Accolade Healthcare Of Pontiac
Inspection history, citations, penalties and survey trends for this long-term care facility in Pontiac, Illinois.
- Location
- 300 West Lowell, Pontiac, Illinois 61764
- CMS Provider Number
- 146010
- Inspections on file
- 26
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Accolade Healthcare Of Pontiac during CMS and state inspections, most recent first.
A resident who was dependent for all transfers and cognitively intact reported hearing a pop and crack in the left knee during a total body mechanical lift transfer that was performed by a CNA without the required assistance of a second staff member, contrary to facility policy. The resident’s feet touched the floor, the left knee hit the side of the bed, and the resident immediately complained of pain. Initial ED evaluation and x‑ray identified a left knee sprain with no fracture, but the resident continued to report pain and later underwent a CT scan ordered by an NP and orthopedic provider, which revealed a left knee fracture. Facility leadership, including the DON and ADON, confirmed that two staff are required for all total body mechanical lift transfers and that this requirement was not followed in this case.
A resident who was dependent for all transfers and cognitively intact reported pain above the left knee and was sent to the hospital, where imaging initially showed a sprain of the medial collateral ligament and the resident received multiple pain medications. At a later orthopedic visit, a CT scan revealed a left knee fracture. The facility’s policy required completion of an Accident/Incident Report on the shift of the event and notification of the State Agency within 24 hours for any major injury, but the DON and Administrator acknowledged that the fracture was never reported to the State Agency, resulting in a failure to follow required reporting procedures.
A resident was returned to the hospital after the facility received a criminal background report indicating the resident was a registered sexual offender, but the facility did not complete or document the required transfer/discharge process. The facility’s policy required appropriate discharge procedures and a written or telephone physician order for transfer or discharge, yet the resident was dropped off at the ED with a stated social concern and later sent back again for nursing home placement without any discharge notice or discharge orders in the medical record. The resident’s POA was informed that the transfer was due to the background check results, and the SSD confirmed the CHIRP findings, while the Administrator verified that no required discharge documentation existed in the chart.
A resident with a C2 neck fracture returned from the hospital with orders for C-Collar care, including daily skin checks and adjustments while lying flat in bed. Staff placed the resident in a recliner that did not lay flat, did not perform daily skin checks, and delayed adjusting the C-Collar, resulting in the resident experiencing pain and discomfort. Facility leadership confirmed that admission orders were not followed.
Two residents with indwelling catheters and wounds did not receive proper Enhanced Barrier Precautions (EBP) as required. EBP signage and PPE were inconsistently provided, and staff failed to use gowns and gloves during high-contact care activities. Staff interviews confirmed that EBP was not routinely practiced, and required cleaning procedures were not followed after handling potentially infectious materials.
The facility did not provide required written bed hold and transfer notices to residents and their representatives during multiple hospitalizations, as confirmed by medical record review and staff interviews. Nursing staff did not distribute the bed hold policy at the time of transfer, and there was no documentation that admissions or social services followed up with the necessary paperwork.
Two dependent residents did not receive scheduled showers as required by facility policy, with no documentation of refusals or alternative hygiene care. Staff interviews confirmed that showers were missed and not properly recorded, and one resident reported rarely receiving assistance with bathing.
A resident with COPD and Atrial Fibrillation, who was receiving oxygen therapy and an anticoagulant, did not have these treatments or their monitoring included in the comprehensive care plan. Despite physician orders and observations confirming the use of oxygen and Apixaban, the care plan was not updated to reflect these needs, as confirmed by the facility administrator.
A resident with a history of urinary tract infections and cord compression did not receive complete incontinence care, as a CNA failed to clean the groin and buttocks areas during perineal care, contrary to facility policy requiring thorough cleansing of all soiled skin areas.
Two residents with end stage renal disease and dependence on dialysis did not have current physician orders for their dialysis treatments, despite receiving dialysis regularly. Staff interviews and facility records confirmed the absence of required orders, even though the facility is responsible for coordinating and documenting dialysis care as part of each resident's plan of care.
Staff did not follow Enhanced Barrier Precautions (EBP) for two residents with indwelling medical devices, as required by facility policy and physician orders. On multiple occasions, a CNA and an RN emptied urine collection bags without wearing gowns, despite posted instructions and care plans specifying the need for gowns and gloves during high-contact care. The DON confirmed that staff are expected to use these precautions.
A resident experienced a severe weight loss of 10.8% in 12 days due to the facility's failure to implement an ordered nutritional supplement and notify the resident's representative. The resident, who had a recent surgery and dementia, was observed without the prescribed supplements during meals. The Registered Dietitian's recommendation was not transcribed into the medical records due to an error, and the facility's policy on providing supplements was not followed.
The facility's kitchen was found in unsanitary conditions, with a can opener covered in grease and rust, and range hood filters with grease and dust build-up. The food preparation table and sink area also had significant contamination risks. The Dietary Manager confirmed these issues, indicating a failure to maintain cleanliness as per the facility's policy.
The facility failed to trend monthly resident infections, potentially affecting all 76 residents. There was no Infection Control Surveillance and Monitoring Policy or documentation of infection patterns and interventions. The Infection Preventionist admitted to not completing the trending.
A facility failed to properly store medications, including Schedule II controlled substances, as a medication cart was found unlocked and unattended multiple times by an LPN. The cart contained controlled substances like Norco and Methylphenidate. The facility's policy requires all medications to be securely stored, with controlled substances in a separately locked drawer.
A facility failed to respect a resident's right to have a service dog present during meals and did not ensure another resident's dignity by leaving their abdomen exposed in the dining room. The facility lacked a policy for service dogs, and a resident with cognitive impairment was not properly covered by an LPN, despite acknowledging the dignity issue.
A resident with a fractured shoulder did not have a physician's order for an arm sling, despite recommendations from the occupational therapist. The resident was observed multiple times without the sling, which was necessary to prevent subluxation. The facility failed to follow the hospital's emergency room orders for continuous sling use.
A resident with chronic pain conditions, including Lumbar Degenerative Disc Disease and Fibromyalgia, reported severe pain levels and inadequate pain relief from prescribed medications. Despite repeated complaints, the facility staff failed to effectively communicate these issues to the Nurse Practitioner in a timely manner, resulting in continued unmanaged pain for the resident.
A facility failed to dispose of discontinued medications for a resident. During an observation, a medication bottle without a label was found in a medication cart, containing vials of Haldol with the resident's name. The DON confirmed the medication was a one-time order and should have been destroyed or returned. The resident's physician order indicated the medication was for intramuscular use as needed for agitation and aggression. The facility's policy requires discontinued medications to be destroyed promptly.
A resident with quadriplegia and multiple sclerosis was unable to reach their call light, which was secured to the wall behind the bed. The resident needed an incontinence brief change but could not call for assistance. Staff confirmed the call light was out of reach and attributed it to a CNA's oversight. Facility policy mandates call lights be within easy reach.
A facility failed to prevent cross-contamination during incontinence care for a resident. A CNA and an RN changed a resident's saturated brief without removing contaminated gloves or performing hand hygiene, despite the facility's hand washing policy requiring such actions after contact with body fluids and after removing gloves.
Improper Mechanical Lift Transfer Causing Resident Knee Fracture
Penalty
Summary
The deficiency involves the facility’s failure to follow its own hydraulic (Hoyer) lift policy requiring two staff members for total body mechanical lift transfers, resulting in an injury to a dependent resident. The facility’s policy, revised on 1/26, states that all nursing staff will be trained on proper use of hydraulic lifts and that staff must obtain assistance from a second staff member. The resident’s MDS documents that the resident is dependent for all transfers and cognitively intact. Nursing progress notes show that in the early morning hours of 11/29, the resident complained of pain above the left knee and was sent to the hospital, where an x‑ray initially showed a sprain of the medial collateral ligament of the left knee and no fracture. The ED nurse later reported that the resident stated hearing a pop when being transferred with a total body mechanical lift, and the resident received multiple pain medications, including Norco, Tylenol, fentanyl, and ketorolac, for pain management. From 11/29 through 12/3, the resident continued to complain of left knee pain and was treated with hydrocodone‑acetaminophen. On 12/3, the NP documented that the resident reported a CNA had hurt her during a prior transfer and insisted that something was wrong with her knee despite a negative x‑ray, requesting further diagnostic testing. The NP noted that an orthopedic referral would be made, and on 12/11 a CT scan of the left knee showed a fracture. On 2/9, the resident reported that a CNA had performed a total body mechanical lift transfer alone, without a second CNA, during which the CNA pushed on her, she heard a pop and a crack, her feet touched the floor, and her left knee hit the side of the bed; the CNA told her to look because she was standing, even though she had not stood in years. That same day, the CNA confirmed performing the mechanical lift transfer without assistance, and the DON and ADON both acknowledged that two staff members are required for all total body mechanical lift transfers, confirming that the transfer was not performed according to facility policy.
Failure to Timely Report Resident Fracture to State Agency
Penalty
Summary
The facility failed to report a resident’s fracture to the State Agency within the required timeframe, contrary to its Accidents and Incidents policy. The policy, revised on 1/26, requires that accidents and incidents, including injuries of unknown origin, be reported to the department supervisor with an Accident/Incident Report completed on the shift of occurrence, and that the DON or designee report any accident or incident involving a major injury to the State Agency within 24 hours. Nursing progress notes show that on 11/29 at 3:04 AM, a resident who is dependent for all transfers and cognitively intact complained of pain above the left knee and was sent to the hospital, where pain medications were administered and an X-ray resulted in a diagnosis of a left medial collateral ligament sprain before the resident returned at 6:00 AM. On 12/11, after an orthopedic visit and CT scan of the left knee, the resident was diagnosed with a left knee fracture. Despite this fracture diagnosis, the DON confirmed on 2/9 that no reportable incident was sent to the State Agency, and the Administrator confirmed that the fracture identified on 12/11 was not reported, resulting in noncompliance with required reporting procedures. The deficiency centers on the facility’s inaction in failing to recognize and report the fracture as a reportable major injury once it was identified by CT scan, despite clear policy requirements and the resident’s dependence for transfers. Surveyor interviews with the DON and Administrator confirmed that the incident was not reported to the State Agency as required.
Failure to Document Required Transfer/Discharge for a Resident Returned to Hospital
Penalty
Summary
The facility failed to follow its required transfer/discharge process and documentation requirements for one resident who was discharged without a proper discharge notice or required elements in the medical record. The facility’s Discharge/Transfer Policy, revised 1/25, requires guidelines for appropriate discharge and transfer procedures and specifies that a written or telephone order from the attending physician is needed for a resident’s transfer or discharge. The resident was admitted to the facility on an unspecified date, and later, hospital notes dated 2/23/26 show the resident was dropped off at the Emergency Department (ED) from the facility with complaints of social concern. The facility reported that during a background check it was discovered the resident had a sexual offense and could not be admitted, and the facility attempted to find alternative placement but was unable to do so, then returned the resident to the ED for nursing home placement after receiving a CHIRP (Criminal History Information Response Process) result dated 2/23/26 indicating the resident was listed as a sexual offender. The resident’s Power of Attorney reported being told by the facility that the resident was being sent back to the hospital due to the background check results, and the Social Service Director confirmed the CHIRP findings and the decision to send the resident back to the hospital. The Administrator confirmed that no discharge documentation or discharge orders were found in the resident’s chart, indicating the required transfer/discharge process was not completed or documented.
Failure to Follow Admission Orders for C-Collar Care
Penalty
Summary
The facility failed to follow admission orders for a resident who returned from the hospital with a C2 neck fracture and an Aspen C-Collar. Upon readmission, the resident had orders for C-Collar care, including daily skin checks and the requirement to be laid flat in a bed for collar adjustments. However, staff placed the resident in a recliner instead of a bed, as the bed had been removed from the room. The recliner did not lay flat, and staff attempted to adjust the C-Collar while the resident was in the recliner, resulting in the resident experiencing pain and discomfort. No daily skin checks were performed as ordered, and the first adjustment of the C-Collar did not occur until several days after readmission. Staff interviews confirmed that the admission orders were not followed, and the facility's policy required review and implementation of all physician orders upon admission or readmission. The failure to follow these orders was acknowledged by facility leadership.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices and Wounds
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two of three residents reviewed for infection control. According to the facility's policy and CDC guidance, EBP requires the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices or chronic wounds. Observations revealed that while an EBP sign was posted on one resident's door, it was missing from another resident's door who had an indwelling catheter. Additionally, required equipment such as gowns and gloves was not consistently available outside resident rooms, particularly for newly admitted residents over the weekend. Staff interviews and record reviews indicated that EBP was not consistently practiced. A CNA was observed emptying a resident's catheter without using the required PPE and did not clean the shared toilet after disposing of urine. The CNA admitted that staff do not routinely use EBP. Physician orders and medical records confirmed that both residents required EBP due to conditions such as urinary catheters, urinary tract infection with E-Coli, and chronic wounds. The lack of signage and equipment was attributed to the resident's recent admission and oversight by the admitting nurse.
Failure to Provide Bed Hold and Transfer Notices During Hospitalizations
Penalty
Summary
The facility failed to provide required written notifications to residents and their representatives regarding hospital transfers and bed hold policies for five residents who were hospitalized. Nursing notes documented multiple instances where residents were transferred to the emergency room or hospitalized, but there was no documentation in the medical records that a bed hold notice or written notice of transfer was provided to the residents or their representatives at the time of each transfer. The facility's own Bed Reserve Policy states that this information should be given at admission and each time a resident is transferred from the facility, but records and interviews confirmed this was not done. Interviews with facility staff, including the Social Service Director and an LPN, revealed that while the bed reserve policy is signed at admission, nursing staff do not provide the bed hold policy form when residents are transferred out. Instead, follow-up is reportedly handled by admissions or social services, but there was no evidence that this occurred for the residents in question. One resident confirmed not receiving any bed hold policy or paperwork during multiple hospitalizations. The lack of documentation and direct statements from staff and residents indicate that the facility did not meet regulatory requirements for notification during resident transfers.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers to two dependent residents who required assistance with activities of daily living (ADLs). According to the facility's Bath/Shower Policy, all residents are to receive a bath or shower at least weekly, with nursing assistants responsible for providing the care and charge nurses responsible for ensuring the schedule is followed. Record review showed that one resident with severe cognitive impairment and significant physical limitations missed multiple scheduled showers over a two-month period, with no documentation of refusals or alternative hygiene measures such as bed baths. Another resident, who was cognitively intact but dependent on staff for ADLs, also missed several scheduled showers, and similarly, there was no documentation of refusals or alternative care provided. Interviews with staff confirmed that showers should be provided and documented according to the schedule, and that refusals or alternative care should also be recorded. However, both the charge nurse and nursing supervisor acknowledged that the affected residents did not receive all scheduled showers and that there was no documentation of refusals or bed baths in the residents' charts. One resident reported rarely receiving scheduled showers and stated that staff often provided excuses for not assisting with bathing.
Failure to Include Oxygen and Anticoagulant Therapy in Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for one resident, as required by its own Care Planning Policy. Despite the resident being observed with a nasal cannula in place on multiple occasions and having documented diagnoses of Chronic Obstructive Pulmonary Disease and Atrial Fibrillation, the resident's care plan did not include interventions or monitoring related to oxygen therapy or anticoagulant medication use. The resident's physician orders specified oxygen therapy to maintain O2 saturation above 90% and the use of Apixaban as a blood thinner, both of which were also reflected in the Minimum Data Set. However, a review of the current care plan revealed that it lacked any mention of the resident's oxygen use, monitoring requirements, or anticoagulant therapy and associated monitoring. The facility administrator confirmed that care plans are expected to be updated with any change in condition and acknowledged that the resident's care plan did not include these critical elements.
Incomplete Incontinence Care Provided to Resident
Penalty
Summary
Facility staff failed to provide complete incontinence care for a resident with a primary diagnosis of unspecified cord compression, who had a history of urinary tract infections and was receiving antibiotics for this condition. During observed incontinence care, a CNA cleansed, rinsed, and dried the resident's inner and outer labia but did not clean the groin or buttocks area, which was acknowledged as incomplete by the CNA when questioned. The resident reported feeling strange and had started a new antibiotic for another urinary tract infection on the same day. The facility's policy requires all soiled skin areas, especially between skin folds, to be washed and dried thoroughly during incontinence care.
Failure to Maintain Physician Orders for Dialysis Treatments
Penalty
Summary
The facility failed to maintain current physician orders for dialysis treatments for two residents who were dependent on renal dialysis and diagnosed with end stage renal disease. For one resident, the medical diagnosis sheet listed dependence on renal dialysis and end stage renal disease, but the physician's order sheet did not include any dialysis treatment orders. Staff interviews confirmed that the resident was receiving dialysis five times a week, yet the necessary orders were missing from the documentation. The regional quality assurance staff acknowledged that the dialysis order had likely been omitted from the physician's order sheet. Similarly, another resident with diagnoses of end stage renal disease, stage 4 chronic kidney disease, and dependence on renal dialysis did not have dialysis treatment orders documented from the time of readmission until a later date. This resident also confirmed receiving dialysis treatments in the facility, and a licensed practical nurse verified the absence of dialysis treatment orders. The facility's own records and agreements indicated that the LTC facility is responsible for the development and implementation of each dialysis resident's overall plan of care, including coordination of dialysis access orders, but failed to ensure that current orders were in place for these residents.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents who were identified as requiring these precautions due to the presence of indwelling medical devices. According to the facility's EBP policy, staff are required to wear gowns and gloves during high-contact care activities for residents at high risk of Multidrug Resistant Organism (MDRO) acquisition, such as those with wounds or indwelling devices. Both residents had care plans and physician orders specifying the need for EBP during high-contact care, including activities involving their indwelling urinary catheters. Despite clear signage and documented orders, staff did not consistently follow EBP protocols. On separate occasions, a CNA and an RN emptied the urine collection bags of the two residents without wearing gowns, as required by policy. Both staff members acknowledged that gowns should have been worn during these activities. The Director of Nursing confirmed that all staff are expected to use gowns and gloves during high-contact care for residents on EBP.
Failure to Implement Nutritional Supplement Leads to Severe Weight Loss
Penalty
Summary
The facility failed to implement an ordered nutritional supplement and did not notify a resident's representative of significant weight loss, resulting in a severe weight loss of 10.8% over 12 days for a resident. The resident, who was admitted to the facility after surgery and diagnosed with dementia, was observed without the prescribed nutritional supplements during meals. The family member present was unaware of any nutritional supplements being ordered or the resident's weight loss. The Registered Dietitian recommended nutritional supplements, which were accepted by the Nurse Practitioner, but the order was not transcribed into the resident's medical records. The Registered Nurse confirmed the absence of the order in the Electronic Medical Record, and the Registered Dietitian acknowledged the error of sending the signed recommendation to an invalid email address. The facility's policy requires that residents unable to meet nutritional needs through regular meals be provided with supplements, but this was not followed in this case.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen food service areas and equipment in a clean and sanitary condition, which could potentially lead to cross-contamination and food-borne illness affecting all 76 residents. During an initial tour of the kitchen, a commercial table-mounted can opener was found with a build-up of a grease-like substance, metal fragments, and rust. The blade of the can opener was missing silver laminate, exposing bare metal and rust. The Dietary Manager confirmed these observations and acknowledged the need for cleaning before further use. Additionally, the range hood filters above the cooking surfaces were covered in a dark and light brown grease-like substance with dust-like strands hanging over the cooking areas. The Dietary Manager admitted that the cleaning service, which cleans the filters every three months, would need to increase the frequency of cleaning. Further inspection revealed that the 15-foot-long metal food preparation table had caulking at the wall junction embedded with brown and black sticky, food-like substances. The caulking had crusted food particles, which the Dietary Manager confirmed could contaminate food preparation areas. The three-well sink area had a windowsill with a significant build-up of dust and grease, and the window frame above had rust and chipped paint. The ceiling above the clean dish racks also had chipped paint and cobwebs. The facility's policy stated that stove hoods and filters should be cleaned monthly, but the current condition indicated a failure to adhere to this schedule, as confirmed by the Dietary Manager.
Failure to Trend Monthly Resident Infections
Penalty
Summary
The facility failed to trend the monthly resident infections, which has the potential to affect all 76 residents residing in the facility. During an interview and record review, it was found that the facility did not provide an Infection Control Surveillance and Monitoring Policy, nor were there any documents showing how the facility trends monthly infections to prevent further infection. Additionally, there was no documentation for identified infection patterns or trends and interventions. On August 21, 2024, the Infection Preventionist admitted to not completing the trending for the facility's infections.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications, including Schedule II controlled substances, were stored appropriately and within the visual control of the nurse. During an observation, the medication cart in the [NAME] Wing was found unlocked and not secured to the wall, with no staff present. An opened stock bottle of Melatonin was sitting on top of the medication cart. The LPN responsible for the cart left it unattended and unlocked multiple times while attending to residents in their rooms. The Director of Nursing confirmed that the medication cart should have been locked when not in sight of the staff. The unlocked cart contained several controlled substances, including Norco and Methylphenidate, which are classified as Schedule II narcotics. The facility's policy, dated 10/2023, requires all medications to be stored safely and properly at all times, with mobile medication carts locked when not under visual control. The policy also mandates that Schedule II controlled substances be stored in a separately keyed and locked drawer within the medication cart.
Failure to Respect Resident Rights and Dignity
Penalty
Summary
The facility failed to respect a resident's right to have a visitor with a service support animal present during meal service. During an observation, a family member of a resident was asked to remove a certified service dog from the dining room despite the resident's request to keep the dog present. The facility's administrator later acknowledged that there was no policy in place for service dogs and that the dietary consulting company had recommended not having the service dog in the dining room during meals. The facility provided documentation indicating that healthcare facilities must permit the use of service animals by persons with disabilities, but this was not adhered to in this instance. Additionally, the facility failed to ensure a resident's right to dignity by not covering a resident's exposed abdomen in the dining room. The resident, who had moderate cognitive impairment and required assistance with dressing due to a stroke, was observed with a bare abdomen while seated in a wheelchair. A Licensed Practical Nurse (LPN) moved the resident's wheelchair without addressing the exposed abdomen, despite acknowledging that it was a dignity issue. This incident occurred in the presence of other residents and visitors, further compromising the resident's dignity.
Failure to Obtain Order and Apply Arm Sling for Resident
Penalty
Summary
The facility failed to obtain a physician's order for an arm sling recommended by the occupational therapist for a resident with a fractured right shoulder. The resident, who had a history of a mechanical fall resulting in a comminuted transverse fracture of the right humeral neck, was observed multiple times without the prescribed arm sling. Despite the occupational therapist's recommendation for the sling to prevent subluxation, the facility did not secure the necessary order, and the resident was seen without the sling during various observations. The resident's family member and the resident themselves indicated the need for the sling, yet it was not consistently applied. The orthopedic physician assistant's nurse confirmed that the hospital's emergency room orders included wearing the sling continuously with specific movement restrictions. However, the facility did not follow through with these orders, as evidenced by the lack of a documented order and the resident's repeated appearances without the sling.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as R29, who was reviewed for pain management. R29, who is cognitively intact, has a history of Lumbar Degenerative Disc Disease and Fibromyalgia, and is prescribed Acetaminophen and Ibuprofen for chronic pain. Despite these medications, R29 reported severe pain levels of 10/10 on multiple occasions and expressed that the current pain management regimen was ineffective. R29 communicated to staff that stronger medication was needed, but felt that her concerns were not adequately addressed, as she was told that stronger medications would not be provided due to concerns about addiction. The facility's Pain Management Policy emphasizes the importance of addressing resident pain through effective communication with physicians. However, the Nurse Practitioner, V11, was not informed of R29's significant pain complaints until several days after they were reported. V11 confirmed that R29 has multiple medical conditions contributing to her chronic pain and expressed reluctance to prescribe narcotic pain medication. The Director of Nurses acknowledged that R29's complaints of uncontrolled pain needed to be addressed, indicating a lapse in the facility's adherence to its pain management policy and communication protocols.
Failure to Dispose of Discontinued Medications
Penalty
Summary
The facility failed to properly dispose of discontinued medications for one resident, identified as R9, among the 22 residents reviewed for physician orders. During an observation on August 21, 2024, at 4:30 PM, it was found that the bottom drawer of the [NAME] Wing Medication Cart contained a medication bottle without a label. Inside this bottle were three new vials of Haldol, an antipsychotic medication, with a sticker bearing R9's name. The Director of Nursing, identified as V2, acknowledged that the Haldol was a one-time order and should have been destroyed or returned to the pharmacy. R9's Physician Order Sheet from July 2024 documented an order received on July 15, 2024, for Haloperidol Lactate Injection Solution 5mg/5ml, to be administered intramuscularly every 8 hours as needed for agitation and aggression, for 14 days. The facility's policy on destroying medication, dated September 2023, states that all discontinued medications or medications of discharged residents should be destroyed as soon as possible.
Call Light Out of Reach for Resident
Penalty
Summary
The facility failed to ensure a call light was within reach for a resident reviewed for call lights. The resident, who has diagnoses including quadriplegia, multiple sclerosis, anxiety disorder, and neuromuscular dysfunction of the bladder, was found sitting in a motorized wheelchair and unable to reach the call light, which was secured to the wall behind the bed. The resident expressed the need for an incontinence brief change but was unable to call for assistance due to the call light's placement. Staff confirmed that the call light was out of reach and explained that it had been misplaced by a CNA who made the bed earlier that morning. The facility's policy requires that call lights be within easy reach of residents when they are in bed or confined to a chair.
Failure to Prevent Cross-Contamination During Incontinence Care
Penalty
Summary
The facility failed to prevent possible cross-contamination during incontinence care for a resident. During an observation, a CNA and an RN were changing a resident's incontinence brief, which was saturated with urine and stool. The CNA donned gloves and used disposable wipes for incontinence care but then grabbed a clean brief without removing the potentially contaminated gloves or performing hand hygiene. The resident urinated again onto the new brief, prompting the CNA to change gloves but still not perform hand hygiene. The CNA continued to provide care, cleaning another bowel movement, and again placed a clean brief under the resident without changing gloves or performing hand hygiene. The facility's hand washing policy requires hand hygiene after contact with body fluids and after removing gloves, which was not followed in this instance.
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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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