these labs were intended to monitor the resident’s leukemia. The Administrator stated that the facility did not have a laboratory policy.
Failure to Ensure Dignified and Respectful Care by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and respect, particularly in relation to care provided by two CNAs referred to as “the twins” or “the sisters.” One resident, R1, cognitively intact per a 12/2/25 assessment, reported that these staff were mean, had poor attitudes, and were physically rough when he did not comply with what they wanted. R1 stated the mistreatment escalated to the point that he needed to change rooms and that, prior to the move, he would rather remain soiled than have these CNAs provide care. After his room change, he reported that these CNAs no longer cared for him and that he preferred they not care for him at all. R1’s daughter confirmed that R1 had complained about the “evil twins” and requested that they have no contact with him, stating that they were unkind to the point that he refused care even when family was present. She reported this to the social services staff member (V11), who she said knew exactly which staff she meant, and she expressed concern that the CNAs were known for such behavior yet continued working there. Another CNA (V9) identified the twins as V3 and V4 and stated that residents had requested they not provide care, including one resident who would rather sit in urine than accept their assistance and who sought help from staff on other hallways. Assignment sheets showed V3 and V4 were regularly scheduled to work in zone 2 during the relevant period. A second resident, R2, admitted for antibiotics and therapy following a hip replacement complicated by sepsis, also had concerns related to the same CNAs. His wife reported in a grievance that staff, identified as “the twins,” did not take their time, moved him too quickly, and caused him discomfort when transferring and seating him, including jerking him out of bed, plopping him into a wheelchair, and allowing him to fall hard onto the toilet. She stated that these CNAs did not treat him with dignity, were rough and rude, and that he was afraid to speak up for fear of retaliation and wanted to go home early. The DON (V2) acknowledged being aware of concerns about V3 and V4 from both R1 and R2, describing the CNAs as task-oriented and noting that R1’s family had asked that they not be his caregivers, leading to his move to another zone. The administrator (V1) also acknowledged awareness of resident complaints and a grievance related to these caregivers.
Failure to Ensure Antibiotic Regimens Were Free From Unnecessary Drugs
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ drug regimens were free from unnecessary antibiotics, contrary to its own antibiotic stewardship policy requiring an indication and stop date for all antibiotic orders. For one resident, a physician ordered Macrobid 100 mg daily for a UTI, but the order lacked a stop date, and the DON/Infection Preventionist (IP) acknowledged the resident did not have an acute UTI at the time and that no repeat urinalysis was done before starting the medication. The DON/IP further stated she had not reassessed this resident’s continued need for Macrobid since it was started. Additional residents were maintained on prophylactic antibiotics without appropriate assessment, diagnosis, or stop dates. One resident was prescribed daily Cephalexin for prophylaxis by hospice due to a history of UTIs, with no associated diagnosis, no stop date, and no urinalysis or culture obtained by the facility before starting the medication; the DON/IP had never discussed this order or its ongoing need with hospice. Another resident received Bactrim twice weekly for prophylaxis based on a personal history of UTIs and the resident’s desire to remain on it, despite never having an acute UTI diagnosis or urinalysis while in the facility, and without any discussion of continued use with the nurse practitioner. A fourth resident was admitted from a hospital on Nitrofurantoin for UTI prevention, and the facility simply continued the order due to a history of UTIs, without obtaining a urinalysis or consulting the nurse practitioner about the need to continue the antibiotic. These practices conflicted with the facility’s written antibiotic stewardship policy requiring drug name, dose, frequency, start and stop dates, route, and indications for use on all antibiotic orders.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and follow its Antibiotic Stewardship Program by not monitoring for inappropriate and unnecessary antibiotic use for four residents reviewed for antibiotic usage. The facility’s policy required that antibiotics be prescribed and administered under the guidance of the Antibiotic Stewardship Program, with staff education on stewardship and all antibiotic orders including drug name, dose, frequency, start date, stop date, route, and indication. The DON, who also served as Infection Preventionist, stated she shared the IP role with the Administrator, who was not a nurse, and acknowledged she was still learning antibiotic stewardship and had not expected to be the IP. She reported she was responsible for monthly antibiotic surveillance and review of prophylactic antibiotic orders with the nurse practitioner, but also stated that some residents remained on prophylactic antibiotics based on history of UTIs or resident/family preference. For one resident, Macrobid was started for a history of frequent UTIs despite no acute UTI at the time, with no stop date and no repeat urinalysis obtained before initiation, and the DON/IP had not reassessed the continued need since the start date. Another resident was placed on Cephalexin for UTI prophylaxis by hospice without an associated diagnosis or stop date, and the facility never collected a urinalysis or discussed the need for continued use with hospice. A third resident received Bactrim twice weekly for a personal history of UTIs, with no stop date, had never been diagnosed with an acute UTI in the facility, had no urinalysis collected there, and the DON/IP had not discussed ongoing use with the nurse practitioner. A fourth resident was admitted from a hospital on Nitrofurantoin for UTI prevention; the facility carried over the order based on history of UTIs, did not obtain a urinalysis before continuing the medication, and the DON/IP did not consult the nurse practitioner about the need to continue it.
Inaccurate Measurement of Physician-Ordered Tube Feeding Volume
Penalty
Summary
The facility failed to ensure accurate measurement and administration of physician-ordered tube feeding for a resident receiving bolus enteral nutrition. The resident had a feeding tube, was NPO, and had an order for Jevity 1.5 cal with fiber, 240 ml via feeding tube five times daily, totaling 1,200 ml per day, for nutrition support related to esophageal dysphagia that had led to malnutrition. During observation of a scheduled tube feeding, an RN used a 30 ml medicine cup and a 120 ml drinking cup to measure the formula instead of the syringe provided for accurate measurement. The RN repeatedly filled the 30 ml cup without verifying the volume at the marked 30 ml line and poured these unmeasured amounts into the drinking cup, which was not filled to the 120 ml level, and then administered the contents via the feeding tube. She stated this was her usual method for administering the resident’s tube feedings. Record review and subsequent measurement of the formula bottles by the DON showed that each bottle contained 1,000 ml and that the bottle used for the observed feeding had been opened the previous day before the resident’s 5:00 PM feeding. The feeding observed was the fifth feeding from that bottle, and based on the ordered regimen, the bottle should have been depleted and an additional 200 ml from a new bottle should have been required if the correct volumes had been administered at each feeding. Instead, only approximately 60 ml from the new bottle was used, indicating that the resident’s tube feeding at that time was short by about 140 ml. The DON confirmed that the resident did not receive the correct amount of tube feeding formula as ordered by the physician and that nurses were expected to use the provided syringe to accurately measure tube feeding volumes, consistent with the facility’s enteral nutrition policy, which requires administering the ordered amount of feeding.
Unsafe Mechanical Stand Lift Transfer and Inadequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer a resident using a mechanical stand lift and to provide adequate supervision to prevent an accident. The resident had multiple diagnoses, including hypertensive heart disease, chronic kidney disease stage 4, atrial fibrillation, type 2 diabetes, repeated falls, reduced mobility, depression, generalized osteoarthritis, and anxiety, and was care planned as high risk for falls with use of a stand lift for transfers. The day before the incident, the resident had a documented fall due to weakness. On the day of the incident, an agency CNA (V8) reported that she knew the resident was a two-person assist or mechanical stand lift transfer and attempted to find another staff member to help, but when no one was available, she proceeded to use the stand lift alone. During the transfer, V8 placed the sling under the resident’s armpits and secured the belt around the resident’s chest, rather than around the waist as described by the restorative CNA (V5) as the correct method. V8 stated that as the transfer was in progress, the resident’s legs gave out, the resident began to slip from the sling strap, and then fell, striking her lower back on the floor. V8 acknowledged this was her first time working at the facility and that she did not know two staff were required for mechanical stand lift transfers, and she also reported that she and another CNA lifted the resident off the floor and into a wheelchair after the fall. The DON (V2) confirmed that the facility’s policy, revised in 2019, requires two staff for all mechanical lift transfers, that staff should not move a resident after a fall until a nurse assesses the resident, and that the stand lift arms were found in an upright position, which can cause the sling to ride up the back. The incident report documented that the resident slipped out of the sit-to-stand machine and that V8 moved the resident off the floor after the fall.
Resident Subjected to Physical and Verbal Abuse by RN
Penalty
Summary
A resident with Alzheimer's Disease and Down Syndrome, who had moderate cognitive impairment and required moderate assistance with activities of daily living, was subjected to abuse by a registered nurse (RN). The RN, while performing a medication changeover at the nursing station, became frustrated with the resident's attempts to communicate and repeatedly asked other staff to move the resident away. Despite multiple attempts by staff, the resident refused to leave the area. The RN then yelled at the resident and physically attempted to push and pull the resident in her wheelchair down the hall, while the resident was visibly distressed, crying, yelling, and resisting by putting her feet down and grabbing the wheelchair wheels. Multiple certified nursing assistants (CNAs) witnessed the incident, describing the RN's actions as dragging the resident backwards in her wheelchair while the resident was kicking, screaming, and crying. Staff intervened to prevent further harm, and the RN left the situation after being confronted. The facility's abuse policy explicitly prohibits abuse or neglect of residents by anyone, including staff. The incident was substantiated as abuse following an internal investigation.
Failure to Act on Monthly Medication Reviews
Penalty
Summary
The facility failed to ensure that monthly medication reviews were acted upon by the physician and did not have a process in place to address these reviews in a timely manner. This deficiency affected four residents who were part of a sample of 32. For one resident, the attending physician did not document a clinical rationale for not attempting a gradual dose reduction (GDR) of Zoloft, despite multiple requests from the pharmacist over several months. Similarly, another resident's medication review for Lexapro also lacked a documented rationale for not attempting a GDR, with repeated requests from the pharmacist going unaddressed. Additionally, a resident continued to have an active order for hydroxyzine despite recommendations from the pharmacist to discontinue it, which were not acted upon over several months. Another resident had an as-needed lorazepam order without criteria for use beyond 14 days, and this issue was not addressed despite repeated recommendations. The Director of Nursing acknowledged the oversight, noting that the previous DON left abruptly, and she was initially unaware of the procedures for handling medication review forms. The facility's policy requires a response to every pharmacist recommendation, but this was not adhered to in these cases.
Failure to Follow Prescribed Menu for Pureed Diets
Penalty
Summary
The facility failed to follow the prescribed menu to ensure nutritional adequacy for residents on a pureed diet, affecting six residents. The deficiency was observed when a cook, identified as V13, prepared pureed chicken by blending chicken breast, chicken broth, and bread, and then served it using a #10 scoop (3.25 ounces) instead of the prescribed #8 scoop (4 ounces) for chicken breast and #20 scoop (1 5/8 ounces) for bread. The dietary manager, V5, confirmed that the diet spreadsheet, which specifies portion sizes, should be followed to ensure residents receive the appropriate amount of protein and vegetables for nutrition. The recipe for Pureed Italian Chicken also indicated the use of a #8 scoop, highlighting the discrepancy in portion sizes served to the residents.
Resident Dignity Compromised by CNA's Rude Behavior
Penalty
Summary
The facility failed to ensure a resident was treated with dignity, as evidenced by an incident involving a cognitively intact resident who required moderate assistance with toileting hygiene. The resident, who has a history of difficulty walking, falling, and insomnia, reported that during the early morning hours, her incontinence brief was soaked, and she pressed her call light for assistance. A CNA responded but stated she was not the resident's assigned CNA and initially refused to change her, displaying rude behavior. The CNA later returned and changed the resident, but the interaction left the resident feeling upset and disrespected. The Director of Nursing (DON) was informed of the incident and confirmed that the resident had reported the CNA's refusal to assist and rude demeanor. The DON acknowledged the resident's alert and oriented status and noted that the resident wears an incontinence brief at night by choice. The facility's policy mandates that all residents be treated with kindness, respect, and dignity, which was not upheld in this instance. The DON was in the process of identifying the CNA involved, who was believed to be from another hall.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to assess and obtain a physician's order for a resident to self-administer medication and keep it at the bedside. The resident, who had diagnoses including chronic obstructive pulmonary disease and malignant neoplasm of the lungs, was observed with an albuterol sulfate inhaler on the bedside table, which he used as needed without staff reminders. The resident's cognitive abilities were intact, and he had been keeping the inhaler at his bedside for about a week. However, there was no staff present during the observation, and the resident's care plan did not indicate permission to keep the inhaler at the bedside. The Director of Nursing confirmed that the facility's policy required an assessment by the interdisciplinary team and a physician's order for a resident to self-administer medications. Despite this, the resident's electronic medical record lacked an assessment for self-administration or bedside storage of medications. The nurse responsible for the resident was unaware of the self-administration, and the resident's order summary indicated the inhaler was scheduled for use four times a day, not as needed. The facility contacted the resident's Nurse Practitioner to obtain the necessary order only after the surveyor's observation.
Failure to Provide Nutritional Supplements to Resident
Penalty
Summary
The facility failed to ensure that nutritional supplements were consistently provided to a resident, identified as R28, who was at risk for weight loss. R28, a female resident with a history of Parkinson's, congestive heart failure, depression, anxiety, and cerebral infarction, was noted to have a low BMI and was recommended to gain weight. Despite dietary recommendations to provide supplements such as health shakes, whole milk, and magic cups with meals, these were not consistently offered. Observations revealed that R28 was not assisted or encouraged to eat during meals, and she was not provided with all her prescribed supplements, contributing to her inadequate food and fluid intake. Interviews with staff indicated that R28 had a poor appetite and required cueing to eat, yet staff did not consistently assist her. The dietary manager noted that R28 refused some supplements and gave them to her tablemates, leading to the decision not to offer them anymore. However, the dietitian stated that supplements should still be offered if listed as part of the resident's nutritional plan. R28's weight decreased from 117 pounds to 113 pounds over several months, indicating a failure to implement effective nutritional interventions as per the facility's Weight Monitoring Policy.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered at the prescribed times, resulting in a medication error rate of 22.22%, which exceeds the acceptable threshold of 5%. This deficiency was observed through the cases of two residents. The first resident, admitted with multiple diagnoses including diabetes mellitus type II and dementia, had a medication schedule that required blood sugar checks and insulin administration at specific times. However, on one occasion, the resident's blood sugar was checked and insulin was administered significantly later than scheduled, after breakfast, which could lead to inaccurate blood sugar readings and potential health risks. The second resident, with a history of conditions such as idiopathic progressive neuropathy and Alzheimer's disease, was scheduled to receive tramadol for pain management at specific times. However, the medication was administered late, outside the facility's policy of allowing a one-hour window before and after the scheduled time. The Director of Nursing confirmed that medications should be administered within this window and that blood sugar checks should occur before meals to ensure accuracy. The facility's failure to adhere to these protocols contributed to the high medication error rate.
Significant Medication Error Due to Timing of Blood Sugar Check
Penalty
Summary
The facility failed to ensure a significant medication error did not occur for a resident reviewed for medications. The resident, admitted with diagnoses including pneumonia, metabolic encephalopathy, diabetes mellitus type II, chronic kidney disease, muscle wasting and atrophy, and dementia, had a medication order for blood sugar checks and insulin administration at specific times. On April 7, 2025, an LPN checked the resident's blood sugar level after breakfast, which was 346, and administered insulin shortly after. The Director of Nursing later stated that blood sugars should be checked before meals to avoid inaccurate readings and potential hypoglycemia if insulin is administered based on post-meal readings. The facility's Medication Pass policy requires medication administration within one hour before and after scheduled times, with documentation for any deviations.
Failure to Implement Enhanced Barrier Precautions for Resident with Wound
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident with a wound, as required by their infection prevention and control program. The resident, who was admitted with diagnoses including heart disease, atrial fibrillation, a personal history of urinary tract infections, and Alzheimer's disease, had a foam dressing on the sacrum that was not fully intact. During an observation, two CNAs were seen providing peri care to the resident without wearing gowns, and there was no isolation or enhanced barrier precaution sign on the resident's door. The resident's care plan indicated the need for enhanced barrier precautions due to the wound, specifying that staff should wear gowns and gloves during high-contact care activities. The Director of Nursing confirmed that the resident should have been on enhanced barrier precautions due to a pressure injury on the coccyx. The facility's policy for preventing the spread of multidrug-resistant organisms also highlighted the necessity of using gowns and gloves for residents with wounds or indwelling medical devices, regardless of colonization status. However, these precautions were not followed, leading to the deficiency.
Failure to Administer Pneumococcal Vaccine to Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as R15 and R40, received the pneumococcal vaccine as part of their immunization protocol. R40 was admitted with multiple diagnoses including diabetes mellitus, chronic kidney disease, and congestive heart failure. Although R40 consented to the pneumococcal vaccine on 8/9/22, his immunization report printed on 4/8/25 did not document the administration of the vaccine. Similarly, R15, who was admitted with conditions such as progressive neuropathy and Alzheimer's disease, also lacked documentation of receiving the pneumococcal vaccine as of 4/8/25. Interviews with the Director of Nursing (V2) and the Social Service Director (V14) revealed that the facility's process involves social services discussing and reviewing immunizations with residents upon admission. The facility's policy, revised on 11/28/16, states that the pneumococcal immunization is offered on admission if no prior history is available. However, the records for R15 and R40 did not reflect the administration of the vaccine, indicating a lapse in following the established protocol. The CDC's guidelines, which the facility claims to follow, recommend that adults over 50 who have not received a pneumonia vaccine should receive the PCV 20 vaccine.
Delayed Notification of Resident's Fall to POA
Penalty
Summary
The facility failed to immediately notify a resident's Power of Attorney (POA) after the resident experienced a fall and a skin tear. This deficiency was identified for one of the three residents reviewed for falls. The resident, who had been admitted with diagnoses including partial paralysis following a stroke, cognitive communication deficits, and mobility abnormalities, was found on the floor with a skin tear on her left elbow. Although the resident's physician was notified, the POA was not informed until later in the morning, contrary to the expectations of the POA and the facility's policy. The Director of Nursing (DON) stated that the policy required the third shift nurse to notify the family at the end of their shift if a fall occurred during the night. However, the facility's Family/Responsible Party Notification of Resident Change of Condition policy allowed for notification by 10:00 AM if the event occurred overnight. The resident's POA expressed dissatisfaction with the delayed notification, emphasizing the importance of timely communication to make informed decisions about the resident's care. The facility's Fall Management Policy did not address family notification, contributing to the deficiency in communication.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to ensure adequate assessment and intervention for a resident with a history of falls. The resident, who had partial paralysis following a stroke and cognitive communication deficits, experienced multiple falls by rolling out of bed. Despite these incidents, the facility did not document a fall on one occasion and failed to implement effective fall prevention measures such as a bed alarm. Staff members, including CNAs and an RN, were not adequately informed about the resident's fall history and the necessary interventions to prevent further falls. The CNAs were unaware of the resident's tendencies to fall out of bed and did not receive this information during shift reports. The RN on duty did not document or assess the resident after a reported fall, and the Director of Nursing was not informed of the incident. The resident's care plan lacked specific interventions to prevent falls, such as keeping the resident out of her room when awake, leaving the door open, frequent monitoring, and using pillows for positioning. The facility's fall management policy was not followed, as the incident was not documented, and the resident was not assessed for injuries. The fall mat intended to prevent injuries was not used correctly, allowing the resident to fall between the mat and the bed.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving two residents. One resident, who has severe cognitive impairment and is dependent on staff for care, was observed by staff inappropriately touching another resident, who was in an almost comatose state and did not react to the incident. The inappropriate behavior occurred in the common lounge area, where staff witnessed the resident lifting the shirt of the other resident and touching her breast. Despite the immediate intervention by staff to redirect the resident, the incident highlights a lapse in ensuring a safe environment for all residents. The resident involved in the inappropriate behavior had a history of being sexually inappropriate verbally and physically with staff, as noted in his care plan. The facility's policy, which was revised shortly before the incident, clearly states that abuse or neglect of residents is not tolerated and that each resident should be free from abuse. However, the incident indicates a failure to adhere to this policy, as the resident was able to engage in inappropriate behavior without immediate prevention, despite staff being present in the area.
Verbal Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) identified as V5. The resident, who was admitted with a right tibia fracture, atrial fibrillation, weakness, and dementia, was reported to have severe cognitive impairment and required assistance with meals. During a breakfast service, V5 was overheard by two other CNAs, V3 and V4, making inappropriate comments to the resident, including telling her she had to eat her breakfast or she would not be able to go home, and later calling her 'fu**ing pathetic.' These statements were confirmed by the witness statements from V3 and V4, and V5 admitted to making these comments when confronted by the Director of Nursing (DON). The facility's investigation substantiated the abuse based on the witness accounts, despite the resident not recalling the incident or expressing any complaints about the care received. The facility's policy, which prohibits abuse or neglect of residents, was violated in this instance. The incident was reported to the Administrator, and V5 was subsequently terminated from the facility for verbal abuse. The report highlights the failure to protect the resident from verbal abuse, as required by the facility's policies and regulations.
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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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