The Citadel At Saint Anne Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockford, Illinois.
- Location
- 4405 Highcrest Road, Rockford, Illinois 61107
- CMS Provider Number
- 145563
- Inspections on file
- 39
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at The Citadel At Saint Anne Place during CMS and state inspections, most recent first.
A resident with no cognitive impairment reported that her personal packages were repeatedly delivered already opened, causing her concern and discomfort. Staff interviews revealed that while mail and packages for residents were supposed to be sorted at reception and delivered unopened by Life Enrichment staff, this resident’s packages were routinely held so the DON could open and inspect them in the reception area or office before delivery, with only approved items passed on. Life Enrichment staff confirmed they picked up the resident’s packages already opened and told her the DON had to review the contents first. The Administrator stated staff should not open resident mail or packages except in front of the resident with consent, and both the Administrator and DON acknowledged there was no signed permission from the resident, despite a facility policy stating that mail may not be opened without the resident’s permission.
A cognitively intact resident with an active order for a daily lidocaine 4% patch for low back pain had MARs indicating consistent administration with only a few documented refusals, yet the resident reported not receiving the patch for several consecutive days. An RN confirmed there were days when the resident did not receive the patch, including occasions when the RN did not realize the resident had gotten out of bed, while the MAR still reflected administration. The DON reported that staff did not reattempt application when the resident refused, contrary to the facility’s medication administration policy requiring medications to be administered as prescribed and in accordance with good nursing practice.
A resident with dementia, stroke, and mobility deficits was transferred from the bathroom by a CNA without required two-person assistance or a gait belt, contrary to the care plan. The resident fell to the floor, sustaining a skin tear, and required help from three staff to return to the wheelchair. Facility policy on safe lifting and movement was not followed.
A resident with severe cognitive impairment and left-sided weakness developed a large bruise and pain in her left upper arm, which was observed by multiple CNAs and nurses. Despite these observations, there was no timely assessment, documentation, or provider notification, resulting in a delay of several days before an X-ray was ordered and a non-displaced humerus fracture was diagnosed. Facility policy required prompt action for such injuries, but this was not followed.
Multiple residents with existing or newly developed pressure ulcers did not receive timely wound assessments, weekly documentation, or prompt treatment interventions. Delays in identifying and treating wounds led to progression to advanced stages, and recommended nutritional support was not always provided. Staff interviews confirmed that required assessments and interventions were not consistently performed, resulting in untreated and worsening pressure ulcers.
Multiple residents experienced significant weight loss or lacked proper weight monitoring due to failures in obtaining accurate weights, identifying and reporting significant changes, and implementing RD recommendations. In several cases, missing or delayed weight documentation prevented the RD from assessing nutritional needs, and recommended interventions were not consistently put into place due to breakdowns in communication and order entry.
Three residents experienced falls and injuries due to inadequate supervision and failure to maintain a safe environment. One resident fell and fractured his hip and wrist after being unable to reach his urinal and not receiving timely assistance. Another slipped out of a mechanical lift during transfer while wearing inappropriate footwear, and a third fell and sustained a black eye and other injuries after being left unattended on the bed during a transfer. In each case, staff did not provide the required assistance or ensure accident hazards were minimized.
Staff failed to prevent cross-contamination during meal service by using the same gloved hands to handle multiple food items, touch clothing, and surfaces without changing gloves, and by not using utensils for lemon wedges. Additionally, a can opener with caked-on debris was used on consecutive days, despite being reportedly cleaned, increasing the risk of food contamination.
The facility failed to correctly transcribe physician orders and ensure accurate medication administration for four residents, resulting in incorrect medications, dosages, and extended courses of treatment. These errors included giving a resident the wrong medications, administering an antibiotic longer than prescribed, providing a lower dose of Budesonide than ordered, and continuing a prednisone taper past the intended stop date.
Six residents with dysphagia or stroke were served pureed peas that contained chunks and pieces of skin, requiring chewing to swallow. The food was not blended to a smooth consistency as required for pureed diets, and this was confirmed by both staff and surveyors during meal preparation.
Three residents experienced a lack of dignity in care, including disruptive nighttime dressing changes, long delays in call light response, dismissive staff interactions, and failure to assist a female resident with personal hygiene related to facial hair. These actions did not align with facility policies requiring respect and dignity for all residents.
A resident with multiple comorbidities, including CHF and pressure ulcers, developed two skin tears on the left arm. Staff failed to assess the wounds or obtain physician treatment orders, and there was no documentation of wound assessment or treatment in the medical record, contrary to facility policy.
A resident with obstructive sleep apnea and other respiratory conditions did not have physician orders in place for CPAP use upon admission, and the care plan lacked specific CPAP instructions. The CPAP equipment was not consistently cleaned or stored according to facility policy, with the mask left unbagged on the bedside table and no documentation of daily cleaning prior to new orders being added.
Multiple residents with significant medical needs reported long delays in staff response to call lights, with one resident experiencing a fall and injury after waiting for assistance and attempting to manage independently. Residents described frequent waits of up to an hour, and staff acknowledged limitations with the facility's outdated call light system and lack of monitoring.
A staff member provided wound care to a resident with a Stage 4 pressure ulcer while only wearing gloves, failing to use a gown as required by the facility's Enhanced Barrier Precautions policy. The infection preventionist confirmed that both gown and gloves were necessary for wound care in residents with chronic wounds.
A resident with left-sided weakness and total dependence on staff for care fell out of bed during incontinence care when only one CNA was present, despite her need for two-person assistance due to limited mobility and size. The care guide did not specify the correct staffing level for incontinence care, and the facility's policies lacked guidance on assessing assistance needs, leading to the resident sustaining a hip fracture.
The facility failed to assess and notify the wound care physician of changes in a pressure injury for a resident, leading to the deterioration of the wound. Another resident developed a stage 2 pressure ulcer due to ineffective pressure-relieving interventions for oxygen tubing. The facility did not adhere to its policy on pressure injury assessment and treatment, resulting in these deficiencies.
The facility failed to supervise and implement fall prevention for two residents at high risk for falls. A resident was left unsupervised in the bathroom, resulting in a fall and injury, while another was placed in an incorrect wheelchair, contrary to their care plan. These actions violated the facility's fall prevention policy.
A facility failed to administer a prescribed lidocaine 5% patch to a resident with osteoarthritis, resulting in unmanaged pain. The RN was unaware of the absence of the patch, and the EMAR showed it was not given on multiple occasions. The LPN confirmed the patch is ordered through the facility's pharmacy, and its absence could lead to pain. This failure deviates from the facility's medication administration policy.
The facility failed to include stop dates for PRN anti-anxiety medications for two residents. One resident had an order for Ativan without a stop date, and another had an order for Lorazepam also lacking a stop date. The facility's policy requires a 14-day stop date for PRN psychotropic medications unless specified otherwise by a physician.
The facility exceeded the acceptable medication error rate with a 7.69% error rate during a medication pass. One resident did not receive a prescribed lidocaine patch, resulting in reported pain, while another resident received diclofenac gel applied incorrectly to both knees instead of just the right knee as ordered. The facility's policies require strict adherence to physician orders.
A facility failed to dispose of an expired insulin pen and did not label an opened insulin pen with the open date for a resident. The resident's physician orders included insulin aspart and insulin glargine, which were documented in the electronic medication administration record. An LPN confirmed that insulin pens should be dated when opened, as per facility policy, but was unsure of the duration for which opened insulin remains effective.
The facility failed to follow infection control protocols, as staff did not change gloves or perform hand hygiene after providing incontinence care to residents, risking cross-contamination. Additionally, staff did not wear gowns during high-contact care activities for residents under Enhanced Barrier Precautions, contrary to facility policies.
A resident was found storing Norco pills in his room, claiming to find them in his bed due to the facility's lack of medication accountability. The LPN administering the medications was surprised when the resident took the medication in her presence, as he usually refused supervision. Facility policies on controlled substances and medication administration were not followed.
A resident with multiple health conditions, including a prosthetic heart valve, did not receive his prescribed anticoagulant medication for eight days due to a failure to enter the medication order into the system. This lapse was identified by a nurse and reported to the on-call NP, and the resident's POA was informed.
Failure to Protect Resident’s Right to Unopened Personal Mail and Packages
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to receive unopened personal mail and packages. Resident 1 (R1), who had no cognitive impairment per the facility assessment, reported that her packages had been delivered to her already opened without her consent, causing her concern and discomfort. R1 stated she did not want anyone but herself to open her packages and that she had been told the DON (V2) was opening her packages before they were delivered to her. Interviews with staff confirmed that all resident mail and packages were received at the reception area, sorted by room number, and then delivered by Life Enrichment staff, with the expectation that they remain unopened. However, staff reported that R1’s packages were held so the DON could open and inspect the contents in the reception area or in the DON’s office before delivery, and that only approved items were then sent on to R1. Life Enrichment staff stated they had picked up R1’s packages already opened and informed R1 that the DON had to go through her items first. The Administrator (V1) stated staff should not open any resident’s mail or packages and that, if needed, packages should be opened in front of the resident with the resident’s consent. Both the Administrator and DON confirmed there was no signed contract or permission from R1 authorizing staff to open her packages, and the facility’s Resident Rights policy states that the facility may not open a resident’s mail without the resident’s permission.
Failure to Accurately Administer and Document Daily Lidocaine Patch
Penalty
Summary
The deficiency involves the facility’s failure to accurately administer and document a prescribed lidocaine 4% patch for a resident with an active order to apply the patch to the lower back once daily for low back pain. The resident’s March and April Medication Administration Records (MARs) show the lidocaine patch as administered every day in March except for two documented refusals, and every day in early April except for one documented refusal. The MARs also indicate that the resident’s pain was well managed, and the resident’s Minimum Data Set reflects that the resident is cognitively intact. On observation, the resident was lying in bed with needs met and no noticeable pain. Despite the MAR documentation, the resident reported that between the end of March and the beginning of April, the lidocaine patch was not administered for a period of four days to one week, and that when this was brought to staff attention, staff responded by asking why the resident had not informed them. A registered nurse who regularly cares for the resident stated that during that time there were days when the resident refused the patch, but also at least two days when the nurse did not realize the resident had gotten out of bed and the patch was not administered at all. The nurse acknowledged that if the patch was not administered, it should not have been signed as given on the MAR. The DON stated that when the resident refused the lidocaine patch, staff did not reattempt application. The facility’s Medication Administration policy requires medications to be administered as prescribed and in accordance with good nursing principles and practices.
Failure to Safely Transfer Resident Resulting in Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident with a history of dementia, stroke, right lower leg wound, and transient ischemic attack without following the resident's care plan, which required two staff members for all transfers and toileting. The CNA transferred the resident alone and did not use a gait belt, instructing the resident to hold onto the bathroom grab bar. During the transfer, the resident's legs gave out, resulting in a fall to the bathroom floor. The CNA was unable to prevent the fall due to the absence of a gait belt and lack of assistance. Multiple staff members responded to the incident, finding the resident on the bathroom floor, kneeling and in pain, with her legs trapped between the toilet seat and grab bar. It required three staff members to safely assist the resident back to her wheelchair. The resident sustained a small skin tear to her left arm as a result of the fall. The facility's policy on safe lifting and movement of residents requires the use of appropriate techniques and devices to ensure safety, which was not followed in this incident.
Failure to Assess, Document, and Notify Provider of Resident Injury
Penalty
Summary
The facility failed to assess, document, notify the provider, and monitor an injury of unknown origin for a resident with severe cognitive impairment and significant physical dependencies. The resident, who had a history of stroke with left-sided weakness and required total assistance for activities of daily living, was observed by staff to have a large bruise on her left upper arm. Multiple CNAs and nurses noticed the bruise, which was initially red and later turned yellow, but there was no documentation or assessment of the bruise in the medical record prior to several days after it was first observed. Staff interviews revealed that the bruise was reported to nurses, but the nurses either assumed it was old or did not take further action, and there was no immediate notification to the provider or documentation of the injury. The resident exhibited pain with movement of her left arm, which was noted by staff during care, but this pain was not promptly reported or documented. It was only after several days, when the unit manager was made aware of the bruise, that the nurse contacted the provider and an X-ray was ordered. The X-ray revealed a non-displaced fracture of the left humerus. The facility's policies required prompt assessment, documentation, and provider notification for new skin issues or injuries of unknown origin, but these procedures were not followed in this case. The investigation found that the lack of timely assessment and documentation led to a delay in diagnosing the resident's fracture. Staff interviews confirmed that the bruise and associated pain were observed and reported among staff, but not properly escalated or recorded. The provider was not notified until three days after the initial observation of the bruise and pain, resulting in a delay in obtaining appropriate medical orders and treatment for the resident's injury.
Failure to Timely Assess, Document, and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents. Several residents were admitted with existing pressure ulcers at various stages, but the facility did not consistently perform timely initial wound assessments, weekly reassessments, or implement treatment interventions as required. For example, one resident was admitted with multiple stage 3 and 4 pressure ulcers, but the first documented wound assessments were not completed until several weeks after admission. Nursing staff confirmed that initial wound assessments, including measurements and wound bed descriptions, should be completed on the day of admission, but this was not done. Additionally, weekly wound assessments and documentation were not consistently performed, and treatments were not always initiated promptly upon identification of new or worsening wounds. Another resident developed a pressure wound that was not treated for 26 days after it was identified, resulting in deterioration to a stage 4 ulcer. The care plan for this resident included daily skin inspections and nutritional support, but there was no evidence that the recommended protein supplement was provided. Wound assessments were missing for several weeks, and treatment orders were delayed. The wound care nurse and DON acknowledged that floor nurses are responsible for initial wound assessments and that treatments should be started as soon as possible, but this did not occur. The wound physician noted that wounds should be identified at earlier stages and emphasized the importance of high-protein supplements and offloading for prevention and healing. A third resident with severe cognitive deficits and total dependence on staff developed multiple pressure ulcers, including stage 3 and 4 wounds, which were not identified until they had progressed to advanced stages. The facility's policy required skin assessments on admission and weekly thereafter, but documentation showed gaps in assessments and delayed identification of wounds. Another resident with a history of noncompliance and high risk for skin breakdown had a stage 4 sacral wound that was not assessed for nearly three months, and new wounds were not promptly identified or treated. Staff interviews revealed that wounds were not always discovered during routine care, and appropriate offloading devices were not consistently used, despite the resident's high risk and previous wound history.
Failure to Accurately Monitor Weights and Implement Dietitian Recommendations
Penalty
Summary
The facility failed to ensure accurate and timely weight monitoring, identification, and reporting of significant weight loss, as well as failed to implement dietitian recommendations for multiple residents. For one resident with multiple diagnoses including anemia, hypertension, and pressure ulcers, significant weight loss occurred over a short period without notification to the Registered Dietitian (RD). The RD was not informed of the weight change, and there were concerns about the accuracy of the weights recorded. The resident's care plan required regular weight monitoring and prompt reporting of significant changes, but these protocols were not followed. Another resident with severe cognitive deficits and a history of malnutrition and pressure wounds was not weighed upon readmission from the hospital, contrary to facility policy requiring daily weights for the first three days post-admission. The RD was unable to assess for significant weight loss due to missing weights, and scheduled weekly weights were not documented in the electronic record. The lack of timely and accurate weight documentation prevented the RD from making necessary nutritional assessments and interventions. Additional residents experienced similar deficiencies. One resident with Alzheimer's and a history of pressure ulcers and hip fracture had a documented 14.3% weight loss over two months, with a missing monthly weight that was not entered into the electronic health record as required. Another resident with a history of fluctuating weights and multiple diagnoses did not receive a recommended nutritional supplement because the RD's recommendation was not converted into a physician order, resulting in the intervention not being implemented. Facility policies required regular weight monitoring, reweighs for significant changes, and prompt communication of RD recommendations, but these were not consistently followed.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for residents at risk for falls and accidents. One resident with diagnoses including adult failure to thrive, diabetes, chronic kidney disease, and low back pain, who required maximum assistance for standing and toileting, was left unable to reach his urinal. Despite having his call light on and waiting for staff assistance, he attempted to retrieve the urinal himself after waiting for half an hour, resulting in a fall that caused a fractured hip and wrist. The resident reported that staff perceived him as independent due to his age and cognitive status, despite his documented need for assistance. Another resident, dependent on staff for toileting and requiring a sit-to-stand mechanical lift for transfers, slipped out of the lift and fell while being transferred from bed to the bathroom. At the time of the incident, the resident was wearing house shoes instead of the required non-slip footwear, which contributed to the fall. Two staff members were present during the transfer, and the resident reported feeling her feet slip and requested the lift be raised, but the fall occurred regardless. A third resident, who required substantial assistance for dressing and transfers and was to be transferred with a gait belt and two staff, sustained a black eye after falling during a transfer. The resident was left sitting on the edge of the bed while the CNA retrieved clothes from the closet, during which time the resident reached for a shirt and fell forward, hitting his head on the lift. The incident resulted in a cut and swelling to the left eyebrow, as well as scrapes to the left knee and ankle. In each case, the facility did not provide the necessary supervision or ensure the environment was free from accident hazards, directly leading to resident injuries.
Failure to Prevent Cross-Contamination in Food Handling and Equipment
Penalty
Summary
The facility failed to handle food in a manner that prevents cross-contamination and did not maintain food preparation equipment to prevent contamination. During lunch service, a cook used gloved hands to handle multiple food items, including lemon wedges, peas, french fries, and fish, without changing gloves between tasks. The cook also touched her clothing, door handles, and food carts with the same gloves and did not change them during the entire lunch service. No utensils were provided for handling lemon wedges, and the cook used her gloved hand to place them on plates for all residents. Additionally, the facility's can opener was observed to have caked-on debris on the sharp cutting tip on two consecutive days. The dietary supervisor confirmed that the can opener had been used and cleaned, but acknowledged that the tip remained dirty and posed a risk of cross-contamination. The supervisor also stated that food should not be touched with potentially contaminated gloved hands and that utensils should be used for items like lemon wedges. The facility's policy requires all food service equipment and utensils to be sanitized according to guidelines and mandates safe food handling practices.
Medication Transcription and Administration Errors
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not correctly transcribing physician orders and not ensuring the correct medications and dosages were administered to residents. One resident with multiple diagnoses, including cerebral infarction and dementia, was given incorrect medications such as cetirizine, gabapentin, quetiapine, and memantine, which was discovered by another RN as the nurse was leaving the room. Another resident with liver cell carcinoma and other chronic conditions received an antibiotic for 12 days instead of the prescribed 5 days because the medication stop date was not entered by the nurse. A third resident with a history of chronic bowel disease and repeated falls was prescribed Budesonide 9mg daily, but only received 3mg due to a pharmacy dispensing error that was not caught by staff. Additionally, a resident with urinary tract infection and other chronic illnesses was given a prednisone taper beyond the intended stop date because the order was not entered correctly, resulting in the medication being continued until the error was discovered. These incidents were identified through interviews and record reviews, and all occurred within a three-month period.
Failure to Provide Properly Pureed Food for Residents with Swallowing Difficulties
Penalty
Summary
The facility failed to provide pureed peas in a smooth consistency for six residents who required pureed diets due to diagnoses such as difficulty swallowing and stroke. During meal preparation, the cook completed the pureeing process for peas, but visible chunks and pieces of skin remained, requiring chewing to swallow. Both the surveyor and the dietary supervisor confirmed the peas were not smooth, and the dietary supervisor acknowledged that peas are difficult to puree but should be blended until smooth. The pureed peas were only reprocessed after the deficiency was identified by staff. All six affected residents had documented medical conditions necessitating pureed diets, including difficulty swallowing and stroke. The facility's own protocol required altered consistency diets to manage aspiration risks, but the initial preparation of the peas did not meet these requirements, as the food was not adequately pureed before being served.
Failure to Maintain Resident Dignity and Timely Care
Penalty
Summary
The facility failed to ensure that residents dependent on staff for care were treated in a dignified manner, as evidenced by multiple incidents involving three residents. One resident, who was cognitively intact and required assistance with transfers and toileting, reported that her dressing changes were routinely performed in the middle of the night, disrupting her sleep. She expressed that only her pain medication was needed at those hours, and that dressing changes should be done before bedtime. Despite raising these concerns in a care conference, the issue persisted, and she also experienced significant delays in call light response, sometimes waiting up to 50 minutes for assistance with toileting, resulting in incontinence and distress. Another resident, who required assistance with activities of daily living, reported that her call light was not answered in a timely manner, often taking an hour or more. On one occasion, staff walked past her room while her call light was on and told her they could not help, leaving her feeling ignored and devalued. The DON acknowledged that this response was inappropriate and that staff should have communicated with the resident about when assistance would be provided. A third resident, who was dependent on staff for personal hygiene, was observed to have visible patches of facial hair, which her daughter stated would have been distressing to her. The resident had an electric razor in her room, but staff had not assisted her with shaving, possibly due to her refusal of showers. The DON agreed that this was a dignity issue and that staff should have addressed her facial hair between showers if needed. Facility policies reviewed emphasized the importance of treating residents with dignity and respect at all times.
Failure to Assess and Obtain Treatment Orders for Resident's Skin Tears
Penalty
Summary
A deficiency occurred when the facility failed to assess and obtain treatment orders for a resident who developed two skin tears on the left arm. The resident, who had diagnoses including congestive heart failure, severe protein-calorie malnutrition, and pressure ulcers, was observed with two dressings on the left arm. The resident reported waiting for dressing changes and was unsure of the exact circumstances of the injury. Review of the resident's medical record showed no physician orders for treatment of the skin tears and no documented assessment of the wounds. Interviews with nursing staff revealed that standard protocol involves cleaning, assessing, and dressing the wound, followed by notifying the physician and obtaining treatment orders, which are then entered into the resident's treatment record. However, in this case, the registered nurse was unaware of the condition of the wounds under the dressings and confirmed there were no orders or assessments documented. The Director of Nursing also confirmed that such wounds should be tracked and treated according to facility policy, which was not done in this instance.
Failure to Ensure Orders and Proper Care for CPAP Equipment
Penalty
Summary
The facility failed to ensure that a resident with a history of pulmonary embolism, obstructive sleep apnea, and other respiratory conditions had appropriate physician orders in place for the use of a CPAP machine upon admission. Review of the resident's records showed that there were no CPAP orders documented from the time of admission until several weeks later, despite the resident's need for this respiratory support. Additionally, the care plan did not include specific CPAP settings or instructions for CPAP care, and there was no evidence that the CPAP was being properly cared for during this period. Observations revealed that the CPAP equipment was not consistently stored in a sanitary manner, with the mask left unbagged on the bedside table. The resident reported that staff typically left the CPAP on the table and only recently began placing it in a bag. The facility's policy required daily cleaning and proper storage of CPAP equipment, but there was no documentation or evidence that these procedures were followed prior to the addition of new treatment orders. The DON confirmed that orders should be entered upon admission and that staff are expected to follow facility policy for cleaning and storage.
Delayed Call Light Response for Multiple Residents
Penalty
Summary
The facility failed to respond to residents' call lights in a timely manner, as evidenced by multiple resident accounts and staff interview. One resident, admitted with adult failure to thrive, Type 2 Diabetes Mellitus, chronic kidney disease, and low back pain, required maximum assistance for standing and toileting. This resident reported activating the call light for help reaching a urinal, but after waiting for half an hour without response, attempted to manage independently, resulting in a fall and self-reported hip injury. The resident stated that staff perceived him as independent due to his cognitive status, despite his physical needs. Another resident with Bell's Palsy, atrial fibrillation, and left-side paralysis, who was cognitively intact, reported that call lights often took a long time to be answered, including an instance where she waited an hour to be changed. A third resident with muscle weakness, COPD, and diabetes, also cognitively intact, described frequent delays in call light response, sometimes waiting up to an hour, and recounted being ignored by staff who walked past while her call light was on. The Director of Nursing acknowledged the facility's outdated call light system and lack of monitoring capability, and no facility policy regarding call lights was provided.
Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
A staff member failed to follow the facility's Enhanced Barrier Precautions policy while providing wound care to a resident with a Stage 4 pressure ulcer. The resident, who had been admitted with this diagnosis, was on Enhanced Barrier Precautions as indicated by signage on her door, which required the use of both a gown and gloves during wound care. During an observed wound care procedure, the staff member wore only gloves and did not don a gown as required. The facility's infection preventionist confirmed that both gown and gloves should have been used for residents with chronic wounds under Enhanced Barrier Precautions, in accordance with the facility's policy last approved in May 2024.
Failure to Provide Adequate Supervision During Incontinence Care Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a resident, who was totally dependent on staff for care due to left-sided weakness from a stroke and was described as a larger individual, fell out of bed during incontinence care. The resident required significant assistance for bed mobility and incontinence care, as she was unable to support herself or roll independently. Despite this, only one CNA was present during the provision of incontinence care, and the resident rolled out of bed, landing on her knees and later being diagnosed with a left femoral neck fracture. Interviews with staff revealed that the determination of whether one or two CNAs were needed for incontinence care was based on the resident's size and bed mobility, but this information was not clearly communicated or documented in the care guide. The CNA providing care at the time of the incident was not informed that two staff members were required for this resident, and the care guide only indicated the need for one staff member for bed mobility, not specifically for incontinence care. Multiple staff members, including the LPN, unit manager, and other CNAs, stated that two staff should have been present due to the resident's condition and inability to support herself. The facility's policies on urinary incontinence did not address the assessment of the level of staff assistance required for incontinence care. As a result, there was a lack of clear guidance and communication regarding the appropriate staffing needed to safely provide care for residents with significant mobility limitations, directly contributing to the resident's fall and subsequent injury.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to properly assess and notify the wound care physician of changes in a pressure injury for a resident, R100, and did not implement pressure-relieving interventions to prevent the development of a new pressure injury. R100, who had a history of type I diabetes mellitus and a hip fracture, was found to have a stage 1 pressure ulcer on his right heel, which later deteriorated to an unstageable pressure injury. Despite recommendations from a vascular surgery appointment to follow up with a wound care doctor, no appointments were set up, and the wound care nurse was not informed of the wound's deterioration. Another resident, R95, developed a stage 2 pressure ulcer behind his right ear due to the continuous use of oxygen tubing. The facility's interventions, such as using ear protectors, were ineffective as they frequently fell off or slid around, and staff did not perform daily checks behind the ears of residents on oxygen. The lack of effective pressure-relieving interventions and inadequate monitoring contributed to the development of the pressure injury. The facility's policy on pressure injury assessment and treatment, revised in July 2024, emphasizes the need for pressure-relieving devices to be observed for effectiveness and interventions to be changed or implemented to prevent pressure injuries. However, the facility failed to adhere to these guidelines, resulting in the deterioration of R100's pressure injury and the development of a new pressure injury for R95.
Inadequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to ensure adequate supervision and fall prevention interventions for two residents at high risk for falls. Resident R114, who was admitted after a fall resulting in a humerus fracture, was left unsupervised in the bathroom despite being on the falling star program, which indicates a high risk for falls. This lack of supervision led to R114 falling from the toilet, resulting in a skin tear and a head injury, necessitating a transfer to the emergency room. The CNA responsible for R114 admitted to leaving her alone due to a busy morning and not being familiar with her needs, which was against the facility's fall prevention policy. Resident R4, with a history of falls and high anxiety, was observed in a high reclining wheelchair despite the care plan specifying a low reclining wheelchair to prevent falls. This discrepancy was noted after R4 had previously fallen from a higher wheelchair, and the intervention was to use a lower one. The Restorative Nurse confirmed that R4 should only be in the low reclining wheelchair, but it was unclear why she was placed in a different one. The facility's fall policy requires daily reviews of falls to identify additional interventions, but this was not effectively implemented for R4.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide a medication as ordered for a resident, identified as R33, who was admitted with diagnoses including osteoarthritis, repeated falls, and anxiety disorder. The physician's orders for August 2024 included a prescription for a lidocaine 5% patch to be applied to R33's lower back in the morning and removed at bedtime. However, observations on August 6, 2024, revealed that the Registered Nurse (RN) did not have the lidocaine patch for R33 and was unaware of the reason for its absence. The resident reported experiencing pain rated at 4-5/10 due to arthritis. The Electronic Medication Administration Record (EMAR) indicated that the lidocaine patch was not administered on August 1, 2, and 6, 2024. A Licensed Practical Nurse (LPN) confirmed that the patch is ordered through the facility's pharmacy and acknowledged that its absence could result in the resident experiencing pain. The facility's policy on administering medications, revised in December 2021, mandates that medications be administered safely, timely, and as prescribed. The failure to provide the lidocaine patch as ordered represents a deviation from this policy, resulting in the resident potentially experiencing unmanaged pain.
Failure to Include Stop Dates for PRN Anti-Anxiety Medications
Penalty
Summary
The facility failed to ensure that as-needed anti-anxiety medications had a stop date for two residents reviewed for psychotropic medications. Resident R4 had a physician order for Ativan 0.5 mg to be taken twice daily as needed, with a start date but no stop date. The Assistant Director of Nursing acknowledged that PRN anti-anxiety medication should have a stop date 14 days after it was ordered. Similarly, Resident R95 had an active order for Lorazepam 2 MG/ML to be taken every 2 hours as needed for anxiety/agitation, also lacking a stop date. The facility's policy on psychotropic medications, last revised in November 2022, states that PRN psychotropic medications should have a stop date of 14 days unless otherwise specified by a physician.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 7.69%, which exceeds the acceptable threshold of 5%. This deficiency was observed during a medication pass involving two residents. The first resident, identified as R33, was admitted with diagnoses including osteoarthritis, repeated falls, and anxiety disorder. The physician's order for R33 included the application of a lidocaine 5% patch to the lower back in the morning and removal at bedtime. However, on the morning of August 6, 2024, the RN administering medications did not have the lidocaine patch for R33 and was unaware of the reason for its absence. Consequently, R33 reported experiencing pain rated at 4-5 out of 10. The second resident, identified as R110, was admitted with diagnoses including osteoarthritis, chronic kidney disease, edema, weakness, and a history of falling. The physician's order for R110 specified the application of diclofenac sodium 1% gel to the right knee twice daily. During the medication pass, the RN applied the gel to both the right and left knees, contrary to the physician's order. The LPN later confirmed that physician orders should be followed precisely and that any changes requested by residents should be communicated to the nurse practitioner for a new order. The facility's policies on administering medications and handling medication errors emphasize adherence to physician orders and define medication errors as deviations from these orders.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly manage medication storage and labeling for a resident, identified as R99, leading to a deficiency. Specifically, an expired insulin pen was not disposed of, and an opened insulin pen was not labeled with the date it was opened. The physician orders for R99 included insulin aspart sliding scale and insulin glargine pen at bedtime, which were documented in the electronic medication administration record. During an observation, it was noted that the insulin aspart pen was opened and dated, but the insulin glargine pen was opened without a date. A Licensed Practical Nurse (LPN) acknowledged that insulin pens should be dated upon opening to ensure effectiveness and admitted uncertainty about the duration for which opened insulin remains effective. The facility's policy mandates recording the open date on multi-dose containers, and another policy specifies that opened insulin pens are good for 28 days at room temperature.
Infection Control Deficiency: PPE and Hand Hygiene Failures
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the use of personal protective equipment (PPE) and hand hygiene practices. On multiple occasions, staff members did not change gloves or perform hand hygiene after providing incontinence care to residents, which could lead to cross-contamination. For instance, a Certified Nursing Assistant (CNA) did not change gloves or perform hand hygiene after wiping a resident's buttocks and then handling clean items. Similarly, during incontinence care for another resident, two CNAs did not wear gowns as required by Enhanced Barrier Precautions (EBP) and failed to change gloves or perform hand hygiene after cleaning the resident. The facility's policies on hand hygiene and Enhanced Barrier Precautions were not followed. The hand hygiene policy requires hand hygiene before moving from a soiled to a clean body site on the same resident, and the EBP policy mandates the use of gowns and gloves during high-contact care activities for residents at risk of transmitting multidrug-resistant organisms (MDROs). Despite these policies, staff did not wear gowns or change gloves during high-contact care activities for residents with wounds or indwelling medical devices, increasing the risk of infection transmission.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to adequately supervise a resident during medication administration, leading to the resident storing medications in his room. The resident, who was part of a sample reviewed for safety and supervision, was observed by a surveyor to have several pills, identified as Norco, stored in a cup on his over-bed table. The resident claimed that he finds medications in his bed and expressed concerns about the facility's lack of accountability for controlled medications. During an interaction with the surveyor, the resident demonstrated his routine of taking pictures of his medications before ingestion, which he claimed was for verification purposes with a hospital. The Licensed Practical Nurse (LPN) responsible for administering the resident's medications confirmed that the resident typically refuses to take medications in her presence, insisting on privacy. On the day of the survey, the LPN was surprised when the resident took the medication in front of her, as this was not his usual behavior. The facility's policies on controlled substances and medication administration were not adhered to, as controlled substances were found unsecured in the resident's room, and there was no documented assessment allowing the resident to self-administer medications safely.
Failure to Administer Anticoagulant Medication
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors. Resident R2, who has a medical history including Parkinson's Disease, Type 2 Diabetes, hypertension, chronic kidney disease, paroxysmal atrial fibrillation, and a prosthetic heart valve, did not receive his prescribed anticoagulant medication, Coumadin, for eight days. This lapse occurred from 3/10/24 to 3/19/24. The error was identified when a nurse noticed the absence of a Coumadin order in the electronic health record and reported it to the on-call Nurse Practitioner. The resident's Power of Attorney was informed, and an INR test was ordered to monitor the resident's blood clotting levels. Interviews with staff revealed that the Coumadin order was not entered into the system after the resident's lab results were reviewed, leading to the missed doses. The facility's policy requires that anticoagulant therapy be prescribed and monitored according to recognized guidelines, including appropriate lab testing and the use of a monitoring tool to track anticoagulant dosage and response. The failure to enter the new Coumadin order into the system resulted in the resident not receiving the necessary medication to ensure the proper functioning of his artificial heart valve.
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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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