Aperion Care Elgin
Inspection history, citations, penalties and survey trends for this long-term care facility in Elgin, Illinois.
- Location
- 134 North Mclean Boulevard, Elgin, Illinois 60121
- CMS Provider Number
- 145740
- Inspections on file
- 30
- Latest survey
- November 30, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Aperion Care Elgin during CMS and state inspections, most recent first.
A resident reported repeated verbal and mental abuse by a CNA, including inappropriate comments, threatening behavior, and the use of profanity. Despite prior instructions for the staff to avoid the resident's unit, the staff members were present in the area, leading to further confrontation and the use of abusive language, as confirmed by a video recording and staff interviews.
Surveyors observed multiple failures in sanitary food handling, including improper dish machine sanitizer levels, uncovered beverages during meal tray transport, and a cook preparing food with soiled gloves. These actions were not in accordance with facility policy or professional standards and affected all residents receiving meals from the kitchen.
The facility failed to follow its Water Management Plan for Legionella, did not ensure proper use of personal protective equipment during laundry handling, and did not enforce infection control practices such as hand hygiene, contact isolation, and disinfection of medical devices between residents. These deficiencies were observed in multiple areas, including resident care, therapy, and medication administration, affecting all residents in the facility.
A resident with multiple sclerosis and moderate cognitive impairment, requiring moderate staff assistance for grooming, was not provided with necessary help for shaving, oral care, or washing. Over several days, the resident was observed with unshaven facial hair, matted hair, and reported not being offered showers or grooming assistance, despite facility policies and care plans indicating these needs.
A resident with multiple medical conditions and identified nutritional risks did not receive a required quarterly nutrition assessment, as documented in the facility's records. The resident experienced a steady weight loss over several months, reported feeling he was losing weight, and was observed eating without staff assistance despite being legally blind. Facility staff confirmed that the assessment was overdue and that the dietitian only evaluates residents with significant weight loss, contrary to policy requirements.
A resident with a midline IV catheter for antibiotic therapy was found to have a soiled gauze dressing under a transparent dressing, with no care plan in place and no documentation of required monitoring or dressing changes. The facility did not follow its own protocols for IV site care, including regular assessment, documentation, and dressing changes.
A resident's family member left a purse containing a firearm in a room, and staff secured the purse after being notified by the family member. However, staff and administration did not report the presence of the firearm to law enforcement or the state survey agency as required by policy and state law, only doing so after being questioned by a surveyor. The resident involved was severely cognitively impaired and unable to participate in the investigation.
A resident with severe cognitive impairment had a purse containing a firearm left at their bedside by a family member. The facility administrator was notified but did not document, investigate, or report the incident as required by facility policy and state regulations. No investigation records or preventative measures were provided, despite the facility's policy mandating such actions.
The facility failed to conduct care plan conferences with residents and their representatives, as required. This deficiency affected all six residents reviewed, with no care plan meetings held quarterly or following significant changes in residents' conditions. The DON confirmed the absence of a care plan coordinator, and the facility lacked a policy to ensure these meetings occurred.
A facility failed to schedule neuropsychological testing for a resident with severe cognitive impairment and epilepsy, as ordered by a neurologist. Despite the neurologist's order, the necessary appointment was not made, and staff confirmed the oversight. The facility's policy requires physician orders to be confirmed and completed by a licensed nurse, which was not followed in this instance.
A resident with severe cognitive impairment and epilepsy did not receive a scheduled ophthalmology appointment as ordered by a neurologist. Despite the neurologist's recommendation for a neuro-ophthalmology referral due to visual impairment concerns, the facility failed to make the appointment, as confirmed by the DON. This oversight occurred despite the facility's policy on processing physician orders.
A resident with multiple neurological and psychological conditions did not receive an MRI as ordered by their neurologist. The MRI was supposed to be scheduled around mid-July, but the facility failed to document or schedule it. The neurologist noted the oversight during a follow-up visit in late November, and the MRI was only completed at the end of December after being reordered. The facility's policy for confirming physician orders was not followed, resulting in the delay.
A resident with severe cognitive impairment and multiple diagnoses had a scheduled neurology appointment, but the facility failed to arrange transportation. The Transportation Coordinator was not informed of the appointment by the nurse, leading to the resident not being included on the transportation list, risking a missed appointment.
A resident with a tracheostomy experienced acute respiratory distress due to the facility's failure to provide appropriate emergency tracheostomy supplies and adequately trained staff. The resident was admitted with a size 6 cuffed trach tube, but during an emergency, the facility lacked the correct emergency tracheostomy exchange kits, and available supplies were expired or incorrect. Nurses were not trained to change trach tubes, leading to the resident's hospitalization for acute hypoxemic respiratory failure.
The facility failed to discard expired food items and did not ensure the dishwashing machine was sanitizing properly. Expired Worcestershire sauces were found in dry storage, and the dishwashing machine failed sanitization tests with no log entries for the observed date.
The facility failed to assess and monitor residents for self-administration and storage of medications, resulting in four residents having unauthorized access to various medications without physician orders or care plans.
The facility failed to assess and care plan residents that smoke per facility policy and did not ensure smoking materials were kept in the designated secure location. Five residents were found with unsupervised access to smoking materials, contrary to their care plans and smoking safety risk assessments.
The facility failed to verify the accuracy of controlled medication counting logs and did not dispose of controlled medications per policy for four residents. Medications were missing or improperly logged, and controlled drug administration sheets were not in the appropriate binders.
The facility failed to provide timely incontinence care to a resident, resulting in soaked clothing and potential skin breakdown. Additionally, another resident's indwelling catheter bag was observed on the floor without a privacy bag, contrary to facility policy.
The facility failed to follow its oxygen and respiratory equipment changing/cleaning policy for three residents. One resident had a nasal cannula on the floor and a dirty humidifier, another had a nasal cannula hanging from a drawer knob, and a third had a nebulizer mask on the floor. Staff confirmed that the equipment should be changed weekly and stored properly, which was not done.
The facility failed to monitor and document behaviors and to develop and update care plans with interventions for residents with known behaviors related to mental disorders. One resident exhibited paranoia and refusal to eat, while another frequently urinated on the floor. Staff interviews confirmed the lack of documentation and appropriate care plan updates for these behaviors.
An LPN failed to administer insulin correctly to two residents, resulting in a 12% medication error rate. The LPN did not prime the insulin pens or hold the dose knob in and count to five before removing the needle, contrary to the manufacturer's instructions.
The facility failed to administer the correct doses of insulin to two residents and scheduled pain medication to another. An LPN forgot to administer a resident's scheduled Tramadol, and another LPN did not properly prime insulin pens or ensure correct dosing for two residents. The DON confirmed the absence of a medication administration policy.
The facility failed to dispose of expired medications for two residents. Expired Vancomycin, Lorazepam, and Scopolamine were found in the medication storage room, and the Medication Record Reports did not show orders for some of these medications. The Director of Nursing confirmed that expired medications should be removed and returned to the pharmacy for disposal.
A resident with a history of alcohol use, chronic pain syndrome, and repeated falls was involved in a serious accident after signing out of the facility without proper assessment for safe independent community access. Despite being hit by a car the previous day and presenting with alcohol on his breath, the resident was allowed to leave unsupervised. The facility lacked documentation of a physician's order for alcohol consumption or independent community access. Staff were aware of the resident's risky behavior but did not take appropriate actions, leading to the resident being found injured and requiring hospitalization.
Failure to Prevent Verbal and Mental Abuse of a Resident
Penalty
Summary
A deficiency occurred when a resident reported experiencing verbal and mental abuse from a Certified Nursing Assistant (CNA) and another staff member. The resident alleged that the CNA entered his room uninvited in a threatening manner, made inappropriate comments such as calling him 'Honey Bunny,' and referenced her father purchasing her a gun. The resident also described an incident where the CNA performed a 'hoola dance' in the hallway while pointing at him. These concerns were reported to the facility administrator, who instructed the involved staff to avoid working near the resident's unit. Despite these instructions, the resident encountered the same staff members in his hallway and reported the incident to the nurse on duty, requesting confirmation from the administrator that the staff should not be present. The resident recorded the interaction, which captured him repeatedly stating that the staff were not to be on his unit and requesting administrative intervention. The video also recorded a female voice off-camera using profanity directed at the resident as the staff walked away. Multiple staff interviews confirmed that the staff lingered in the area for several minutes after being told to leave, and there was an argument between the resident and the CNA. Facility records and emails documented the resident's repeated complaints about the CNA's behavior, including previous incidents of the CNA entering his room without permission and making inappropriate comments. The facility's abuse prevention policy defines verbal abuse as a form of mental abuse, including the use of oral or gestured communication within hearing distance of residents. The investigation concluded that profanity was used in the shared environment between the CNA and the resident, and the staff member was ultimately terminated for customer service reasons.
Failure to Maintain Sanitary Food Handling and Meal Service Practices
Penalty
Summary
The facility failed to follow sanitary practices in the kitchen and during meal service, affecting all residents who received food prepared in the facility kitchen. During an initial kitchen tour, a dietary aide was observed using a dish machine with chlorine sanitizer levels above the posted guidance range. The aide had not tested the machine prior to use, and there was confusion among staff regarding the correct sanitizer concentration, with posted guidance indicating 50-100 ppm but test results showing 200 ppm. The dish machine service representative later confirmed that the correct test strips should register between 50-100 ppm, and the facility's policy required staff to check sanitizer levels before use and not proceed if out of range. During meal service, trays prepared in the main dining room were transported to resident rooms on a cart with uncovered juice and water cups. The cart was stationed in a hallway with staff, visitors, and residents passing by. When questioned, a staff member assisting with tray delivery was unaware of the reason for the uncovered beverages. Facility policy required all foods to be covered during transport to control the spread of infectious disease, but this was not followed for several residents who received uncovered drinks. Additionally, a cook was observed preparing a meal while wearing gloves soiled with pureed food and gravy. Without changing gloves, the cook handled a hamburger bun and added toppings, directly violating sanitary food handling practices. The unsanitary practice was observed and reported to the dietary manager, and the facility menu confirmed the food items being prepared at the time.
Widespread Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement and document its Water Management Plan for Legionella as required by its own policies. The Maintenance Director did not monitor or document water temperatures in accordance with the plan, only checking a limited number of locations and failing to log hot water tank temperatures. There was no documentation of control measures or monitoring activities prior to a specific date, and the required weekly flushing and cleaning of eye wash stations was not performed as outlined in the facility's risk assessment and water management guidelines. Laundry staff did not adhere to the facility's linen handling policy, as soiled laundry was handled without the use of required personal protective equipment such as aprons or gowns. The staff member responsible for laundry confirmed that only gloves were used, and no aprons or gowns were available in the laundry room, contrary to policy requirements for handling potentially contaminated linens. Multiple infection control breaches were observed during resident care and medication administration. A resident on contact isolation for ESBL in urine was allowed to participate in group activities and therapy without appropriate precautions, and therapy staff were unaware of the resident's isolation status. Hand hygiene was not performed by staff between glove changes or after providing care, and medical devices such as blood pressure monitors were not disinfected between uses on different residents. These lapses occurred despite facility policies requiring hand hygiene and equipment disinfection between resident contacts.
Failure to Provide Required Grooming Assistance to Resident Needing Moderate Support
Penalty
Summary
The facility failed to provide necessary assistance with grooming and personal hygiene for a resident who required moderate staff support due to multiple sclerosis, weakness, and moderate cognitive impairment. The resident's care plan and MDS indicated a need for moderate assistance with grooming, and her condition could fluctuate throughout the day. Despite these documented needs, observations over several days revealed that the resident had not received help with shaving, oral care, or washing her face and hands. The resident reported not being offered a shower or grooming assistance, and staff interviews confirmed that grooming care was expected on non-shower days, but there was no documentation of refusals except for one instance where a bed bath was provided instead of a shower. Physical observations showed the resident had visible whiskers on her chin and upper lip, stringy and matted hair, and a shiny face, indicating a lack of grooming. The resident stated she was not allowed to have a razor and had not been offered shaving assistance. Staff interviews revealed inconsistent accounts regarding when grooming and showers were provided, and documentation did not support claims of frequent refusals. Facility policies required regular assessment and assistance with shaving and grooming, but these were not followed as documented in the resident's records and observed condition.
Failure to Complete Required Quarterly Nutrition Assessment
Penalty
Summary
The facility failed to follow its policy to complete quarterly nutritional assessments for a resident with multiple medical conditions, including polyosteoarthritis, legal blindness, vitamin D deficiency, chronic gastritis, and nicotine dependence. The resident was cognitively intact and had a care plan identifying several nutritional risks, with a goal to maintain stable weight. Despite this, the electronic medical record showed that the last nutrition assessment by the Dietary Manager was completed in late October, and no further assessments were documented for nearly six months. The resident's weight steadily declined over this period, with a loss of over 11 pounds. During interviews, the Dietary Manager confirmed that quarterly nutrition assessments are required for residents not seen by the dietitian, and the Director of Nursing stated that the dietitian only evaluates residents with significant weight loss. The resident reported feeling that he was losing weight and was observed eating unassisted, dropping food onto his lap and tray without staff assistance. The facility's policy requires quarterly documentation and assessment in accordance with the MDS schedule, but this was not followed for the resident in question.
Failure to Monitor and Maintain Midline IV Catheter
Penalty
Summary
The facility failed to properly monitor and care for a midline peripheral intravenous catheter for a resident who was admitted with multiple diagnoses, including a lumbar vertebra fracture, dependence on renal dialysis, and gait abnormalities. The resident was receiving intravenous antibiotics and had a midline catheter inserted, but the transparent dressing covering the site was observed to have a gauze dressing underneath that was stained with dried blood and obscured the insertion site. The Director of Nursing confirmed the presence of the soiled gauze and acknowledged that the dressing should have been changed according to protocol. There was no care plan in place for the resident's midline intravenous line, and there was no documentation that the circumference of the resident's arm was being measured as required. Additionally, prior to a certain date, there was no evidence in the Medication Administration Record or Treatment Administration Record that the midline line was being flushed or monitored every shift. The facility's own policy required regular dressing changes, monitoring for infection and bleeding, and measurement of arm circumference, none of which were consistently documented or performed.
Failure to Timely Report Firearm Incident to Authorities
Penalty
Summary
The facility failed to report a suspicion of a crime involving a firearm being brought into the facility by a visitor, in violation of both facility policy and state law. A resident's daughter, who possessed a concealed carry license, left her purse containing a firearm in the resident's room after a visit. Upon realizing this at home, she called the facility and informed a nurse that her purse, which contained a firearm, needed to be secured. The nurse retrieved the purse and handed it to the Social Services Director, who then secured it in a locked office and notified the Administrator by text message. The Administrator later placed the purse in the facility safe. Despite being informed that a firearm was present in the facility, neither the nurse, the Social Services Director, nor the Administrator contacted local law enforcement or the Illinois Department of Public Health (IDPH) as required by facility policy and state law. The facility's policy mandates that law enforcement and the Department of Public Health be notified within 24 hours when there is a reasonable suspicion that a crime has been committed in the facility by a non-resident. The Administrator only reported the incident to law enforcement and IDPH after being questioned by a surveyor, well after the required reporting timeframe had passed. The resident involved was severely cognitively impaired, required extensive assistance with activities of daily living, and was unable to be interviewed due to hospitalization. The roommate of the resident was also immobile and unaware of the incident. Facility records and interviews confirmed that the firearm was not discovered or reported to authorities in a timely manner, as required by both facility policy and the Illinois Concealed Carry Firearms Act.
Failure to Investigate Firearm Incident in Accordance with Policy
Penalty
Summary
The facility failed to investigate an incident involving the presence of a firearm in accordance with its own policy and state regulations. A resident, who was severely cognitively impaired and dependent on staff for most activities of daily living, had a purse containing a firearm left at their bedside by a family member. The facility administrator was notified of the incident but did not initiate an investigation, document the occurrence, or report it to law enforcement or the Department of Public Health at the time. The administrator stated that he did not believe there was malicious intent and therefore did not follow the required procedures. The facility's policy required all incidents to be documented and investigated, including interviews with involved parties and submission of a final written report to the Department of Public Health within five working days. Despite these requirements, the administrator did not provide any investigation records, a timeline of events, interviews, or preventative measures related to the firearm incident. Additionally, there was no documentation of following state police guidelines for firearm safety, and the facility had signage indicating firearms were banned on the premises.
Failure to Conduct Care Plan Conferences
Penalty
Summary
The facility failed to hold care plan conferences with residents and their representatives, and did not invite them to participate in the care planning process. This deficiency was identified for all six residents reviewed in the sample. The facility's documentation showed that care plan meetings were not held quarterly or following significant changes in residents' conditions, as required. For instance, one resident with severe cognitive impairment had not had a care plan meeting documented since September 2024, despite multiple MDS assessments being completed afterward. Another resident, who was transitioned to hospice care, had not had a care plan meeting since September 2024, even though several MDS assessments were completed subsequently. Similarly, a resident with multiple diagnoses, including heart failure and psychosis, had only one documented care plan meeting since 2018, despite numerous MDS assessments. The lack of care plan meetings was consistent across all reviewed residents, indicating a systemic issue within the facility. The Director of Nursing acknowledged that the facility did not have a care plan coordinator and that no staff member was assigned to ensure care plans were conducted. The facility's admission packet stated that care planning conferences should involve residents and their families, but this was not being implemented. The facility administrator confirmed the absence of a policy regarding care plan meetings and the lack of a care plan coordinator, contributing to the deficiency.
Failure to Schedule Neuropsychological Testing as Ordered
Penalty
Summary
The facility failed to schedule neuropsychological testing for a resident as ordered by the neurology physician. The resident, who was admitted with multiple diagnoses including severe cognitive impairment, epilepsy, and mild vascular dementia, was seen by a neurologist who ordered neuropsychological testing to better understand the resident's brain function and aid in care planning. Despite the neurologist's order, the facility did not make the necessary appointment for the neuropsychological testing. The resident's electronic medical record and Minimum Data Set indicated severe cognitive impairment and a need for assistance with activities of daily living. Interviews with facility staff, including the Director of Nursing, confirmed that the neuropsychological testing was not scheduled. The facility's policy on processing physician orders requires that orders be confirmed and completed by a licensed nurse, but this was not adhered to in this case, leading to the deficiency.
Failure to Schedule Ophthalmology Appointment for Resident
Penalty
Summary
The facility failed to schedule an ophthalmology appointment for a resident as ordered by the neurologist. The resident, who was admitted with multiple diagnoses including severe cognitive impairment, epilepsy, and vascular dementia, was seen by a neurologist who recommended an ophthalmology referral due to visual impairment concerns. Despite this order being documented in the resident's medical records, the facility did not make the necessary appointment, as confirmed by the Director of Nursing. The resident's medical history includes significant cognitive and physical impairments, requiring assistance with daily activities and supervision. The neurologist's notes indicated the resident's cognitive challenges and the need for a neuro-ophthalmology referral, which was not acted upon by the facility. The facility's policy on processing physician orders was not followed, leading to the oversight in scheduling the required ophthalmology appointment.
Failure to Schedule MRI as Ordered by Neurologist
Penalty
Summary
The facility failed to ensure a resident received an MRI as ordered by the neurologist. The resident, who was admitted with multiple diagnoses including epilepsy, cognitive impairment, and other neurological and psychological conditions, was supposed to have an MRI scheduled around July 15, 2024, as per the neurologist's discharge instructions. However, the facility did not have documentation to show that the MRI was scheduled as ordered. The neurologist noted during a follow-up visit on November 25, 2024, that the MRI had not been completed, despite it being ordered previously. The Director of Nursing confirmed that the MRI was supposed to be completed before the resident's next visit on November 25, 2024, but it was not done until December 30, 2024, after the neurologist ordered it again. The facility's policy requires a licensed nurse to check and confirm any orders following a physician visit, but this process was not followed, leading to the delay in the MRI procedure.
Failure to Arrange Transportation for Resident's Medical Appointment
Penalty
Summary
The facility failed to ensure transportation arrangements were made for a resident with a scheduled physician follow-up appointment. The resident, who was admitted with multiple diagnoses including severe cognitive impairment, required assistance with various activities of daily living. The resident had a scheduled neurology appointment on March 17, 2025, which was documented by the neurologist. However, the facility's Transportation Log did not include this appointment, indicating that transportation had not been arranged. The Transportation Coordinator stated that it was the nurse's responsibility to inform them of appointments so that transportation could be arranged. In this case, the nurse did not communicate the resident's appointment to the Transportation Coordinator, resulting in the resident not being included on the transportation list. Consequently, the resident was at risk of missing the scheduled neurology appointment due to the lack of transportation arrangements.
Failure to Provide Adequate Tracheostomy Care and Emergency Supplies
Penalty
Summary
The facility failed to ensure that emergency-sized tracheostomy tubes were available for a resident who required tracheostomy care, leading to acute respiratory distress and emergency hospitalization. The resident, who had a history of nontraumatic subarachnoid hemorrhage, ruptured aneurysm, and acute respiratory failure, was admitted with a size 6 cuffed trach tube. However, during an emergency, the facility lacked the appropriate emergency tracheostomy exchange kits, and the available supplies were either expired or incorrect in size. Licensed nurses at the facility were not adequately trained to change tracheostomy tubes, which contributed to the deficiency. One nurse was unable to reinsert a new trach tube when the resident's tube decannulated, and another nurse was not trained to change entire trach tubes during an emergency. This lack of training and preparedness resulted in the resident being transferred to the hospital for acute hypoxemic respiratory failure, where the trach tube was eventually replaced by emergency paramedics. The facility's policies and procedures did not clearly outline the responsibilities of licensed nurses in reinserting trach tubes, nor did they provide instructions on how to perform the procedure. The Director of Nursing confirmed that the facility expected nursing staff to ensure that residents with tracheostomies have the required emergency supplies at the bedside, including trach tubes of the same size and a downsized tube, along with an obturator. However, these expectations were not met, leading to the resident's hospitalization.
Expired Food and Dishwashing Machine Sanitization Issues
Penalty
Summary
The facility failed to discard expired food items from the dry storage and did not follow dishwashing machine operation guidelines. During an initial tour of the kitchen, two one-gallon Worcestershire sauces were found to be expired. The Dietary Manager acknowledged the expired items and stated they would be discarded. The facility's food storage guidelines require discarding food past its expiration date and food prepared in the facility after seven days of proper refrigeration. Additionally, the facility did not ensure the dishwashing machine was sanitizing properly. The Dietary Aide ran the dishwashing machine, and upon testing, the sanitization test strip showed no color change, indicating it was not sanitizing. The Dietary Manager confirmed the issue and noted that the dishwashing machine should have a chlorine-based sanitization agent between 50 and 100 ppm. The dishwashing sanitization log had no entry for the observed date, contrary to the facility's guidelines requiring checks before first use and twice daily recordings of sanitizer concentration.
Failure to Assess and Monitor Self-Administration of Medications
Penalty
Summary
The facility failed to assess residents for self-administration and storage of medication, as well as notifying and ordering medications for residents who were self-administering. This deficiency was observed in four residents. One resident had a bottle of generic day time severe cold and cough medicine on their bedside table without a physician's order or care plan allowing self-administration. Another resident had several bottles of medications, including iron, Vitamin C, fish oil, and apple cider vinegar tablets, without any orders for self-administration or storage at bedside. A third resident had a medicine cup with red liquid for wound healing that had been left since the previous night, also without an order for self-administration. The fourth resident had an unlabeled bottle of Milk of Magnesia on top of their drawer, which they used for constipation without a physician's order or assessment for self-administration. The Director of Nursing (DON) confirmed that only one resident in the facility was allowed to self-administer medications and that the residents in question were not supposed to self-administer. The DON stated that an assessment should be completed for residents who wish to self-administer medications, and this should be documented in their medical record with a care plan initiated. The DON also mentioned that medications should be stored in a locked space in the resident's room for safety and that nurses should monitor residents taking their medications. The facility's policy on self-administration of medication requires a written order from the attending physician for a resident to administer or retain any medication in their room. The policy also states that medications should be labeled and come from the pharmacy. For medications brought from outside, the nurse should inform the physician and obtain an order to administer. The facility failed to follow these guidelines, resulting in residents having unauthorized and potentially unsafe access to medications.
Failure to Adhere to Smoking Policies and Care Plans
Penalty
Summary
The facility failed to assess and care plan residents that smoke per facility policy and did not ensure smoking materials were kept in the designated secure location. This deficiency was observed in five residents. One resident was found with an opened pack of cigarettes and matches on his bedside table, despite his care plan stating that smoking materials should be kept in the social service office. Another resident admitted to having cigarettes and a lighter in his pocket. A third resident had a cigarette and lighter in an unlocked nightstand drawer, contrary to his smoking safety risk assessment. A fourth resident had a carton of cigarettes on his bedside table, but his care plan did not address his smoking habits or the storage of smoking materials. The fifth resident was observed multiple times with cigarettes and a lighter on her bedside table and dresser, and her record lacked a smoking assessment and care plan. The Social Services Director confirmed that residents who smoke should have a yearly smoking assessment and quarterly reviews, along with a care plan addressing whether they are allowed to have smoking materials in their rooms. However, the facility did not adhere to these policies, resulting in residents having unsupervised access to smoking materials. This lack of compliance with the facility's smoking policy and care plans posed potential safety hazards for the residents involved.
Failure to Verify Controlled Medication Logs and Dispose of Medications Properly
Penalty
Summary
The facility failed to verify the accuracy of controlled medication counting logs and did not dispose of controlled medications per facility policy for four residents. Specifically, one resident's Pregabalin medication punch card had missing pills that were not logged in the control drug administration record, and there was no order for Pregabalin in the resident's medication review report. Another resident's Hydrocodone-APAP medication punch card had pill slots taped over with pills inside, contrary to the facility's policy for disposing of controlled medications. Additionally, two residents had their Lorazepam controlled drug administration record sheets wrapped around the medication bottles instead of being in the unit's narcotic control counting log binder, and one of these residents did not have an order for Lorazepam in their medication review report. During observations, the LPN and RN present were unsure why the controlled medication sheets were not in the appropriate binders and why the medications were not logged correctly. The Director of Nursing stated that she expected all controlled administration sheets to be kept in the medication cart's narcotic control sign-off binder and for nurses to verify the correct count during shift changes. The facility's policy on counting controlled substances emphasized the importance of verifying the accuracy of log sheets, ensuring the integrity of liquid medications, and properly disposing of controlled medications, which was not followed in these instances.
Failure to Provide Timely Incontinence Care and Proper Catheter Bag Positioning
Penalty
Summary
The facility failed to provide timely incontinence care to a resident dependent on toileting and failed to keep an indwelling catheter drainage bag off the floor. One resident was observed with a strong smell of urine, and upon further inspection, it was found that the resident's incontinent brief, shirt, and bed pad were soaked with urine. The resident's coccyx was red, indicating potential skin breakdown. The CNA provided incontinence care but did not apply barrier cream as required. The resident's care plan indicated the need for frequent checks and peri-care after each incontinence episode, which was not adhered to, leading to the observed condition. The DON confirmed that staff are expected to check for incontinence care at least every two hours to prevent skin breakdown and infection. Another resident was observed with an indwelling catheter bag on the floor without a privacy bag. The LPN acknowledged that the catheter bag should not be on the floor. The facility's urinary catheter care policy specifies that urinary drainage bags and tubing should be positioned to prevent contact with the floor, either directly or through a secondary containment device. This policy was not followed, leading to the observed deficiency.
Failure to Follow Respiratory Equipment Changing/Cleaning Policy
Penalty
Summary
The facility failed to follow its oxygen and respiratory equipment changing/cleaning policy for three residents. One resident, a [AGE] year-old male with moderately impaired cognition, was observed with his nasal cannula on the floor and a dirty humidifier, both without date/label. The resident mentioned that the staff did not care about changing the tubing, and he had filled the humidifier water chamber himself. A Licensed Practical Nurse (LPN) confirmed that the night shift is responsible for changing and labeling the tubing and filling the water reservoir, and that the oxygen tubing should be stored in a plastic bag. Another resident, a [AGE] year-old female with intact cognition, was observed with her nasal cannula hanging from a drawer knob instead of being stored in a plastic bag. The resident stated that she was not provided with a plastic bag for her nasal cannula. A third resident, a [AGE] year-old female with mild cognitive impairment, was observed with a nebulizer mask on the floor. An LPN confirmed that the nebulizer mask should be stored in a plastic bag and kept inside a drawer. The facility's policy requires weekly changes and proper storage of respiratory equipment, which was not followed in these cases.
Failure to Monitor and Document Resident Behaviors
Penalty
Summary
The facility failed to monitor and document behaviors and to develop and update care plans with interventions for residents with known behaviors related to mental disorders. Resident R61, who was diagnosed with psychosis, paranoid delusions, and dementia, exhibited behaviors such as believing he was being poisoned and refusing to eat. Despite these behaviors, the last documented Behavior/Mood Charting assessment for R61 was on 12/06/2023. Additionally, R61's care plan did not include interventions recommended by his inpatient psychiatric hospital discharge report, such as maintaining focus on reality or addressing his diagnosis of Major Depressive Disorder (MDD) and schizoaffective disorder. Interviews with staff confirmed the lack of documentation and appropriate care plan updates for R61's behaviors. Resident R1, diagnosed with schizoaffective disorder bipolar type, insomnia, generalized anxiety disorder, and vascular dementia with behaviors, was found in bed with his pants unzipped and a strong foul urine smell in the room. R1's roommate reported that R1 frequently urinated on the floor. Despite these behaviors, there was no documentation of behavior episodes in R1's Electronic Medical Record (EMR), and his care plan did not address the behavior of urinating on the floor. Interviews with staff, including the Director of Nursing (DON), revealed that the facility did not have a policy for behavioral monitoring, and there were no orders for behavior monitoring every shift for R1 and R61. The facility's failure to document and address these behaviors in the care plans led to the identified deficiencies.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 12%. During medication administration, an LPN administered insulin to two residents without following proper procedures. Specifically, the LPN did not prime the insulin pens before administering the doses and did not continue to press down the pens after injecting the doses before removing the needles. This was observed during the administration of 11 units of Aspart insulin to one resident and 12 units of Humalog insulin and 2 units of Lyumjev insulin to another resident. The Medication Review Reports for both residents confirmed the orders for the insulin doses. The manufacturer's instructions for the insulin pens, revised in August 2023, clearly state the need to prime the pen before each injection and to hold the dose knob in and count to five before removing the needle. The LPN's failure to follow these instructions led to the medication errors observed during the survey.
Failure to Administer Correct Medication Doses
Penalty
Summary
The facility failed to administer the correct doses of insulin medications to two residents and scheduled pain medication to another resident. Specifically, an LPN signed off on a resident's scheduled 9 AM Tramadol medication but forgot to administer it. The medication punch card confirmed that the dose was not removed. The resident had an order for Tramadol HCI Oral Tablet 50 MG to be given once daily for chronic pain. Additionally, another LPN administered incorrect doses of insulin to two residents. The LPN did not prime the insulin pens before administering the doses and did not continue to press down the pens after injecting the doses before removing the needles. This resulted in the residents potentially receiving incorrect doses of insulin. The Director of Nursing confirmed that the facility did not have a medication administration policy but expected nurses to administer medications as ordered and sign them off in the Medication Administration Record once completed.
Failure to Dispose of Expired Medications
Penalty
Summary
The facility failed to dispose of expired medications for two residents. During an inspection of the medication storage room, it was found that the refrigerator contained two bottles of Vancomycin liquid solution for one resident with expiration labels dated 4/01/2024. Additionally, the Medication Record Report (MRR) for this resident did not show an order for Vancomycin. Another resident's hospice kit in the same refrigerator contained expired medications, including Lorazepam oral solution, Scopolamine gel, and Vancomycin liquid solution, with expiration dates ranging from 12/31/2023 to 3/02/2024. The MRR for this resident showed an order for Lorazepam but not for Scopolamine and Vancomycin. The Director of Nursing confirmed that expired and discontinued medications should be removed and returned to the pharmacy for disposal. The facility's policy on medication storage, revised on 7/02/2019, aims to ensure proper storage, labeling, and expiration dates of medications. However, the observation revealed that the policy was not followed, leading to the presence of expired medications in the storage room. This deficiency was identified through observation, interview, and record review, highlighting a lapse in the facility's adherence to its medication management protocols.
Failure to Ensure Resident Safety with Substance Use Disorder
Penalty
Summary
The facility failed to ensure the safety of a resident with substance use disorder, identified as R2, who was involved in a serious accident while out in the community. Despite being hit by a car the previous day and presenting with alcohol on his breath, R2 signed himself out of the facility without being assessed for safe independent community access. This failure resulted in R2 being found on the side of the road by a bystander and requiring hospitalization for multiple injuries, including fractures of the ribs and elevated blood alcohol levels. Records indicate that R2 had a history of alcohol use, chronic pain syndrome, repeated falls, and multiple injuries related to alcohol intoxication. Despite being cognitively intact, R2 required supervision for all activities of daily living. The facility lacked proper documentation to show that R2 had a physician's order to consume alcohol or to be safe in the community without supervision, especially after the recent accident. Staff members, including nurses and physicians, were aware of R2's alcohol use and risky behavior but failed to take appropriate actions to ensure his safety. The facility's policies regarding community access and substance abuse were not effectively implemented, leading to R2 being granted independent pass privileges without meeting the necessary criteria. The lack of proper assessments, documentation, and supervision ultimately contributed to the serious accident and subsequent hospitalization of R2.
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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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