Allure Of Zion
Inspection history, citations, penalties and survey trends for this long-term care facility in Zion, Illinois.
- Location
- 3615 16th Street, Zion, Illinois 60099
- CMS Provider Number
- 145443
- Inspections on file
- 33
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Allure Of Zion during CMS and state inspections, most recent first.
A resident with a diagnosis of anxiety had a PRN order for lorazepam, a psychotropic medication, to be given every four hours as needed for anxiety without any documented duration or stop date. The facility pharmacist stated that PRN psychotropic medications require a stop date, and the facility’s psychotropic medication policy limits PRN psychotropics to 14 days unless the physician documents a rationale and specific extended duration. The absence of a stop date or defined duration on this PRN lorazepam order resulted in a deficiency.
Two residents with dementia and known wandering behaviors were not adequately supervised, resulting in one resident entering another's room and lying in her bed for over 30 minutes without staff intervention. Staff failed to immediately redirect or remove the resident, despite both having care plans requiring such actions, and facility policies mandating supervision and prompt intervention for wandering behaviors.
A resident with severe cognitive impairment and bladder incontinence was left in soiled clothing for several hours without timely incontinence care, despite being dependent on staff. Observations revealed the resident was wearing two heavily soiled incontinence briefs, and staff interviews confirmed that care had not been provided as required by the care plan and facility policy.
A resident with severe cognitive impairment and a history of falls and skin tears did not have required fall and skin tear prevention interventions in place, including a properly attached chair alarm and protective sleeves on both arms, despite care plans and physician orders. Staff were unclear about the correct use of these interventions, resulting in inadequate supervision and protection.
A CNA did not change gloves between dirty and clean tasks while providing incontinence care to a resident with a history of ESBL in the urine, despite Enhanced Barrier Precautions being in place. The CNA handled personal care, clothing, shared equipment, and grooming without changing gloves, and was unaware of the reason for the resident's precautions. The DON confirmed that glove changes are required to prevent infection spread.
A resident with advanced dementia and multiple medical conditions was not properly supervised or assessed upon admission, resulting in an unwitnessed fall and rib fracture. Staff were aware of the resident's high fall risk but did not provide adequate supervision or evaluate mobility needs before the incident occurred.
A resident with multiple serious diagnoses did not receive physician-ordered Augmentin as scheduled due to a delay in pharmacy delivery and staff not realizing the medication was available in the facility's convenience box. The antibiotic was not administered until nearly two days after the order was written, despite documentation and staff interviews confirming the medication's availability on site.
Multiple residents reported missing money from their personal belongings, including cash kept in nightstands, purses, and pouches. In one case, a resident observed a staff member going through her drawer before discovering her money was gone. Other residents and their families noticed funds missing when attempting to use them for personal needs. All affected residents were alert and oriented, and the facility's policy prohibits misappropriation of resident property.
A resident's reported missing money was not promptly reported or investigated according to facility policy. The Social Service Director notified the administrator, but there was a delay in informing the DON and state authorities, resulting in a failure to follow required procedures for reporting and investigating alleged misappropriation of property.
A resident's missing cash was reported by her daughter on two occasions, but the allegations were not immediately reported to the state agency as required. The Social Service Director notified the administrator, but the DON was not informed until days later, resulting in a delay that did not comply with facility policy for reporting suspected misappropriation of property.
A resident's reports of missing money were not immediately investigated after being reported to the Social Service Director and administrator. The DON was not informed until days later during a leadership meeting, resulting in a delay that did not follow facility policy requiring immediate investigation of alleged misappropriation.
Two residents with Stage 4 sacral pressure ulcers were not provided with low air loss mattresses as ordered by their wound care physician and outlined in their care plans. Both residents were observed without the required pressure-redistributing support surfaces, and staff confirmed that these interventions should have been in place according to facility policy.
Staff did not wear required gowns while providing direct care and wound dressing changes to a resident with a Stage 4 pressure wound who was on Enhanced Barrier Precautions (EBP), despite facility policy and CDC guidelines mandating gown and glove use during high-contact care activities.
A nurse failed to properly account for a resident's controlled medication when, after administering a dose of Lorazepam, she accidentally discarded a bottle containing 10 remaining tablets into the garbage. The error was discovered during a narcotic count, and the missing medication was not recovered. The nurse left the area before the discrepancy was resolved, contrary to facility policy, resulting in a failure to protect the resident's belongings and medication.
A resident's Lorazepam administration was not accurately documented, with a missing time and signature for one dose and inconsistencies between the medication count and records. LPNs involved could not clarify who administered the dose, and the facility's policy requiring complete documentation for controlled substances was not followed.
A resident with recurrent UTIs and a positive ESBL test did not receive a timely Infectious Disease consultation due to a failure by a nurse to execute a physician's order. The Nurse Practitioner had instructed the RN to initiate the referral process, but the order was not entered, and no appointment was made. This oversight was discovered during a survey, highlighting a lapse in following the facility's policy for carrying out physician orders.
A resident was moved to a different room without receiving written notice or being shown the new room and introduced to the new roommate. The move followed an incident with another resident, but the facility did not adhere to its policy of providing written notice and involving the resident in the decision-making process.
A resident with a history of traumatic brain injury and dementia, known for wandering and aggressive behavior, was inadequately supervised, leading to the resident entering other residents' rooms. Video footage and staff interviews confirmed the resident's frequent wandering and aggressive incidents, highlighting a failure to implement effective care plan interventions and provide necessary supervision.
A resident was sent to the hospital with another resident's transfer paperwork, leading to a mix-up in documentation. The error was identified when an ER nurse contacted the facility to clarify the resident's identity. The Director of Nursing admitted to printing the wrong paperwork, resulting in a billing error for a procedure the resident did not undergo.
Two residents developed severe pressure ulcers due to the facility's failure to identify and address areas of pressure. One resident developed stage 4 pressure injuries on both heels, requiring surgical debridement, while another developed an unstageable pressure ulcer on the left hip, which progressed to stage 4. The facility did not conduct timely skin assessments or follow its own policies for pressure injury prevention, leading to delayed interventions and inadequate care.
A resident with severe cognitive impairment and multiple health issues experienced significant weight loss due to the facility's failure to perform weekly weights as ordered by a physician. The resident's care plan did not address the weight loss, and the dietician was unaware of the need for weekly monitoring, leading to a delay in intervention.
The facility failed to store medications according to policy, with refrigerated medications found in non-refrigerated narcotic boxes and an unlocked medication cart accessible to unauthorized individuals. Additionally, the facility lacked temperature logs for medication room refrigerators, risking improper storage conditions.
The facility failed to ensure monthly Medication Regimen Reviews (MRRs) by a licensed pharmacist for five residents, each with various medical conditions. The deficiency was due to missing documentation after the previous DON left, and a recent pharmacy switch. The new pharmacy is now responsible for MRRs, but the old DON did not print the MRRs from the previous system.
A facility failed to obtain and display a physician's order for a resident's code status, despite the resident having a POLST form indicating a DNR status. The resident's electronic medical record and physician's orders did not reflect this, contrary to the facility's policy. Staff acknowledged the oversight and the potential for delays in emergencies.
The facility failed to conduct PASRR Level 2 assessments for two residents with serious mental illness. One resident was admitted with psychosis and anxiety, receiving antipsychotic medications, yet no Level 2 review was conducted. Another resident with bipolar and major depressive disorders also lacked a Level 2 assessment. The Admissions Director was unaware of the requirement, and the facility's policy on coordinating assessments was not followed.
A resident with severe cognitive impairment and incontinence issues did not receive thorough incontinence care. A CNA failed to cleanse the resident's perineal and groin area after removing two wet incontinence briefs, one of which contained feces. The DON acknowledged the oversight and noted the CNA's need for further education.
Two residents at risk for falls were not properly monitored due to ineffective use of clip alarms. One resident's alarm was not attached, and another's alarm was missing a clip, leaving both residents vulnerable to falls. Staff confirmed the alarms were not functioning as intended.
A resident with heart disease and pneumonia was administered oxygen at an incorrect rate and with contaminated tubing. The oxygen was set at 4 liters per minute instead of the prescribed 2 liters, and the tubing was reused after falling on soiled linens and the floor. CNAs did not follow infection control procedures, and the facility's policy on changing contaminated tubing was not followed.
The facility failed to implement proper infection control measures for two residents. One resident with a stage 4 pressure ulcer and a PICC line was not placed on enhanced barrier precautions, and staff did not use PPE as required. Another resident with an indwelling urinary catheter was not provided with appropriate infection control, as a CNA did not perform hand hygiene or wear a gown while providing care. These actions were contrary to the facility's infection prevention policies.
A resident was injured after a CNA used a mechanical stand lift instead of following the care plan, which specified a two-person assist with a gait belt. The incident resulted in a fall and a head injury requiring an ER visit. The facility's policy mandates adherence to the resident's care plan and the use of two staff members for mechanical lifts.
A facility failed to complete skin assessments for a resident for four weeks, resulting in an unstageable pressure ulcer that progressed to Stage 4 and required surgical debridement. The resident, who had moderate cognitive impairment and was at risk for pressure ulcers, was often left lying on her back for long periods. The facility's DON confirmed the lapse in skin assessments, and the wound physician noted the wound's deterioration despite weekly treatments.
PRN Psychotropic Medication Order Lacked Required Stop Date
Penalty
Summary
The deficiency involves the facility’s failure to ensure an as-needed (PRN) psychotropic medication order included a required duration or stop date. One resident, identified as having a diagnosis of anxiety on a face sheet printed on 2/17/26, had an order on the same date’s Order Summary Report for lorazepam, a psychotropic medication, to be administered every four hours as needed for anxiety, with no duration or stop date specified. During an interview on 2/27/26 at 10:23 AM, the facility pharmacist stated that a PRN psychotropic medication such as lorazepam requires a stop date. The facility’s undated “Use of Psychotropic Medication(s)” policy states that PRN psychotropic medications shall be limited to no more than 14 days unless the attending physician documents in the medical record a rationale for extending the order and indicates a specific duration. This lack of a documented stop date or specified duration for the resident’s PRN lorazepam order, despite the facility policy and pharmacist’s statement that such orders must be time-limited, constitutes the identified deficiency.
Failure to Monitor and Intervene for Dementia Residents with Wandering Behaviors
Penalty
Summary
The facility failed to adequately monitor and intervene for two residents with dementia who exhibited wandering behaviors. On the morning of 12/8/25, one resident with severe cognitive impairment was observed entering another cognitively impaired resident's room and lying in her bed, both fully clothed. Video surveillance reviewed by the administrator showed the resident wandering unsupervised throughout the facility for about an hour before entering the other resident's room. Staff did not remove the resident from the room until over 30 minutes after entry, and there was no staff presence observed during this period. Both residents had documented histories of wandering and confusion, with care plans indicating the need for staff to distract and intervene as appropriate. Interviews with staff revealed that when the incident was discovered, immediate intervention did not occur. A CNA who found the resident in the bed reported the situation to an RN, who was occupied with medication administration and did not act immediately, instead waiting for the day shift to assist. The RN stated uncertainty about the nature of the relationship between the residents and did not know how long the resident had been in the room. Facility policies required immediate redirection and supervision of wandering residents, but these were not followed, resulting in a lack of timely intervention for both residents involved.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A resident with severe cognitive impairment, Parkinson's Disease, congestive heart failure, and bladder incontinence was observed to have not received timely incontinence care despite being dependent on staff for assistance. The resident was noted sitting in a reclining wheelchair with wet pants and a strong urine odor. Staff interviews and record reviews revealed that the resident had not been changed since approximately 8:00AM, and by late morning, the resident's clothing remained soiled. The resident's care plan required perineal cleaning with each incontinence episode, but this was not followed. Further observations showed that the resident was wearing two incontinence briefs, both heavily soiled, which staff stated was a common practice for this resident. The assigned CNA confirmed that no incontinence care had been provided since the start of her shift. The interim DON acknowledged that wearing two briefs was not appropriate and that the resident had gone too long without being changed or repositioned. The facility's policy required appropriate treatment and services for incontinent residents to prevent infections, but this was not adhered to in the resident's care.
Failure to Implement Fall and Skin Tear Prevention Measures
Penalty
Summary
The facility failed to implement and maintain fall and skin tear prevention measures for a resident with significant risk factors, including severe cognitive impairment, Parkinson's Disease, congestive heart failure, and a history of falls and skin tears. Despite care plans and physician orders specifying the use of a chair alarm at all times and protective sleeves on both arms, observations revealed that the resident had two alarms attached to her chair but neither was clipped to her, and only one protective sleeve was in use while the other was left in the chair. Staff interviews confirmed a lack of understanding regarding the proper use of the alarms and the necessity of protective sleeves for the resident's fragile skin. Record review indicated multiple prior incidents of skin tears and falls, with care plans and orders updated to address these risks. However, during the survey, the required interventions were not consistently in place, as evidenced by the resident's exposed right arm and improperly applied alarms. The facility's policy mandates that interventions to reduce environmental hazards and provide adequate supervision must be implemented, but these measures were not effectively carried out for this resident.
Failure to Change Gloves During Incontinence Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to change gloves during incontinence care for a resident with a history of ESBL (Extended-spectrum beta-lactamase) in the urine, despite physician orders and care plan instructions for Enhanced Barrier Precautions. During observed care, a CNA removed a soiled incontinence brief, cleansed the resident's perineal area, applied a clean brief, assisted with clean clothing, handled a mechanical lift remote, and combed the resident's hair without changing gloves between tasks. The CNA admitted to not changing gloves as required and was unaware of the specific reason for the resident's precautions. The Director of Nursing confirmed that gloves should be changed when moving from dirty to clean tasks, especially for residents with a history of ESBL, to prevent the spread of infection.
Failure to Supervise High Fall Risk Resident on Admission
Penalty
Summary
A deficiency occurred when a resident with a high risk for falls was not adequately supervised upon admission to the facility. The resident, who had diagnoses including vascular dementia, wet gangrene, and osteomyelitis, arrived at the facility before the start of the incoming nurse's shift and had not yet been officially admitted or assessed by nursing staff. Both the registered nurse and the CNA on duty were aware that the resident was a high fall risk, but the resident had not been evaluated for mobility or supervision needs prior to the incident. The CNA reported that she found the resident attempting to get up from bed and, unsure of the resident's mobility status, suggested the use of a urinal and unfolded a walker without confirming if it belonged to the resident. The CNA then left the room to dispose of trash, during which time the resident attempted to get up independently and fell. The fall was unwitnessed, but the resident was found on the floor, reported head and back pain, and was subsequently sent to the hospital for evaluation. Following the fall, the resident's daughter reported ongoing pain, which led to further assessment and the discovery of a minimally displaced rib fracture. The facility's policy required that the environment be free of accident hazards and that residents receive adequate supervision to prevent accidents. In this case, the lack of timely assessment and supervision for a high-risk resident directly led to the fall and injury.
Delay in Administration of Ordered Antibiotic
Penalty
Summary
A deficiency occurred when a resident with diagnoses including wet gangrene, osteomyelitis, and dementia was not administered Amoxicillin-clavulanate (Augmentin) as ordered by the discharging physician. The hospital discharge instructions specified that the resident was to receive Augmentin every eight hours, with the next dose due on the evening of admission. Although the physician order was entered with the correct start date, the medication was not administered until nearly two days later. Facility records and staff interviews revealed that the delay was due to the medication not being delivered promptly and a lack of awareness that Augmentin was available in the facility's convenience box. Nursing staff documented that the medication was unavailable, and the DON confirmed that the nurse did not know the convenience box contained the required medication. The delay in administration was further compounded by communication with the pharmacy regarding medication availability.
Failure to Protect Residents from Misappropriation of Money
Penalty
Summary
The facility failed to protect residents from the misappropriation of their money, as evidenced by multiple incidents involving four residents. One resident reported waking up to find a staff member going through her nightstand, after which she discovered $210 missing from her drawer. The resident was alert and oriented, and her account of the incident remained consistent when discussed with staff and police. The staff member identified as being assigned to her care that night matched the resident's description and was seen entering the room on video footage. Another resident's daughter reported that money kept in envelopes for personal use was missing from the resident's purse on two separate occasions. The daughter had placed the money in the resident's room, and the loss was only discovered when the resident attempted to use the funds. The incidents were reported to the Social Service Director after the second occurrence. In a separate case, a resident reported $35 missing from her bedside dresser, which had been left there by her Power of Attorney for snacks and beverages. The loss was discovered during interviews related to another theft investigation, and the POA confirmed the funds had been provided. A fourth resident reported $40 missing from a pouch he kept with him at all times, only noticing the loss when he attempted to use the money at a vending machine. Staff confirmed the resident had money in his pouch the previous day, but a search of his room did not recover the missing funds. All four residents involved were alert and oriented at the time of the incidents, and the facility's policy prohibits misappropriation of resident property.
Failure to Timely Report and Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to implement its Abuse Policy regarding the timely reporting and investigation of an alleged misappropriation of money for one resident. The resident's daughter reported missing envelopes of money on two separate occasions to the Social Service Director, who notified the administrator. However, there was a delay in reporting the allegations to the Director of Nursing and the Illinois Department of Public Health (IDPH). The Director of Nursing stated she was not informed of the missing money until six days after the initial allegation, during a morning meeting, and confirmed that no investigation or report to IDPH had occurred prior to her being notified. Facility policy requires that all allegations of abuse, neglect, exploitation, or misappropriation of resident property be reported immediately to the administrator and state agencies, and that an immediate investigation be initiated. In this case, the policy was not followed, as the allegations were not promptly reported or investigated. The documentation shows that the required notifications and investigation were delayed, contrary to the facility's written procedures.
Failure to Timely Report Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to ensure that an alleged misappropriation of a resident's money was reported immediately to the State Survey Agency as required. The incident involved a resident whose daughter reported missing envelopes of cash on two separate occasions. The first report involved two envelopes containing $23 each, noticed missing several days after being left in the resident's room. The second report involved four envelopes totaling $86 missing from a zipper pocket in the resident's purse. In both cases, the Social Service Director notified the facility administrator, but there was a delay in reporting the allegations to the Illinois Department of Public Health (IDPH). According to interviews and record review, the Director of Nursing was not informed of the missing money until several days after the initial report, during a leadership meeting. The facility's policy requires that all alleged violations involving misappropriation of property be reported to the administrator and state agency immediately, or within specified timeframes depending on the severity. The delay in reporting the allegations to IDPH did not meet these requirements, resulting in a deficiency.
Failure to Promptly Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to promptly initiate an investigation into an alleged misappropriation of money for one resident. The resident's daughter reported missing envelopes containing cash on two separate occasions to the Social Service Director, who notified the administrator but did not immediately begin an investigation. Documentation shows that the missing money was first reported as two envelopes totaling $46, and later as four envelopes totaling $86, all of which were kept in the resident's room or personal belongings. Despite these reports, a full investigation was not initiated until several days later, after the issue was brought up during a leadership meeting. Interviews and record reviews revealed that the Director of Nursing was not informed of the missing money until the leadership meeting, and acknowledged that the incident should have been reported and investigated immediately according to facility policy. The facility's policy requires immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation, but this protocol was not followed in this case, resulting in a delay in addressing the alleged misappropriation.
Failure to Provide Low Air Loss Mattresses for Residents with Stage 4 Pressure Ulcers
Penalty
Summary
The facility failed to provide low air loss mattresses for two residents with Stage 4 sacral pressure ulcers, despite physician orders and care plans specifying this intervention. One resident was admitted with a Stage 4 sacral pressure ulcer and deep tissue damage to the right heel, with both the wound physician's plan of care and the resident's care plan indicating the need for a low air loss mattress. However, during observation, the resident was found in bed without the required mattress and confirmed not having a special mattress. The wound care nurse also verified that the resident did not have a low air loss mattress and stated that all residents with pressure wounds should have one. A second resident, also admitted with a Stage 4 sacral pressure ulcer, was observed in her room without a low air loss mattress. During the survey, maintenance staff entered to replace her standard mattress with a low air loss mattress, and the resident confirmed she was receiving the new mattress as recommended by the wound care doctor. The facility's policy requires evidence-based interventions, including appropriate pressure-redistributing support surfaces, for all residents with pressure injuries. Despite this policy and physician recommendations, the required mattresses were not provided to these residents.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with a Stage 4 pressure wound who had a current order for EBP. During a dressing change, three staff members, including a wound care nurse, a CNA, and a life enrichment staff member, provided direct care and assisted with wound care activities without wearing gowns, as required by the facility's EBP policy. The infection prevention nurse confirmed that staff are expected to wear gowns, gloves, and masks when providing close contact care to residents on EBP, especially those with Stage 4 or greater wounds. The facility's policy and CDC guidelines specify that gowns and gloves are necessary during high-contact care activities for residents on EBP.
Failure to Safeguard and Account for Controlled Medication
Penalty
Summary
A deficiency occurred when a nurse (LPN) failed to properly account for a resident's controlled medication, specifically Lorazepam tablets. The nurse reported that after administering a dose, she accidentally discarded the entire bottle containing 10 remaining tablets into the garbage. This was discovered during the routine narcotic count, which revealed the bottle was missing. The nurse admitted to possibly giving another dose in the morning and stated she realized the error only during the count. Video footage confirmed the nurse was seen preparing medications and discarding the bottle, but did not show her administering the medication. The resident involved was unable to communicate whether the medication was received, and the medication was supplied in bottles by hospice. The facility's policy requires staff to remain in the area until all discrepancies are resolved or reported as unresolved, but the nurse left the building before the issue was fully addressed. Other staff members noted the nurse's unusual behavior and that she had access to multiple medication carts. The missing medication was not recovered, as the garbage had already been removed. Documentation showed the medication was last signed out for administration, but the remaining tablets were unaccounted for, resulting in a failure to safeguard the resident's controlled substances as required.
Failure to Accurately Document and Reconcile Controlled Substance Administration
Penalty
Summary
The facility failed to ensure accurate reconciliation and documentation of a controlled substance for one resident. The Controlled Substance Proof of Use form for a bottle of Lorazepam showed that one tablet was removed, but there was no time recorded or signature from the person who administered it. The next documented administration was later that same day, with the appropriate signature and time. The resident's Medication Administration Record (MAR) did not show a corresponding administration for the undocumented dose, and staff interviews revealed confusion about who administered the medication and when. One LPN stated that she might have given another dose in the morning, but the count in the bottle did not match the documentation. Another LPN stated she did not administer the medication during her shift and described how the count and documentation were reconciled after the discrepancy was discovered. The facility's policy requires that all controlled substances removed from the medication cart or cabinet be recorded on the designated usage form with clear and complete documentation. In this instance, the required documentation was incomplete, with missing time and signature for the administration of Lorazepam. Staff interviews confirmed that the documentation was not completed at the time of administration, and the process for reconciling the medication count was not followed as per policy.
Failure to Execute Physician Order for Infectious Disease Consultation
Penalty
Summary
The facility failed to carry out a physician's order for an Infectious Disease consultation for a resident, identified as R2, who was reviewed for Quality of Care. R2 had a history of recurrent urinary tract infections (UTIs), with the most recent one testing positive for extended-spectrum beta-lactamases (ESBL) on 12/19/24. Despite the Nurse Practitioner (V4) giving an order on 12/26/24 to the Registered Nurse (V5) to start the referral process for an Infectious Disease consultation, the order was not entered, and no appointment was made. This oversight was discovered on 1/8/25 when V4 noticed the missing order in R2's medical records. Interviews revealed that V5 recalled receiving the order but failed to act on it, and the Director of Nursing (V2) was unaware of the lapse until the surveyor's inquiry. The Assistant Director of Nursing (V3) noted that telehealth appointments with Infectious Disease doctors could be arranged quickly, suggesting that timely action could have facilitated a prompt consultation. The facility's policy requires nurses to note and carry out physician orders, which was not adhered to in this instance, leading to the deficiency.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to notify a resident in writing about a room change initiated by the facility. The resident, identified as R1, was moved to a different room after an incident where a male resident entered her room and kissed her on the cheek. The facility decided to move R1 to prevent further incidents with the male resident, R2. However, R1 expressed dissatisfaction with the move, stating she was not at fault and preferred her previous room due to its view. She also reported difficulties with her new roommate, who kept the TV volume high, affecting R1's ability to hear her visitors and her own TV. R1 was not shown her new room or introduced to her new roommate before the transfer, and she did not receive any written notice about the room change. The Social Service Director, identified as V4, confirmed that the facility's practice was to move the resident who complained about an incident. V4 also stated that while a form is filled out for room changes, it is not provided to the resident. The facility's policy requires written notice of room changes, including reasons for the move, and assistance from social services to help the resident adjust. However, there was no documentation in R1's electronic medical record regarding the room change, and the facility did not adhere to its policy of providing written notice and involving the resident in the decision-making process.
Inadequate Supervision of Wandering Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with wandering and aggressive behaviors, leading to the resident entering other residents' rooms. On December 4, 2024, video footage from November 24, 2024, showed the resident independently walking down the hallway and entering two different resident rooms. A Certified Nursing Assistant (CNA) was seen redirecting the resident out of the rooms, but the resident continued to wander. Interviews with staff revealed that the resident frequently wanders and has a history of aggressive behavior, including grabbing a CNA's arm and causing pain. The resident's psychiatric evaluations and behavior notes indicate a history of traumatic brain injury, dementia, and aggressive outbursts, requiring medication to manage behavior. The resident's care plan, printed on December 4, 2024, identified the resident as an elopement risk and wanderer due to disorientation and impaired safety awareness. However, the care plan interventions, such as distracting the resident with activities and identifying wandering patterns, were not effectively implemented. Staff interviews confirmed that the resident requires constant supervision to prevent entering other residents' rooms, but this level of supervision was not consistently provided, leading to the deficiency in ensuring a safe environment for all residents.
Incorrect Transfer Paperwork Sent with Resident
Penalty
Summary
The facility failed to ensure that the correct transfer paperwork was sent with a resident to the hospital, resulting in a mix-up of documentation. On March 6, 2024, a resident identified as R2 was sent to the hospital after pulling out his gastrostomy tube (g-tube) and required emergency room care to have it replaced. However, the transfer paperwork sent with R2 mistakenly contained the information of another resident, R1. This error was discovered when an emergency room nurse contacted the facility to clarify the identity of the resident in the emergency room. The Director of Nursing, identified as V2, admitted to printing the incorrect face sheet and code status for R1, which was then sent with R2 to the hospital. This mistake led to a billing error, as R1's wife discovered a charge for a tube feeding procedure that R1 did not undergo, since R1 remained at the facility on the day in question. The facility's policy on transfer and discharge requires specific information to be provided to the receiving provider, which was not adhered to in this instance.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to identify and address areas of pressure for two residents, leading to the development of severe pressure ulcers. Resident R45 developed two stage 4 pressure injuries on both heels, which required surgical debridement. The resident had a history of severe cognitive impairment and required substantial assistance for daily activities. Despite being at high risk for pressure ulcers, as indicated by the Braden Scale, the facility did not adequately monitor or report changes in skin condition. The Wound Nurse, V11, was not notified of the wounds until they had progressed significantly, and the initial assessment was delayed. The facility's policy required nursing assistants to report skin concerns immediately, but this protocol was not followed, resulting in the advanced stage of the wounds. Resident R56 also developed an unstageable pressure ulcer on the left hip, which progressed to a stage 4 ulcer requiring debridement. The resident's care plan indicated a risk for pressure ulcers, but weekly skin assessments were not conducted as required by the facility's policy. The wound was initially identified as a blister, but it was not properly monitored, leading to its progression. The Wound Nurse, V11, acknowledged that weekly assessments should have been performed due to the resident's high risk for skin breakdown, but these assessments were not documented or conducted. The facility's failure to adhere to its own policies and procedures for pressure injury prevention and management contributed to the development and progression of severe pressure ulcers in both residents. The lack of timely skin assessments and communication among staff members resulted in delayed interventions and inadequate care. The Director of Nursing and other staff members recognized the oversight and expressed concern over the failure to identify and address the skin issues before they became severe.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to perform weekly weights as ordered by a physician for a resident, resulting in a significant weight loss of 7.96% over a three-month period before it was identified by the facility staff. The resident, who has severe cognitive impairment and multiple diagnoses including traumatic subdural hemorrhage, type 2 diabetes, and anemia, experienced a weight loss of 5.47% within less than one month, dropping from 120.6 lbs to 114 lbs. The resident's care plan did not address the weight loss, and the physician's orders for weekly weights were not followed, leading to a further weight reduction to 111 lbs by July. The Director of Nursing acknowledged the issue, noting that the dietician was not aware of the resident's need for weekly weights, and the lead certified nursing assistant was not notifying staff to weigh the resident weekly. The dietician stated that the resident was not on the list for review due to the lack of recorded weights, which prevented timely intervention. The facility's policy on weight monitoring emphasizes the importance of maintaining acceptable nutritional status and requires weekly weight monitoring for residents with weight loss, which was not adhered to in this case.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to store medications according to their policy, as observed during a survey. On the 400-hall and 200-hall medication carts, liquid Norco and Lorazepam, which require refrigeration, were found stored in the narcotic box instead of a refrigerator. Additionally, the 200-hall medication cart was found unlocked, allowing unrestricted access to medications, except for those in the double-locked narcotic box. This cart was left unattended near a common use bathroom, posing a risk of unauthorized access by visitors, staff, and residents. Furthermore, the facility did not maintain temperature logs for the medication room refrigerators, as confirmed by the LPN and the DON. Without these logs, there is no assurance that medications requiring refrigeration were stored at the correct temperatures, potentially compromising their effectiveness. The facility's Medication Storage policy mandates that all drugs and biologicals be stored in locked compartments and that refrigerated products be kept at temperatures between 36-46 degrees Fahrenheit, with daily temperature recordings.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a Medication Regimen Review (MRR) was completed by a licensed pharmacist on a monthly basis for five residents. These residents, identified as R8, R26, R41, R56, and R61, were part of a sample of 24 residents reviewed for MRR compliance. Each of these residents had only one MRR completed in 2024, with R8, R41, R56, and R61 having their reviews in June, and R26 in July. The residents had various medical conditions, including type 2 diabetes mellitus, major depressive disorder, hypertension, anxiety, depression, atrial fibrillation, bipolar disorder, COPD, osteoarthritis, and Parkinson's disease. The deficiency was attributed to a lack of documentation and oversight following the departure of the facility's previous Director of Nursing (DON). The facility's administrator, identified as V1, stated that many documents, including MRRs, went missing after the old DON left. The facility had recently switched pharmacies, and the new pharmacy was responsible for conducting MRRs and documenting them in the Electronic Medical Records (EMR). However, the old DON had access to the previous pharmacy's system and was supposed to print out the MRRs, which was not done. The facility's pharmacy services policy and procedure outlined the responsibilities of providing pharmaceutical services, including the accurate management of medications and collaboration with facility leadership to address pharmaceutical concerns affecting resident care.
Failure to Obtain and Display Resident's Code Status
Penalty
Summary
The facility failed to obtain and display a physician's order for a resident's code status, which is a critical component of the resident's advance directives. The resident, who has multiple diagnoses including Parkinson's disease, unsteadiness, repeated falls, lack of coordination, and syncope, had a POLST form dated December 2021 indicating a Do Not Resuscitate (DNR) status. However, the resident's electronic medical record and physician's orders for July 2024 did not reflect this code status, which is a violation of the facility's policy on residents' rights regarding treatment and advance directives. During interviews, a registered nurse and the Director of Nursing acknowledged the absence of the code status in the electronic medical record and the lack of a physician's order. They expressed concern that this oversight could lead to delays in emergency situations, as staff would need to search through the resident's chart to locate the POLST form. The facility's policy emphasizes the importance of supporting and facilitating a resident's right to formulate an advance directive, which was not adhered to in this case.
Failure to Conduct PASRR Level 2 Assessments for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that a PASRR Level 2 assessment was completed for residents with serious mental illness, affecting two residents in the sample. Resident R66 was admitted with diagnoses including unspecified psychosis and anxiety, and was prescribed antipsychotic medications such as Quetiapine, Risperidone, and Haloperidol. Despite these indicators of serious mental illness, R66's PASRR Level 1 assessment indicated no need for a Level 2 review. The Admissions Director, V5, admitted to not being aware of the requirement for a PASRR Level 2 for residents with serious mental illness and stated she had not been trained on the process. Similarly, Resident R41, who had diagnoses of bipolar disorder and major depressive disorder, was also not subjected to a PASRR Level 2 assessment upon admission. The Administrator, V1, acknowledged that the admissions process failed to identify the need for a Level 2 review for R41. The facility's policy mandates coordination with the PASRR program to ensure appropriate care for individuals with mental disorders, but this was not adhered to in these cases.
Inadequate Incontinence Care for a Resident
Penalty
Summary
The facility failed to provide thorough incontinence care for a dependent resident, identified as R37, who has severe cognitive impairment and is always incontinent of bladder. R37's medical history includes hemiplegia, hemiparesis, cerebral infarction, and dementia with behaviors. During an observation, a Certified Nursing Assistant (CNA), identified as V14, was seen providing toileting assistance to R37. V14 removed two incontinence briefs from R37, both of which were wet with urine, and the inner brief had feces on it. Despite the strong urine odor and the presence of feces, V14 only cleansed R37's buttocks and applied a clean brief without cleansing the perineal and groin area. The Director of Nursing (DON), identified as V2, stated that perineal care should be performed after each incontinent episode to prevent infection and provide dignity to each resident. The facility's policy on incontinence care, dated February 2023, requires that residents who are incontinent receive appropriate treatment to prevent infection. V14 admitted to not realizing the need to clean R37's groin area, attributing the oversight to being newer and needing more education. This incident highlights a deficiency in the facility's adherence to its incontinence care policy.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure fall prevention measures were effectively implemented for two residents, both of whom were identified as being at risk for falls. The first resident, R3, had a history of severe cognitive impairment and was at risk for falls due to incontinence. Despite having a physician's order for a clip alarm to be in place, the alarm was found unattached to the resident, rendering it ineffective. This was confirmed by a Licensed Practical Nurse who acknowledged that the alarm should have been clipped to the resident to alert staff if the resident attempted to get up. Similarly, the second resident, R30, also had severe cognitive impairment and a history of falls. Observations revealed that the clip alarm intended to prevent falls was not properly attached to the resident, as the clip was missing from the cord. This was noted on two separate occasions, and a Certified Nursing Assistant confirmed the alarm's ineffectiveness due to the missing clip. The alarm was later replaced, but subsequent observation showed it was still not clipped to the resident, leaving the resident at risk of falling.
Failure to Administer Oxygen Correctly and Maintain Infection Control
Penalty
Summary
The facility failed to ensure that oxygen was administered at the physician-prescribed rate and did not handle oxygen tubing in a manner to prevent cross-contamination for a resident. The resident, who had diagnoses including heart disease, pleural effusion, and pneumonia, was observed with oxygen set at 4 liters per minute instead of the prescribed 2 liters per minute. The resident was heavily incontinent of bowel, and the oxygen tubing was found lying on soiled linens and the floor. Despite this, the tubing was picked up and placed directly back into the resident's nose by the CNAs, without being replaced or cleaned. The CNAs involved in the incident did not follow proper infection control procedures, as they reused the contaminated nasal cannula. The Director of Nurses confirmed that oxygen is a medication and must be administered as ordered by the physician, and that contaminated tubing poses a serious infection control issue. The facility's policy states that oxygen tubing should be changed if it becomes soiled or contaminated, which was not adhered to in this case.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for two residents, leading to deficiencies in care. One resident, identified as having a stage 4 pressure ulcer and a PICC line, was not placed on enhanced barrier precautions despite having conditions that warranted such measures. Observations revealed that staff did not wear gowns or eye protection when caring for this resident, and there were no isolation signs or personal protective equipment (PPE) available outside the resident's room. The facility's policy required enhanced barrier precautions for residents with wounds or indwelling medical devices, but these were not followed in this case. Another resident, who required enhanced barrier precautions due to an indwelling urinary catheter, was also not provided with appropriate infection control measures. A Certified Nursing Assistant (CNA) failed to perform hand hygiene or wear a gown while emptying the resident's urinary drainage bag, despite the resident being on isolation. The CNA then proceeded to assist another resident without performing hand hygiene, further compromising infection control. The Director of Nursing confirmed that staff should wear PPE and perform hand hygiene before and after providing care to residents on enhanced barrier precautions, but these protocols were not adhered to in this instance.
Failure to Follow Resident's Care Plan During Transfer
Penalty
Summary
The facility failed to transfer a resident according to the resident's care plan, resulting in a fall and injury. On 04/24/24, a resident (R1) was observed with two staples in the top posterior area of her head. The resident's family expressed concerns about the use of a mechanical stand lift, which was not part of R1's care plan. The Assistant Director of Nursing (ADON) confirmed that the Certified Nursing Assistant (CNA) used the mechanical stand lift inappropriately and did not report the resident's weakened condition to the nurse before attempting the transfer. The resident's care plan specified a two-person extensive assist with a gait belt, not a mechanical stand lift. The incident occurred on 04/11/24, when the resident was being transferred using a mechanical stand lift, resulting in a fall in the resident's room. The fall was witnessed by the CNA, and the resident sustained a small scrape to the back of her head, which required an ER visit. The facility's Safe Resident Handling/Transfers Policy mandates that two staff members must be utilized when transferring residents with a mechanical lift, and all transfers should be performed according to the resident's individual plan of care. The CNA's failure to adhere to these guidelines led to the resident's fall and subsequent injury.
Failure to Perform Timely Skin Assessments Leads to Severe Pressure Ulcer
Penalty
Summary
The facility failed to complete skin assessments for a resident for four weeks prior to identifying a pressure injury that had become unstageable. This resident, who had moderate cognitive impairment and was at risk for developing pressure ulcers, was found to have an unstageable pressure ulcer on the coccyx, which later progressed to a Stage 4 wound requiring surgical debridement. The resident's granddaughter, who held power of attorney, reported that the resident was often left lying on her back for long periods, and the wound had become infected by the time the resident was hospitalized and placed on hospice care. The facility's Director of Nursing confirmed that no skin assessments were performed for approximately four weeks before the discovery of the resident's sacral wound. The facility's wound physician noted that the wound had worsened over time despite weekly assessments and adjustments to the wound treatment. The facility's policy on pressure injury prevention and management was not followed, leading to the resident's wound deteriorating from unstageable to Stage 4, necessitating surgical intervention.
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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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