Alden Park Strathmoor
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockford, Illinois.
- Location
- 5668 Strathmoor Drive, Rockford, Illinois 61107
- CMS Provider Number
- 145259
- Inspections on file
- 29
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Alden Park Strathmoor during CMS and state inspections, most recent first.
A resident was admitted from the hospital with discharge paperwork that contained conflicting information about an IV Ceftriaxone order, which was listed as both discontinued in one area and as an active discharge order in another. The IV antibiotic was never started on the resident’s MAR, and the DON later reported that the resident was on hospice, had no IV access, and was not receiving IV antibiotics. Despite the facility policy requiring verification of any order that appears inappropriate for the resident’s condition, the admitting nurse did not contact the physician to clarify the admission orders.
A resident with severe cognitive impairment, malnutrition, and dependence on enteral tube feeding experienced a rapid, significant weight loss of over 20% in about two weeks, dropping from just over 120 lbs to the low 90s. Nursing staff informed the resident’s POA and discussed plans to increase tube feeding volume and rate but did not promptly notify the physician or RD when the significant weight loss was first identified, resulting in several days without documented nutritional interventions. The RD reported learning of the weight loss only after pulling a weekly weight exception report, and the DON stated that staff are expected to immediately notify the RD and physician of significant weight changes, particularly for tube-fed residents, in accordance with the facility’s significant weight loss policy.
A resident with orders for Lantus 40 units at HS and Novolog per sliding scale with meals received Novolog instead of the ordered HS Lantus dose when an LPN removed an insulin pen from a bag labeled as Lantus that actually contained both insulin types. After administering the injection, the LPN noticed the pen color did not match Lantus and realized Novolog had been given. The DON was notified, the resident was reassessed with repeat blood glucose checks, the NP and POA were contacted, and the resident was sent to the ER, where the diagnosis was documented as accidental insulin overdose with hypoglycemia before the resident returned with stable vitals and no new orders.
A resident with paraplegia, stage 4 pressure ulcer, and chronic incontinence was left in a soiled brief overnight after experiencing severe diarrhea. Despite requesting assistance, the resident was not changed until the following morning, when a wound care nurse found stool in the brief and on the sheets. Staff interviews confirmed the resident's dependence on regular incontinence checks, and facility policy required checks at least every two hours.
A resident with paraplegia, stage 4 sacral ulcer, and third-degree burns to both lower legs did not receive daily wound care as ordered by the physician. Observations showed undated and uninitialed dressings, and records indicated missed wound care on two days. The resident, who was alert and oriented, reported that dressings were not being changed as required. Staff confirmed the importance of daily wound care and documentation, and facility policy mandates recording all dressing changes.
A resident with paraplegia, a stage 4 sacral pressure ulcer, and lower leg burns did not receive daily wound care as ordered, with missed treatments and undated dressings observed. Staff interviews confirmed the importance of daily wound care and documentation, and facility policy required both individualized care and proper record-keeping.
Dietary aides did not wash their hands or wear gloves after handling dirty dishware and before touching clean items, resulting in a failure to prevent cross-contamination. This was observed by surveyors and confirmed by the CDM, with the potential to affect all residents in the facility.
The facility did not screen, educate, or offer influenza and pneumococcal vaccines to several residents as required, and failed to administer the pneumococcal vaccine to a resident who had consented. Documentation was missing for all affected residents regarding vaccine screening, education, or administration, as confirmed by the Infection Preventionist.
A resident with a UTI and multiple chronic conditions was placed on contact isolation after a positive culture for Klebsiella pneumonia (MDRO). Although initially told she could leave her room with proper hand hygiene, staff later required her to remain in her room with the door closed for several days, despite her independence and compliance with infection control. Staff interviews confirmed this restriction, even though facility policy allowed for room exit with precautions, resulting in the resident being denied her right to movement.
A resident with a gastrostomy tube consistently received tube feedings at a lower rate and volume than recommended by the dietitian due to conflicting orders in the medical record. Staff administered the feeding at 55 ml/hr and 1100 ml total, instead of the recommended 60 ml/hr and 1200 ml, and did not clarify or update the orders as required by facility policy.
A CNA did not perform hand hygiene or change gloves after assisting a resident with incontinence care, instead proceeding to handle clean clothing and mobility equipment. This action was inconsistent with the facility's hand hygiene policy, which requires hand hygiene when moving from a soiled to a clean body site.
Three residents were not screened, educated, or offered the COVID-19 vaccine or booster upon admission, and there was no documentation in their medical records to indicate that these steps were taken. The Infection Preventionist confirmed the lack of documentation, which was not in accordance with facility policy requiring these actions for all new admissions.
A resident suffered a burn injury after falling against a wall-mounted radiator, and another resident sustained burns from spilling hot tea on her lap. The facility lacked processes to monitor radiator temperatures and ensure hot beverages were served at safe temperatures, posing risks to all residents.
The facility failed to store controlled medications properly, as observed in two medication rooms where morphine and ABHR suppositories were found in unlocked refrigerators. The Director of Nursing confirmed that these substances should be double-locked to prevent misuse. Facility guidelines and federal regulations emphasize the need for secure storage of controlled substances.
A resident with severe COPD and other medical conditions experienced a significant drop in oxygen saturation. The facility failed to complete a full assessment and notify the physician promptly, leading to the resident being transported to the emergency department in respiratory distress and failure.
A resident with Alzheimer's and other conditions experienced a 10.22% weight loss in one month due to the facility's failure to provide necessary meal assistance and interventions. Despite a care plan requiring supervision, staff did not assist or cue the resident during meals, and another resident took food from her plate without intervention.
The facility failed to maintain proper sanitization logs and ensure food was covered during transportation. Observations revealed missing test results for dishwasher sanitizing temperatures and sanitation bucket chemical levels. Additionally, dietary staff were seen transporting uncovered desserts, contrary to facility policy.
The facility failed to ensure proper pressure ulcer interventions for five residents, leading to incorrect air mattress settings and lack of proper repositioning. This resulted in deficiencies in care for residents with documented pressure ulcers or those at high risk for developing them.
The facility failed to properly label and store medications, including undated multi-dose vials of fluphenazine, expired haloperidol, and an unlocked bottle of lorazepam, leading to potential risks for residents.
A resident with hemiplegia, type 2 Diabetes, and depression was not treated with dignity in the dining room. The resident was rushed to finish his meal so other residents could be taken back to their rooms, resulting in the resident not getting enough to eat. The DON confirmed that residents should be allowed sufficient time to eat and that staff should not mention other residents' names as reasons for delays.
A facility failed to keep a urinary catheter drainage bag below the bladder level during a resident's transfer. The resident, with chronic kidney disease and an indwelling catheter, had the drainage bag raised above the bladder by a CNA, which was corrected after an LPN's intervention.
A facility failed to properly store a resident's nebulizer mask and tubing, which were found undated and uncovered in a bedside table drawer. The DON confirmed that such equipment should be dated and stored in plastic bags to prevent cross-contamination.
A resident with multiple diagnoses was observed with a medication cup containing five pills on her bedside table, which she had not taken. The nurse confirmed that the resident refuses to take her medications when staff are in the room, except for a prescribed narcotic. The physician orders did not include any orders for self-administration, and the care plan did not have any interventions for self-administration. The facility's policy requires medications to be administered safely as prescribed and by the same staff at the time of preparation.
Failure to Clarify Conflicting Admission Orders for IV Antibiotic
Penalty
Summary
The facility failed to clarify and implement admission medication orders for one resident when the resident was admitted from the hospital. The hospital discharge packet dated 12/13/25 included a discharge order for Ceftriaxone 2 grams IV every 24 hours through 1/2/26, but the resident’s December 2025 MAR shows that this IV antibiotic order was not initiated on the admission date. The DON stated that the resident returned from the hospital on hospice and, to his knowledge, did not have IV access and was not receiving IV antibiotics. Upon reviewing the hospital discharge packet, the DON noted that in one section the antibiotics were documented as discontinued, but in another section Ceftriaxone was listed under discharge orders, and acknowledged that the admitting nurse should have called to clarify the conflicting orders. The facility’s policy on physician orders for medications or treatments, dated 6/2022, requires that any dose or order that appears inappropriate considering the resident’s age, condition, or diagnosis be verified with the attending physician, which was not done in this case.
Failure to Promptly Notify Clinicians and Intervene for Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s physician and Registered Dietician (RD) of a significant weight loss and to initiate timely nutritional interventions. The resident had severe cognitive impairment, was dependent on enteral tube feeding, and had been assessed as malnourished. Weight records showed a drop from 121.4 lbs to 96.9 lbs, then to 94 lbs and 92.8 lbs over a short period, reflecting approximately a 20% weight loss within two weeks. Nursing documentation noted that the nurse informed the resident’s power of attorney about the weight loss and discussed plans to increase tube feeding volume and rate, clarifying that the resident was on a total volume regimen rather than continuous feeding. However, there was no documentation that the physician or RD were notified at the time the significant weight loss was identified. The RD stated that she was not notified of the resident’s weight loss until she independently pulled the weight and vitals exception report prior to a scheduled weight meeting, and that she does not always receive direct notification of significant weight changes. The DON explained that the documentation system triggers for significant weight changes and that such changes should be brought to management the day they are noted so that the nurse practitioner and RD can be notified and recommendations obtained. The DON further stated that staff are supposed to notify the RD and physician immediately when there is a weight change, especially for residents on tube feeding who are at high risk for weight fluctuations, and acknowledged that in this case notification occurred days later. The facility’s policy on significant weight loss defined thresholds for significant loss and required assessment by a licensed dietician, but the resident experienced a 28.6 lb loss within two weeks with no documented nutritional interventions for five days following the identified weight loss.
Wrong Insulin Type Administered Due to Storage and Verification Failure
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received the correct type of insulin as ordered. The resident had physician orders for Lantus 40 units at bedtime and Novolog per sliding scale three times daily with meals. During an evening medication pass, an LPN administered Novolog instead of the ordered bedtime Lantus dose. The LPN reported that the medication bag was labeled as Lantus, but the insulin pen inside was actually Novolog, and both types of insulin had been stored together in the same bag. After administering the dose, the LPN noticed the pen color was incorrect and recognized that the wrong insulin had been given. Following the administration error, the LPN immediately notified the DON, and the resident was assessed and had blood sugar rechecked. The nurse practitioner and the resident’s power of attorney were notified, and the resident was sent to the emergency room. Progress notes document that the resident was transferred for evaluation and treatment related to blood glucose and later returned with stable vital signs and a blood sugar of 137. The hospital after-visit summary lists a diagnosis of accidental or unintentional insulin overdose with hypoglycemia, and notes that the resident’s point-of-care glucose was checked multiple times in the emergency room and that the resident received education on signs and symptoms of hypoglycemia before being discharged back to the facility.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
A resident with paraplegia, stage 4 sacral pressure ulcer, third degree burns on both lower legs, clostridium difficile infection, neuropathic bladder, and chronic embolism/thrombosis of the right lower extremity was found to have been left in a soiled brief for an extended period overnight. The resident was totally dependent on staff for toileting hygiene and was always incontinent of bowel, requiring frequent checks and assistance. According to the resident, after experiencing severe diarrhea one night, she requested assistance to be changed around 9:45 PM, but was told by a CNA that the next shift would handle it. No staff attended to her until approximately 6:15 AM the following morning, when the wound care nurse found her still soiled, with stool present in her brief and on her sheets. Staff interviews confirmed that the resident was alert, oriented, and unable to feel if she was wet or soiled, necessitating regular incontinence checks. The wound care nurse corroborated the resident's account, noting the presence of stool and a strong odor in the room, as well as soiled sheets. The facility's policy required resident checks at least every two hours, especially for those who are bedbound and require assistance with turning and incontinence care. The Director of Nurses also stated that such checks are necessary to maintain resident dignity and prevent infection and skin breakdown.
Failure to Perform and Document Ordered Burn Wound Care
Penalty
Summary
A resident with multiple complex medical conditions, including paraplegia, stage 4 sacral pressure ulcer, third-degree burns to both lower legs, and chronic bowel incontinence, was admitted to the facility with physician orders for daily wound care to the right and left lower extremities. Observations revealed that the dressings on the resident's sacral area and both calves were not dated or initialed. Review of the treatment administration record showed that wound care was not performed on either lower extremity on two specific dates, despite daily orders. The resident reported that staff were not changing the dressings as required, and both a Certified Nurse Aide and the Wound Care Nurse confirmed the resident was alert and oriented, emphasizing the importance of adhering to wound care orders to prevent infection and promote healing. The Director of Nurses acknowledged that wound care should be documented immediately after being performed, and lack of documentation indicates either the care was not provided or not recorded. The facility's policy requires documentation of dressing changes on the treatment administration record or electronic health record. The failure to perform and document wound care as ordered for the resident's non-pressure wounds constituted a deficiency in providing appropriate treatment and care according to physician orders and facility policy.
Failure to Perform and Document Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were performed as ordered for a resident with multiple complex medical conditions, including paraplegia, a stage 4 sacral pressure ulcer, and third-degree burns on both lower legs. The resident was assessed as totally dependent on staff for hygiene, dressing, rolling, and transfers, and was always incontinent of bowel. Physician orders required daily wound care to the sacrum, but documentation showed that wound care was not performed on at least two specified days. During observation, the resident's wound dressings were found to be undated and uninitialed, and the resident reported that staff were not changing the dressings daily as required. Interviews with staff confirmed the importance of daily wound care and proper documentation, with the wound care nurse and DON both acknowledging that lack of documentation could mean the care was not provided. The facility's policy required individualized care plans and documentation of dressing changes on the treatment administration record or electronic health record. The failure to perform and document wound care as ordered constituted a deficiency in the facility's pressure ulcer care practices.
Failure to Prevent Cross-Contamination in Dietary Services
Penalty
Summary
Dietary aides failed to follow proper hand hygiene protocols while handling dishware, leading to a risk of cross-contamination. Specifically, one dietary aide loaded dirty cups into the dishwasher and then immediately handled clean pots without washing her hands or wearing gloves. Another dietary aide placed dirty breakfast dishes on a shelf and then handled clean food trays without washing his hands or wearing gloves. The Certified Dietary Manager confirmed that staff should not touch clean dishes after handling dirty items and should practice good hand hygiene. The facility's policy requires food and nutrition services staff to prevent cross-contamination by practicing good hand hygiene, hand washing, and glove use. These actions were observed in a facility with a census of 156 residents, and the failure to follow proper procedures had the potential to affect all residents.
Failure to Screen and Offer Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to properly screen, educate, and offer influenza and pneumococcal vaccines to residents as required by policy and CDC/ACIP recommendations. Specifically, five residents were not screened for or offered the influenza vaccine during influenza season, nor were they screened for or offered the pneumococcal vaccine upon admission. In one case, a resident who had provided consent for the pneumococcal vaccine did not receive it. Documentation was lacking for all five residents regarding screening, education, or administration of either vaccine. Interviews with the Infection Preventionist confirmed that there was no documentation to support that these residents had been screened for, educated on, or offered the required vaccines. The facility's own policies state that all residents should be offered the influenza vaccine from October through March and the pneumococcal vaccine upon admission, unless contraindicated or already immunized. These failures were identified through record review and staff interviews, indicating a breakdown in the facility's immunization practices for new admissions and during the influenza season.
Resident Confined to Room During Contact Isolation Despite Independence
Penalty
Summary
A resident with a history of type 2 diabetes, fibromyalgia, generalized anxiety, chronic pain, restless leg syndrome, major depression, and a urinary tract infection (UTI) was placed on contact isolation after a urinalysis revealed Klebsiella pneumonia (MDRO). Physician orders indicated contact precautions for E. coli in the urine. Initially, staff informed the resident that she could leave her room if she practiced hand hygiene, but this guidance was later changed, and she was required to remain in her room with the door closed for the last four to five days of her isolation period. The resident, who was independent in her care and compliant with hand hygiene, was not allowed to leave her room despite her requests and inquiries to multiple staff members, including the Assistant Administrator and previous DON. Staff consistently told her that remaining in her room was facility policy. Interviews with staff, including the Unit Manager, RN, Assistant Administrator, and previous DON, confirmed that the resident was not permitted to leave her room while on contact isolation, even though she was independent and able to follow infection control measures. The Corporate RN stated that residents on contact isolation for a UTI could leave their rooms if they performed hand hygiene and avoided contact with other residents or food. The facility's actions resulted in the resident being confined to her room against her wishes, without clear justification based on her ability to comply with infection control protocols.
Failure to Implement Dietitian-Recommended Tube Feeding Order
Penalty
Summary
A resident with a gastrostomy tube was observed to have their tube feeding pump set at an infusion rate of 55 ml per hour with a total volume of 1100 ml, despite a dietitian's recommendation to increase the rate to 60 ml per hour and a total volume of 1200 ml to address undesirable weight loss. The resident's medical record contained two conflicting tube feeding orders, both starting on the same date, one for 55 ml/hr and one for 60 ml/hr. The medication administration record and progress notes indicated that the resident consistently received the lower rate and volume over several days. During review, a registered nurse identified the discrepancy between the orders and acknowledged the need for clarification from the dietitian, confirming that only one order should be active. The dietitian confirmed her recommendation for the higher rate and volume to maintain the resident's weight. The resident's care plan required tube feeding to be administered as ordered, and facility policy directed staff to verify feeding orders. The failure to update and implement the dietitian's recommended tube feeding order resulted in the resident not receiving the prescribed nutritional support.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to perform proper hand hygiene and did not change gloves after assisting a resident with bladder and bowel incontinence care. The resident, who had diagnoses including Alzheimer's Disease, narcolepsy, anemia, adult failure to thrive, dementia, and a history of falling, was transferred to the toilet, where he urinated and had a large bowel movement. After the resident used toilet paper to wipe himself, the CNA pulled up the resident's clean incontinence brief and pants without performing hand hygiene or washing hands. This action was observed and confirmed to be inconsistent with the facility's hand hygiene policy, which requires hand hygiene when moving from a soiled to a clean body site.
Failure to Screen, Educate, and Offer COVID-19 Vaccine to New Admissions
Penalty
Summary
The facility failed to screen, educate, or offer the COVID-19 vaccine or booster to three residents upon admission, as required by facility policy. For each of these residents, there was no documentation in their medical records indicating that they had been screened for COVID-19 vaccination status, provided with education about the vaccine, or offered the vaccine or booster. Additionally, there was no record of these residents receiving the vaccine while in the facility. During an interview, the Infection Preventionist confirmed that there was no documentation to support that these residents had been screened, educated, or offered the COVID-19 vaccine or booster. Facility policy required that all residents be screened and offered the vaccine upon admission, and that documentation of education, administration, or refusal be maintained in the medical record. This process was not followed for the three residents identified in the report.
Resident Burns Due to Unsafe Radiator and Hot Beverage Handling
Penalty
Summary
The facility failed to ensure the safety of a resident, resulting in a burn injury. A resident, identified as R2, sustained a deep partial-thickness burn to her right foot after falling against a wall-mounted radiator in her room. The incident occurred when R2 fell out of bed and her foot became trapped under the heater, causing a burn that required hospitalization and wound debridement. The facility did not have a process in place to monitor the temperatures of the radiators, and the Maintenance Director confirmed that the facility did not check the temperatures of the radiators or monitor outdoor temperatures. Another incident involved a resident, identified as R3, who sustained full-thickness burns to her thighs and buttocks after spilling hot tea on her lap. The Dietary Manager stated that the facility's policy required hot beverages to be served at a temperature of 120 degrees Fahrenheit or below. However, on the day of the incident, an Activity Aide refilled a carafe with hot water from a pot on the stove without checking the temperature before serving it to R3. This resulted in R3 suffering burns from the scalding hot water. These failures in monitoring and controlling the temperature of radiators and hot beverages posed a risk to all 160 residents in the facility. The lack of adequate supervision and safety measures led to Immediate Jeopardy, as these incidents demonstrated a significant risk of harm to the residents. The facility's inaction in implementing proper safety protocols and monitoring systems contributed to these preventable accidents.
Removal Plan
- All residents' heaters were reviewed for conditions that may make them unsafe. All resident beds were visually inspected to ensure they were not touching or within a close distance of the heaters.
- All staff were educated on room safety checks and notifications to appropriate parties/vendors of equipment malfunction. Ongoing for all incoming staff not on duty.
- The President of Facilities Environmental Services and Life Safety was called in to verify that all resident's heaters are in good repair and functioning properly.
- All staff were educated on updated hot beverage and temperature policy. Ongoing for all incoming staff not on duty.
- Coded door knobs were replaced on both kitchen doors to ensure only kitchen staff are to enter and exit from the kitchen, and have access to kitchen equipment and supplies.
- A crowd control belt was added at the kitchen entrance at the elevator to remind any staff other than Dietary to ask for dietary's assistance.
- Resident Council Meeting held to educate residents on the updated hot beverage policy.
- Resident Council Meeting held to educate residents on room safety and keeping themselves away from thermal surfaces.
- The facility Administrator and IDT reviewed related policies and procedures. The following policies were reviewed: Incident/Accidents; Fall Management; Dietary Food and Beverage temperatures.
- The Administrator initiated a QA audit tool for environmental safety checks to ensure that environmental hazards are resolved. Heaters in residents' rooms and common areas shall be maintained in a manner to prevent residents from prolonged contact with thermal surfaces. Weekly temperature checks of the radiator's thermal surface will be conducted with an Infrared Thermometer and placed on a log. Random room audits will be conducted 1 time per week for the duration of the heating season, and then on an as needed basis to ensure residents are safely placed away from the radiators. The results of the QA Audits shall be reviewed monthly by the Facility QAPI team to determine any necessary changes. Ongoing for QA monitoring.
- The Administrator initiated a QA audit tool for hot beverage serving and temperature taking, to ensure that dietary staff are preparing hot liquids and taking temps of liquids as per the policy and ensure that hot beverages are served at the appropriate temperature. All resident wings will be reviewed 2 times a week for 30 days, then 1 time a week for 30 days, and then on an as needed basis until ongoing compliance is achieved. The results of the QA audits shall be reviewed monthly by the Facility QAPI team to determine any necessary changes. Ongoing for QA monitoring.
- An emergency QA meeting was held by the Administrator with the Interdisciplinary Care Team and Medical Director to review the removal plan. The QA committee shall meet monthly thereafter and review the results of the QA audits. Changes to the policy and procedure shall be made as indicated by the QA results. The Medical Director and Interdisciplinary Care Team approved this Removal Plan. This will be monitored by the Administrator. Ongoing for QA monitoring.
Improper Medication Storage Leading to Potential Diversion
Penalty
Summary
The facility failed to store medications properly to prevent diversion, as observed during a survey of five medication rooms. In the A wing medication room, an unlocked refrigerator contained an unopened bottle of morphine sulfate liquid, labeled for a resident. Similarly, in the C wing medication room, an unlocked refrigerator contained two ABHR suppositories in a clear plastic baggie, labeled for another resident. The Director of Nursing confirmed that morphine and lorazepam, both controlled substances, should be stored under two locks to prevent misuse or abuse. The facility's Medication Pass Guidelines and the Drug Enforcement Administration's classification of morphine as a Schedule II narcotic emphasize the need for double-lock storage of controlled substances. Additionally, the National Institutes of Health highlights the abuse potential of lorazepam, a Schedule IV medication, which should also be securely stored. The facility's Medication Storage Policy requires medications to be returned to the pharmacy if a patient has not returned within 30 days, which was not adhered to in the case of the deceased resident whose medications were still present.
Failure to Notify Physician and Complete Assessment for Change in Condition
Penalty
Summary
The facility failed to ensure a complete assessment was completed with a resident's initial change in condition and did not immediately notify the physician of the change. The resident, who had a history of severe chronic obstructive pulmonary disease (COPD) and other significant medical conditions, experienced a drop in oxygen saturation levels. Despite this, the facility did not obtain physician orders for an increase in oxygen per nasal cannula, which led to the resident being transported to the local emergency department 4.5 hours after the initial change in condition. Upon arrival, the resident was in respiratory distress and failure. The resident's medical history included acute respiratory failure, pneumonia, and dependence on supplemental oxygen, among other conditions. On the day of the incident, the resident's oxygen saturation dropped to 88% and then to 77% when her head was lowered to change her adult brief. The nurse temporarily increased the oxygen to 5 liters, but there was no complete assessment documented or notification to the doctor of the change in condition. The resident's oxygen saturation continued to drop, and she was eventually sent to the hospital in respiratory arrest. Interviews with staff revealed that the resident's baseline oxygen saturation was 93%-96% on 3 liters of oxygen. The staff acknowledged that a drop to 88% would be considered a change in condition that should have been reported to the physician. However, the physician was not notified in a timely manner, and the resident's condition deteriorated. The facility's policies on oxygen titration and change of condition were not followed, contributing to the delay in appropriate medical intervention.
Failure to Assist Resident with Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate assistance and interventions for a resident (R48) with significant weight loss. R48, a female with Alzheimer's Disease, cerebrovascular disease, dementia, osteoarthritis, and chronic kidney disease, experienced a 10.22% weight loss in one month. Despite a diagnosis of failure to thrive and a care plan indicating the need for supervision and assistance during meals, staff did not provide the necessary support. Observations showed that R48 was left unattended during meals, with no staff assisting, cueing, or prompting her to eat. Additionally, another resident took food from R48's plate without staff intervention. The facility's records indicated that R48 had orders for fortified foods and nutritional supplements, but no new interventions were added following her significant weight loss. The dietician confirmed that R48 required supervision during meals and expected staff to assist and intervene as needed. The Director of Nursing attributed the weight loss to a recent illness (shingles), but no additional measures were taken to address the resident's nutritional needs during this period.
Failure to Maintain Sanitization Logs and Cover Food During Transportation
Penalty
Summary
The facility failed to maintain proper sanitization logs and ensure food was covered during transportation, affecting all residents. Observations revealed that the dishwasher sanitizing temperature and sanitation bucket chemical levels were not consistently tested and documented. Specifically, the March dishwasher log was missing eight temperature test results, and the March sanitation bucket log was missing 34 sanitation level test results. The Dietary Manager confirmed the importance of these tests and acknowledged the lapses in documentation, which are crucial for preventing foodborne illnesses among residents. Additionally, food transportation practices were found to be inadequate. Dietary staff were observed transporting uncovered dessert cakes and chocolate puddings from the basement kitchen to the first-floor kitchenette and dining areas. The Dietary Manager admitted that food should be covered to prevent contamination from dust and other particles but was unsure why the desserts were not covered during transportation. The facility's policy mandates that food be transported in covered containers, which was not adhered to in these instances.
Failure to Ensure Proper Pressure Ulcer Interventions
Penalty
Summary
The facility failed to ensure proper pressure ulcer interventions were in place for five residents, leading to deficiencies in care. For Resident 146, the air mattress was incorrectly set at 270 pounds instead of the resident's actual weight of 176 pounds, which could affect the air distribution and firmness necessary for wound healing. The wound care nurse and unit manager were unaware of who was responsible for ensuring the correct settings on the air mattress, indicating a lack of proper protocol and oversight. Resident 2 was found with an air mattress set at 340 pounds, significantly higher than her actual weight of 161.8 pounds. The unit manager admitted to setting the beds correctly upon delivery but was unsure how the settings could have been changed. The wound care nurse was also unaware of why Resident 2 was on an air bed, highlighting a gap in communication and understanding of the resident's care plan. Other residents, including Resident 11, Resident 36, and Resident 75, also experienced issues with incorrect air mattress settings and lack of proper repositioning. These residents had documented pressure ulcers or were at high risk for developing them, yet the facility failed to implement and monitor appropriate preventative measures. The facility's policy on pressure injury prevention and treatment was not effectively followed, leading to these deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for multiple residents. Specifically, multi-dose vials of fluphenazine decanoate for two residents were found opened and undated, making it impossible to determine their usability. Additionally, eight multi-dose vials of haloperidol labeled with a resident's name were found expired and still stored in the medication room without any current orders for the medication. A registered nurse confirmed that the vials should have been dated and discarded after 30 days, and the expired haloperidol should have been removed to prevent potential misuse. Furthermore, a controlled medication, lorazepam, prescribed to a resident was found improperly stored in an unlocked refrigerator in the memory care wing. The medication, which is a Schedule IV controlled substance with potential for abuse, was not double-locked as required. The Nurse Consultant/Pharmacy verified that lorazepam should be stored under two locks for safety. The facility's policy on controlled drug storage was requested but not provided, indicating a lapse in adherence to proper medication storage protocols.
Failure to Treat Resident with Dignity in Dining Room
Penalty
Summary
The facility failed to treat a resident with dignity while in the dining room. The resident, who has diagnoses including hemiplegia, type 2 Diabetes, and depression, was observed feeding himself lunch. As other residents finished eating, they asked staff to be taken back to their rooms but were told they had to wait until all residents were done eating. A Certified Nursing Assistant (CNA) was heard saying that the residents had to wait until the resident and others were done eating. When asked if he was finished, the resident said yes and was taken back to his room with half of his meal left uneaten. The resident later confirmed he did not get enough to eat and felt like a deterrent to others. The Director of Nursing (DON) stated that residents should be allowed the time they need to finish eating and that there are enough staff available to help residents return to their rooms. The DON also mentioned that staff should not mention another resident's name as a reason for the delay. The facility's care plan, revised in June 2023, indicates that care should be provided in a manner that maintains or enhances each resident's dignity and respect, recognizing their individuality.
Improper Handling of Urinary Catheter Drainage Bag During Transfer
Penalty
Summary
The facility failed to ensure a urinary catheter drainage bag remained below the level of the bladder during a transfer for one resident. The resident, who was admitted with multiple diagnoses including retention of urine and chronic kidney disease, was observed being transferred from a geriatric chair into bed by two CNAs. During the transfer, one CNA raised the urinary drainage bag above the level of the bladder and placed it on the resident's lap in the mechanical lift sling. An LPN supervising the transfer advised the CNA to place the drainage bag below the bladder, which was then done. The incident was noted during a quarterly assessment that documented the resident had an indwelling catheter.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure a resident's breathing treatment equipment was stored in a manner to prevent cross-contamination. A male resident with acute and chronic respiratory failure, among other conditions, had a physician's order for a medicated breathing treatment every six hours. On the morning of 04/02/24, the resident's nebulizer mask and tubing were found inside the top drawer of his bedside table, neither dated nor covered. The Director of Nursing confirmed that nebulizer and oxygen tubing and masks should be dated when first used and stored in a plastic bag when not in use. The facility did not provide a policy on the storage of resident breathing treatment/oxygen equipment when requested.
Failure to Safely Administer Medications
Penalty
Summary
The facility failed to safely administer medications as ordered by the physician for a resident diagnosed with hemiplegia, hypertension, delusional disorders, and anxiety. The resident was observed with a medication cup containing five pills on her bedside table, which she had not taken. The nurse assigned to the unit was not present near the resident's room at the time of observation. The resident mentioned that she forgot to take the medications, and the nurse later confirmed that the resident refuses to take her medications when staff are in the room, except for a prescribed narcotic. The Director of Nursing stated that unless care planned, a resident is to be observed taking the medications, and medications should not be left at the bedside. The physician orders did not include any orders for self-administration of medications, and the resident's care plan did not have any interventions for self-administration. The facility's policy on medication administration requires that medications be administered safely as prescribed and that the same staff prepare and administer the medications at the time of preparation. The medication administration record showed that five medications were administered to the resident during the 8 AM medication administration on the observed date.
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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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