Arcadia Care Havana
Inspection history, citations, penalties and survey trends for this long-term care facility in Havana, Illinois.
- Location
- 609 North Harpham Street, Havana, Illinois 62644
- CMS Provider Number
- 145774
- Inspections on file
- 46
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 20 (3 serious)
Citation history
Health deficiencies cited at Arcadia Care Havana during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, impaired vision, osteoporosis, and multiple other comorbidities experienced two falls due to environmental hazards and equipment issues. In one incident, the resident reported that while attempting to lie down after walking in the hall, the bed moved because the brakes were not locked, causing the resident to fall to the floor. In another incident, the same resident, who wandered and actively sought exits, tripped over a mechanical lift that had been left in a hallway near a door, falling with their legs caught between the lift’s legs. These events occurred despite a facility fall prevention policy requiring locked bed brakes and hallways kept clear of clutter and hazards.
A resident with cervical stenosis and severe neck and knee pain had an MRI of the cervical spine ordered by a pain specialist, but the facility failed to ensure the test was completed. Facility policy assigns licensed nurses responsibility for arranging ordered diagnostic tests and monitoring results, yet the MRI was not performed as scheduled on two separate occasions, and there was no documentation explaining the missed appointment. The scheduler reported not being informed that the initial MRI was not completed or that it had been rescheduled, resulting in the resident not receiving the ordered imaging.
The facility failed to implement its infection prevention and control policies for scabies, including surveillance and contact precautions. Multiple residents had physician orders for antiparasitic topical medication for scabies, yet the infection surveillance report did not document parasitic or skin infections for these individuals. One resident with a widespread, itchy rash and numerous sores was diagnosed with scabies and treated, but there were no contact precaution orders, no isolation signage, and no PPE at the room entrance. A CNA and an LPN reported using only gloves or no PPE when entering rooms of residents treated for scabies and were unsure who was affected. The DON acknowledged that no skin scrapings were performed, surveillance records were not maintained for residents treated as scabies cases, and no isolation precautions were posted on doors, while the administrator stated they were unaware residents were being treated for scabies until informed by surveyors.
The facility failed to provide and document scheduled showers and hygiene assistance for several dependent residents, despite a policy and shower schedule requiring at least twice-weekly bathing. A resident with hemiplegia and dementia had multiple missed shower days and incomplete, unsigned shower sheets. Another resident with DM, stage 4 CKD, mobility issues, and an excoriation disorder had several undocumented shower days, was observed with blood-stained clothing, and reported not consistently receiving help with showers. A third resident with hemiplegia and chronic back pain lacked shower documentation on scheduled days, and the DON could not produce shower sheets. A fourth resident with dementia, morbid obesity, incontinence, and a history of UTIs had no bathing documentation over an extended period, was associated with a persistent urine odor in the room and hallway, and reported not receiving regular showers or in-bed washing when showers were missed; the DON confirmed the absence of required documentation for these residents.
The facility failed to reasonably accommodate two cognitively intact residents’ requests to electronically monitor their own rooms. One resident with hemiplegia, anxiety, and restless leg syndrome signed the required consent form but was subjected to additional corporate-imposed conditions, including paying a professional to install the camera, obtaining a private internet service, being prohibited from using the facility’s free Wi‑Fi (which is otherwise available to residents), and hiring a security company to monitor the feed. Another resident with MS, chronic pain, and PTSD, who is technologically savvy, was told he could not use a Bluetooth-based setup to view his room and was similarly informed he must use his own internet provider and a security company, even though his proposed system did not use the internet. These actions prevented both residents from exercising their right to use electronic monitoring devices in their rooms.
Staff engaged in a loud, profane, and physically violent altercation in a resident care area, during which a CNA yelled obscenities at an RN and then grabbed another CNA by the throat, slammed her into a doorway, and threw her to the floor while residents were present and within hearing distance. Several residents later reported being scared, upset, or angry after witnessing or learning of the incident, and nursing notes documented crying, fear, and a sad, worried affect in multiple residents. In a separate situation, a resident reported loaning a CNA money after she complained about her finances, and another resident reported being asked for money by the same CNA, raising concerns about potential exploitation despite the facility’s abuse and exploitation policy.
The facility failed to substantiate clear allegations of abuse and exploitation despite its own policy definitions and resident accounts. In one event, a CNA loudly cursed, threatened others, and physically pushed another CNA in front of multiple alert and oriented residents, leading to fear, crying, and ongoing distress documented in nursing notes. The Administrator acknowledged residents witnessed the incident but deemed it unsubstantiated because no resident was physically involved or directly threatened. In a separate event, a resident who manages his own finances reported loaning a CNA $50 that was not repaid, while another resident reported the same CNA had asked him for money; the CNA refused to participate in the investigation. The Administrator, despite describing both residents as reliable historians, concluded the allegation was unsubstantiated due to lack of proof of the loan and asserted it was not misappropriation because the money was offered voluntarily.
The facility did not ensure that all CNAs, including those from a temporary agency who made up about half of the CNA staff, received the required 12 hours of in-service training in areas such as dementia care and abuse prevention. The Administrator acknowledged having no documentation of any trainings completed by agency staff and confirmed that the temporary agency was treated as not responsible for the performance or training of its personnel. Several residents reported that agency staff did not know what was going on, did not seem to care, did not know the residents, and did only the bare minimum, reflecting concerns about the skills and preparedness of these CNAs.
The facility failed to maintain safe, comfortable temperatures in the dining room after the main heating unit malfunctioned, despite policies requiring operable heat and appropriate cold-weather measures. Staff, including RNs, CNAs, and dietary personnel, reported that the dining room had been extremely cold for weeks, with residents’ teeth chattering and residents needing coats, gloves, hats, and blankets while still complaining of being cold. A small wall-mounted heater was installed but was widely described as ineffective, and a long-standing unsealed, rusted door allowed a strong draft into the room. Multiple residents reported the dining room was "freezing," that they had to wear multiple layers and blankets, that it was hard to eat or they left meals early due to the cold, and one resident reported a sore throat. Surveyors observed an immediate temperature drop entering the dining room, residents bundled in outerwear during meals, and documented temperatures as low as 57°F via the maintenance director’s monitoring application, with no specific or documented temperature checks performed after the heating failure and prior grievances about heat issues lacking documented resolution.
A resident receiving short-term rehab, with cognitive deficits and a right femur fracture, was verbally abused by an agency CNA who swore at the resident and disregarded reported hip pain during a transfer, in the presence of the resident’s spouse. The CNA was described by staff and the spouse as rude, impatient, and berating toward the resident. The facility’s abuse prevention policy prohibits such conduct, and the CNA job description requires safeguarding resident welfare and interacting tactfully, yet the CNA’s file lacked documentation of abuse training.
The facility failed to maintain a safe transportation van, resulting in a resident and the resident’s family member being transported over a long distance in the dark and rain with non-functioning headlights and broken windshield wipers. The transportation driver reported that the van’s headlights had been dim or non-functional since he started work, that he had previously driven at night with the Maintenance Director in the same unsafe condition, and that the van had high mileage and persistent dashboard warning lights. During the trip with the resident, the driver had to travel slowly on the interstate due to poor visibility, and a CNA later observed that the resident and family member returned very upset and tearful. The Maintenance Director confirmed the headlights were burnt out, acknowledged difficulty replacing them, and was unable to produce maintenance records, while grievance logs noted headlight issues without documented resolution or follow-up.
The facility failed to maintain sufficient housekeeping, laundry, and maintenance staffing, resulting in chronically dirty resident rooms, overflowing trash, stained and feces‑smelling linens, and unclean linen storage areas. Staff reported that only one housekeeper or one laundry aide often covered the entire building, with no laundry staff on later shifts, leading to routine shortages of clean washcloths, bed pads, towels, and mechanical lift slings. A resident stated their sheets always smelled like feces, that they bought their own washcloths, and that their room had not been cleaned for weeks, while others described toilets overflowing into rooms with feces on the floor for extended periods. Surveyors observed damaged walls, missing or makeshift window coverings, and a flickering over‑bed light that had not been repaired. A mechanical lift was found extremely dirty and missing its emergency button, and staff reported residents being stuck in the air when batteries died and that one of two lifts had been broken for about a month, contributing to missed showers and transfers.
Surveyors found that the facility did not maintain adequate direct care staffing to meet residents’ ADL, hygiene, and hydration needs, and did not have a complete facility assessment specifying required direct care staffing levels. On multiple reviewed days, CNA staffing on day and night shifts was below the minimum numbers identified by the DON. Several residents who were dependent on staff for showers and personal hygiene did not receive scheduled showers, and some were observed with long, untrimmed fingernails. Despite a policy requiring fresh ice water at least three times daily, residents across all hallways were observed without bedside water and reported not receiving fresh ice water regularly, sometimes having to save water from meals. Numerous CNAs, LPNs, and RNs reported chronic understaffing, inability to complete showers and water passes, and prolonged call light response times, including nights with only one CNA or two CNAs for the entire building.
A resident's belongings or money were wrongfully used due to the facility's failure to provide adequate protection, resulting in unauthorized or inappropriate use.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not provide quarterly financial statements to residents or their representatives, as confirmed by interviews with a resident, a resident's Power of Attorney, and both current and former Business Office Managers. The administrator acknowledged the lapse, which affected all residents in the facility.
Following a change in facility ownership, all residents and their representatives did not receive or sign updated admission agreements within the required timeframe. The Business Office Manager did not ensure timely distribution and completion of these contracts, as confirmed by both record review and interviews.
A resident's unused trust fund balance was not refunded to their representative within the required 30-day period following the resident's death. Despite multiple requests from the resident's Power of Attorney, the facility had not returned the funds, and the Regional Director of Operations confirmed the delay and lack of a specific facility policy for timely distribution.
Multiple residents were left without access to disposable or cloth hand towels in their restrooms, and some bathrooms were found to be unclean, with issues such as black debris in toilet bowls and urine on floors. Residents reported going several days without towels, leading them to dry their hands on their clothes or not at all. Housekeeping staff and supervisors confirmed a facility-wide shortage of paper towels, and supply records indicated only one recent order. The administrator was unaware of the shortage until notified by staff.
A resident with multiple chronic conditions did not receive physician-ordered bilateral lower extremity compression stockings for edema, as staff failed to apply them as directed. The same resident also did not receive required nail care, resulting in long fingernails with visible debris, despite care plan instructions for hygiene assistance on bath days.
The facility failed to have an RN on duty for eight hours a day, seven days a week, affecting all 46 residents. The staffing data showed no RN coverage on multiple dates, including weekends and a holiday. The facility employs two RNs, including the DON, and relies on LPNs for weekend coverage. The DON confirmed staffing vacancies and the lack of agency RNs.
The facility failed to employ a Certified Dietary Manager and certified dietary staff, as observed during a survey. The Dietary Manager lacked a valid CDM certificate and had an expired food handler certificate, while other dietary staff also lacked necessary certifications. This deficiency affects the quality and safety of nutritional services for all 46 residents.
The facility failed to provide adequate staff during meal service, leading to delays in serving meals to residents in the dining room. Staff prioritized delivering room trays, leaving the dining room unattended. Residents expressed concerns about the delays and insufficient staffing during a council meeting.
The facility failed to label and date a bag of frozen zucchini and multiple loaves of bread as required by its food storage policy. During a kitchen tour, it was found that these items lacked a delivery, use-by, or expiration date. The Dietary Manager acknowledged the oversight, which has the potential to affect all 46 residents in the facility.
A facility failed to complete a PASARR Level I screening and Level II referral for a resident with unspecified psychosis and other conditions. The facility's policy mandates these screenings before admission, but documentation was missing. The MDS/Care Plan Coordinator noted the absence of records, possibly due to a change in facility ownership, and planned to verify the screenings with the relevant agency.
A facility failed to provide scheduled showers for a resident who requires assistance due to hemiplegia following a stroke. The resident only received bed baths, with no showers documented, despite expressing a desire for a proper shower. The facility's records showed showers were scheduled at midnight, leading to refusals and the resident not receiving any showers, contrary to the facility's policy.
The facility failed to maintain proper orders and labeling for respiratory equipment for three residents. One resident had outdated oxygen tubing and undated nebulizer tubing, another used a BiPAP machine without documented orders, and a third had undated nebulizer and oxygen tubing. These issues indicate non-compliance with the facility's policies on respiratory care.
A resident admitted with Polymyalgia Rheumatica and CHF did not receive timely specialized rehabilitative services as prescribed. Despite orders for therapy evaluations and treatments, the resident's physical therapy did not start until ten days post-admission, leading to frustration and disappointment. The delay in initiating therapy services resulted in a deficiency identified by surveyors.
The facility failed to make the state survey binder accessible to residents and inaccurately posted its location. During a resident council meeting, several residents were unaware of the binder's location. It was found outside the Administrator's office, obscured by other binders, with a note incorrectly stating it was at the nurses' desk. This affects all 46 residents.
The facility did not post daily staffing information, including total hours worked by nursing staff, as required. Observations on two occasions revealed outdated staffing information dated 3/15/25, despite being checked on later dates. The DON confirmed the oversight, noting the night nurse's responsibility for updating the information. This affects all 46 residents in the facility.
A resident with a history of traumatic brain injury and cognitive impairment experienced multiple falls due to inadequate fall interventions at the facility. Despite the facility's policy requiring individualized fall prevention strategies, the interventions remained ineffective, leading to injuries and hospital visits. Staff acknowledged the inadequacy of the interventions and the resident's impulsive behavior.
The facility failed to provide ongoing resident-centered activities, affecting all 40 residents, due to the sudden departure of the Activity Director. Observations and resident interviews confirmed the absence of scheduled activities, with residents expressing a desire to participate in activities like Bingo and music. The Social Service Director, newly assigned to the Activity Director role, confirmed the lack of activities and the vacancy left by the former Activity Director.
A Business Office Manager at an LTC facility misappropriated $11,815 from residents' pooled trust accounts over eight months by forging signatures and depositing funds into a personal account. The facility failed to monitor the trust account monthly, and several residents' signatures were forged on withdrawal logs. The lack of oversight and adherence to policies led to an Immediate Jeopardy situation.
The facility failed to report allegations of misappropriation of resident funds, affecting all residents reviewed. A Business Office Manager was suspected of making fraudulent charges and unauthorized withdrawals from residents' accounts, but the facility did not notify the police or state agency promptly. An audit revealed a significant deficit in the residents' pooled trust fund, and many residents were unaware of the misappropriation. This led to an Immediate Jeopardy situation.
The facility failed to investigate allegations of misappropriation of funds by the Business Office Manager, who was not removed from contact with residents during the investigation. This affected all residents reviewed, as the BOM allegedly made unauthorized withdrawals from residents' accounts. Despite reports from residents and the bank, the facility did not act promptly, resulting in a significant deficit in the residents' trust fund.
A resident developed a facility-acquired unstageable pressure ulcer on the right heel and a stage three ulcer on the right buttock due to the facility's failure to implement adequate pressure ulcer prevention and care interventions. Despite being at high risk, the resident did not receive necessary interventions such as daily skin checks, heel protectors, or proper repositioning, leading to the development and worsening of pressure ulcers.
The facility failed to hold Resident Council Meetings for five months, affecting all 36 residents. The absence of an Activity Director led to the cessation of meetings, leaving residents without a platform to voice concerns. Residents reported issues such as long wait times for call lights, cold meals, and inadequate staffing. The Administrator in Training was unaware of these complaints, and documentation showed repeated grievances without resolution.
The facility failed to maintain an adequate supply of washcloths and towels, forcing staff to use inappropriate substitutes for resident hygiene. Additionally, the main shower room's curtain was moldy, a condition known to staff for an extended period. Residents expressed dissatisfaction with the lack of basic hygiene supplies.
The facility failed to inform residents about the grievance process and did not address complaints raised in resident council meetings. Residents were unaware of how to submit grievances or who the grievance official was. Complaints about church services and outings were repeatedly voiced without resolution, affecting all 36 residents.
The facility failed to provide a consistent program of activities for residents, with no activities observed on several days and no activity staff employed for over two months. Residents expressed dissatisfaction, citing boredom and lack of engagement, while staff confirmed the absence of scheduled activities. The deficiency was compounded by the lack of updated activity assessments and care plans for residents.
The facility failed to employ a full-time Activity Director, resulting in a lack of scheduled activities, activity calendars, and resident council meetings for all 36 residents. Observations and interviews confirmed the absence of activities, with only a brief bingo session offered. The Social Service Director and Administrator-In-Training acknowledged the deficiency, citing the vacancy in the Activity Director position since March 2024.
The facility failed to provide sufficient nursing staff, resulting in delayed medication administration and incomplete treatments. An LPN reported being unable to complete all tasks due to being the only nurse on duty during certain shifts. Residents expressed concerns about the lack of morning staff, leading to late medications.
The facility failed to provide RN services for eight hours daily and lacked a DON to oversee the Nursing Department, affecting all 36 residents. The Nurse Master Schedule showed multiple days without RN coverage, and interviews confirmed the absence of a DON since February. The Facility Assessment Tool highlighted the need for a DON to support resident care.
The facility has not employed a Certified Dietary Manager since August 2023, leading to dietary aides managing kitchen operations without sufficient staff. This deficiency affects all 36 residents, as the aides struggle to handle additional responsibilities. The Administrator in Training confirmed the difficulty in filling the position.
The facility failed to maintain proper food storage and sanitation practices, leaving shredded ham unrefrigerated overnight and failing to label or date food items. The kitchen environment was not clean, with grime on equipment, dust on vents, and missing floor tiles. Improper storage of salt and paper goods was also noted, potentially affecting all 36 residents.
The facility failed to address resident complaints, maintain adequate staffing, and implement infection control practices. Residents reported a lack of church services and activities, while the facility lacked a full-time DON, Activity Director, and Dietary Manager. Infection control measures were inadequate, with staff not using protective gear for residents needing enhanced precautions. The facility also faced staffing shortages, insufficient linens, and broken dietary equipment, impacting resident care and services.
The facility failed to employ a licensed administrator to manage operations, with V1, the designated administrator, visiting infrequently. V2, an Administrator-In-Training without a license, has been managing the facility since November 2023. Staff confirmed V2 is the only administrator present, indicating a lack of proper oversight.
The facility failed to implement QAPI plans, leading to unresolved resident complaints, insufficient nursing staff, and inadequate training on QAPI, dementia care, and infection control. The absence of key department heads contributed to the lack of activities and unresolved grievances. Observations revealed improper infection control practices, equipment disrepair, and linen shortages. Interviews highlighted residents' dissatisfaction with services and staffing issues, while the administrator confirmed the lack of corrective plans.
The facility failed to have a DON or the required number of members at quarterly Quality Assurance Meetings, potentially affecting all 36 residents. The review of sign-in sheets over the past year showed the absence of a DON, with meetings having fewer members than required. The Administrator in Training confirmed this absence, and the facility's daily census documented 36 residents.
The facility failed to repair essential kitchen equipment, including ovens, a steam table, and a freezer door, affecting meal preparation for 36 residents. Staff reported these issues to the Administrator months ago, but no repairs were made, and there was no formal work order process. The Administrator in Training was unaware of the equipment failures, indicating a lack of communication and oversight.
Failure to Maintain Safe Bed Locks and Clear Hallways Resulting in Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe and functioning bed locks and a clear, hazard‑free pathway, resulting in multiple falls for one resident. The resident had severe cognitive impairment (BIMS 4/15), dementia with psychotic disturbance, Alzheimer’s disease, generalized anxiety disorder, depressive disorder, a history of TIA and cerebral infarction, osteoporosis, muscle wasting, protein calorie malnutrition, impaired vision, and required partial/moderate staff assistance with ADLs including bed mobility and transfers. The facility’s fall prevention policy required adherence to manufacturer recommendations for equipment, identification and removal of environmental hazards, keeping the environment free of clutter, and ensuring bed locks were checked and in the locked position at all times. Despite this, the resident reported that while attempting to lie down after ambulating in the hall, the bed moved because the brakes were not locked, causing the resident to roll off the bed onto the floor. Documentation identified that the bed brakes were not locked at the time of this fall. The deficiency also includes the facility’s failure to keep hallways clear of equipment, contributing to another fall for the same resident. The resident, who was described as confused, with impaired memory, using antipsychotic medication, and known to wander, be restless, and actively seek exits, was ambulating in a hallway and attempting to exit a nearby door when the resident tripped over a mechanical lift that had been left in the hallway. The resident was found on the floor with legs between the lift’s legs. The facility’s policy required that the environment be kept clear of clutter and hazards that could affect ambulation, but the mechanical lift was left in the hall walkway instead of being stored away, creating an obstacle in the resident’s walking path. These conditions led to two separate falls for the resident, one related to an unlocked or malfunctioning bed brake and one related to equipment obstructing the hallway.
Failure to Ensure Completion of Ordered MRI for Resident With Severe Cervical Pain
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician-ordered MRI of the cervical spine was obtained for a resident experiencing severe pain. The facility’s policy titled “Physician Notification of Laboratory/Radiology/Diagnostic Results” dated 12/2025 states that licensed nurses are responsible for notifying the laboratory of physician orders for testing and for monitoring receipt of test results so that prompt, appropriate action may be taken. A pain clinic progress note dated 3/19/26, signed by a pain specialist, documents that the resident, an older adult with cervical stenosis and right knee pain, reported severe cervical pain rated 10/10, with a range of 4–10, described as tender, exhausting, penetrating, miserable, and tiring, interfering with general activity, mood, walking, sleep, enjoyment of life, and relationships. The treatment plan included an MRI of the cervical spine without contrast. A subsequent pain clinic progress note dated 4/16/26 documents that the resident did not receive the MRI ordered on 3/19/26. On interview, the pain specialist’s medical assistant confirmed that at the 4/16/26 follow-up visit, the MRI had not been completed. A hospital X-ray technician reported that the resident was scheduled for MRI appointments on 4/9/26 and again the day before the 4/24/26 interview, but the resident did not show up for either appointment and therefore had not had the MRI. The social service director, identified as the scheduler, stated that they were not made aware that the resident did not receive the MRI on 4/9/26 and that there was no documentation explaining why the MRI was not done on that date. The social service director also stated they were not aware that the MRI had been rescheduled, resulting in the resident still not having received the ordered MRI.
Failure to Implement Scabies Surveillance and Contact Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the management of scabies. The facility’s policies required surveillance, documentation of suspected and confirmed infections, and implementation of contact precautions for transmissible conditions such as scabies and rash of unknown origin. Despite this, the Infection Surveillance Report from January 1, 2026, through March 24, 2026, documented no parasitic or skin infections, even though multiple residents had physician orders for antiparasitic topical medication (Permethrin) for Sarcoptes scabiei. The report only partially noted three residents as having been treated with antiparasitic medication without marking the parasite option, and it omitted several other residents who were treated for scabies during February and March. For one resident with extensive symptoms, documentation showed an itchy rash over most of the body, a request for dermatology referral, and a weekly skin observation noting a new rash over the body with physician notification. The medical director’s nurse stated that the medical director diagnosed this resident with scabies and ordered antiparasitic cream. The treatment administration record showed the antiparasitic medication was applied, and the resident was observed with numerous red, itchy sores on the chest, back, and arms, actively scratching. However, there were no physician orders for contact precautions in the electronic health record, and the resident’s room did not have contact precautions signage or PPE available at the door on the days of surveyor observation. Staff interviews further demonstrated a lack of implementation of required isolation precautions and surveillance. A CNA reported applying scabies cream to the resident while only wearing gloves and stated they usually did not wear PPE when entering rooms of residents treated for scabies and were unsure who had scabies. An LPN stated that no one had informed staff that the resident actually had scabies, acknowledged not using PPE when entering the room, and confirmed that the resident’s roommate had not been moved and that no contact isolation sign was posted. The DON stated that no skin scrapings had been done on any residents with scabies, that surveillance records were not being kept despite residents being treated as scabies cases, and confirmed that no isolation precautions were implemented on residents’ doors. The administrator stated they were unaware that any residents were being treated for scabies until informed by surveyors.
Failure to Provide and Document Scheduled Showers and Hygiene Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers or alternative bathing and to document these services for multiple dependent residents, contrary to its Bathing - Shower and Tub Bath Policy and posted shower schedule. The policy requires that residents be offered a shower, tub bath, or bed/sponge bath according to preference at least twice weekly and as needed, and the shower schedule lists specific days for each resident. For one resident with hemiplegia, chronic pain, dementia, and dependence on staff for bathing and grooming, the Section GG ADL report showed multiple missed scheduled shower days, and the available shower sheets were incomplete and lacked required nurse or DON signatures, including one sheet noting three refusals and pain without complete documentation. Another resident with Type II DM, stage 4 CKD, asthma, gait and mobility abnormalities, weakness, and an excoriation (skin-picking) disorder had a care plan indicating a need for supervision and assistance with bathing and showering. The GG ADL Lookback report did not show showers on several scheduled days, and only one shower sheet was found for the review period, which was incomplete and unsigned. During observation, this resident was found in bed with a shirt and protective sleeves stained with blood from scabs and reported having received only one shower more than a week prior, stating they did not always get help with showers on scheduled days and felt dirty when showers were missed. A third resident with hemiplegia, chronic back pain, disability-related activity limitations, and muscle disorder, requiring one to two staff for bathing and grooming, had no documented showers on two scheduled dates, and the DON confirmed that shower sheets for those dates were unavailable. A fourth resident with anemia, schizoaffective disorder bipolar type, morbid obesity, chronic pulmonary embolism, osteoarthritis, overactive bladder, bipolar disorder, major depressive disorder, heart disease, cervical spondylosis, and a history of UTIs had a care plan indicating dependence on staff for bathing and hygiene due to dementia, morbid obesity, and large skin folds. For this resident, there was no documentation of bathing or showers over a 10-day period, and surveyors repeatedly noted a strong, persistent malodorous urine smell in the resident’s room and hallway. This resident reported urinary incontinence, needing help to be changed and cleaned after episodes, not consistently receiving two showers weekly, and not being washed in bed when scheduled showers were missed. The DON confirmed that all residents are scheduled for twice-weekly showers and acknowledged the lack of documentation for the identified dates for all four residents.
Failure to Reasonably Accommodate Residents’ Requests for Electronic Room Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ requests to electronically monitor their own rooms, despite state guidance that residents have the right to purchase and use an electronic monitoring device after providing notice via the Electronic Monitoring Notification Consent Form. One resident (R1), who is cognitively intact with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, anxiety, and restless leg syndrome, reported that she requested electronic monitoring of her room and signed the required consent. She stated she was repeatedly told the facility was waiting for a response from corporate and that she was given a long list of requirements, which she felt were intentionally burdensome. The Social Services Director (V16) confirmed that R1 had requested electronic monitoring and had signed the consent, and further relayed corporate’s requirements that the resident pay a professional to install the camera, not use facility Wi‑Fi, obtain her own internet service, and contract with a security company to monitor the feed. At the same time, V16 confirmed that residents are allowed to use the facility’s Wi‑Fi at no charge for phones and laptops, and that the Maintenance Director typically hangs residents’ wall decorations and pictures. A second cognitively intact resident (R3), with diagnoses including multiple sclerosis, chronic pain, and post‑traumatic stress disorder, described using Bluetooth on his phone to connect to his TV for gaming and noted that, based on his prior work experience with Google, he was technologically savvy and could potentially view his room through his TV and phone. R3 stated that after he mentioned this capability to a CNA, the Social Services Director informed him he was not allowed to monitor his room without a consent form, which he agreed to sign, but she then told him he would have to use his own internet provider even though his proposed system did not use the internet. R3 expressed that he did not believe the facility should be able to require him to incur costs to monitor his own room. V16 confirmed she told R3 he could not monitor his room via Bluetooth and that any monitoring must be done through the resident’s own internet provider with a security company monitoring it for him. These actions and requirements resulted in the facility not allowing or reasonably accommodating the residents’ requests to electronically monitor their rooms.
Failure to Protect Residents From Abuse, Mental Distress, and Possible Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including mental abuse and exploitation, as required by its Abuse Prevention and Reporting policy. The policy defines abuse as the willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish, and mental abuse as verbal or nonverbal conduct that causes or has the potential to cause humiliation, intimidation, fear, or agitation. Despite this policy, a certified nurse aide (V5) engaged in a loud, profane, and aggressive altercation with staff in a resident care area, with residents present in the hallway and within hearing distance in their rooms. On the date of the incident, a registered nurse (V8) directed V5 to report to the dining room, which escalated into V5 yelling, cursing, and using profane, degrading language toward V8 in an area where residents were present and could hear. Another CNA (V7) intervened by telling V5 to stop yelling because she was scaring the residents. V7 reported that V5 then grabbed her by the throat, lifted her off the ground, slammed her into a door, and threw her to the floor. V8 similarly reported that V5 grabbed V7 by the throat, slammed her into a doorway, and flung her to the ground. The facility’s Final Abuse Investigation Report acknowledged that V5 raised her voice, used profanity, and pushed V7 with residents present, but concluded the allegation was not substantiated because no residents were physically involved in the altercation. Multiple residents later described fear, distress, and ongoing emotional impact from witnessing or being aware of the altercation. One resident recalled V5 beating up V7 and stated that the yelling and cursing were very scary. Another resident, who described himself as generally able to take care of himself, reported seeing V7 on the ground holding her neck and crying and expressed concern for residents who could not protect themselves. Nursing notes documented a resident with a sad and worried look, another resident crying and verbalizing fear after witnessing the altercation, and a resident stating he was struggling with having been a witness and was very angry about it. The administrator acknowledged that the whole building was in an uproar over the incident. In a separate matter, a resident reported loaning a CNA (V3) $50 after she complained about her money situation, and another resident reported that V3 had asked him for money but he refused; the administrator deemed this allegation unsubstantiated because the resident could not prove he had given the money, despite the facility’s policy defining exploitation as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion.
Failure to Substantiate Resident Abuse and Exploitation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to recognize and substantiate clear instances of abuse under its own Abuse Prevention and Reporting policy. The policy defines abuse as the willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish, and mental abuse as verbal or nonverbal conduct that causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, or degradation. It also defines exploitation as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion. Despite these definitions, the Administrator, who serves as the Abuse Coordinator, determined that two separate abuse allegations were not substantiated. In the first incident, the facility’s Final Abuse Investigation dated 1/23/26 documented that a CNA (V5) raised her voice, used profanity, and pushed another CNA (V7) in the presence of residents, with residents witnessing the altercation and staff member screaming, cursing, and threatening anyone who tried to calm her down. Multiple residents (R1–R7) later described being present or affected: one resident recalled the CNA “beating up” the other CNA and described it as very scary; another resident, who described himself as able to care for himself, expressed concern for residents who could not protect themselves; another resident reported the building was tense afterward. Nursing notes documented residents as alert and oriented, with one having a sad and worried look, another having episodes of crying and verbalizing fear related to witnessing the altercation, and another stating he was struggling with having been a witness and was very angry about it. The Administrator acknowledged that five residents were in the hallway and witnessed the attack but concluded the allegation was not substantiated because no residents were physically involved, none were within arm’s reach of the aggressor CNA, and the CNA did not specifically threaten to harm a resident. In the second incident, the facility’s Final Abuse Investigation dated 3/6/26 documented that a resident (R2) reported loaning a CNA (V3) $50, which she did not repay. R2, who manages his own finances and is described by the Administrator as alert, oriented, usually laid back, and not known to fabricate stories, stated he gave the CNA a $50 bill after she complained about her money situation. Another resident (R3), also described as alert, oriented, and not known to fabricate stories, reported that the same CNA had asked him for money, which he refused. The CNA in question refused to participate in interviews and made herself unavailable despite multiple attempts to contact her. Nonetheless, the Administrator determined the allegation was unsubstantiated, stating that R2 could not prove he had given the money or even possessed $50, and further asserted that it should not be considered abuse because the resident had offered the money on his own accord and, therefore, it was not misappropriation of funds.
Failure to Ensure Required In-Service Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including those provided by a temporary staffing agency, received the required 12 hours of in-service training, including dementia care and abuse prevention. Review of the Client Service Agreement between the facility and the temporary agency showed that the facility acknowledged agency CNAs as independent contractors and agreed that the agency was not their employer and was not responsible for their performance or non-performance. The agreement also documented that the agency had no responsibility for, control over, or involvement in the scope, nature, quality, character, timing, or location of the work performed by these CNAs. During the survey, the Administrator stated she did not have any documentation of trainings completed by the agency staff and confirmed she would not be able to provide any such documentation, noting that approximately 50% of the CNA staff were from the temporary agency. Interviews with residents further described concerns related to the care provided by agency CNAs. One resident stated that agency staff were "horrible" and did not seem to know what was going on. Another resident reported that agency staff did not care and had no idea what they were doing. A third resident stated that agency staff did not know anything about the residents and always did the bare minimum. These resident statements, combined with the lack of training documentation and the facility’s reliance on agency CNAs for about half of its CNA staffing, formed the basis of the deficiency related to failure to ensure required in-service training for all CNAs.
Failure to Maintain Safe and Comfortable Temperatures in Dining Room After Heating System Failure
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, comfortable temperature in the dining room during very cold winter weather and after a primary heating unit malfunctioned. The facility’s own Code White-Extreme Weather Policy requires notification of the Maintenance Director and Administrator for heating failures, movement of residents to adequately heated areas if a unit fails or temperatures become uncomfortable, and ensuring the heating system is operable with extra blankets available. Resident rights documents state that residents must be kept safe, comfortable, and in a homelike environment that promotes quality of life. Despite these policies, the main dining room heating unit stopped working correctly, and the Maintenance Director acknowledged there were no maintenance records for the unit and that only random temperature checks were done, with no specific or documented monitoring of dining room temperatures after the unit failed. Staff interviews and observations showed that the dining room remained uncomfortably cold for weeks while residents continued to be served meals there. Multiple CNAs and nursing staff reported that the dining room was “freezing,” that residents’ teeth were chattering, and that residents had to wear coats, gloves, stocking hats, and use extra blankets, which still did not alleviate the cold. Staff stated that management required them to bring residents to the dining room for meals despite the cold and that they would “get into trouble” if they did not. Dietary staff confirmed that all or many residents complained daily about the cold, that a small wall-mounted space heater had recently been installed but “did not help at all,” and that they were keeping the kitchen door open and placing blankets in window sills to try to reduce drafts. A door near the serving window, which had not been used for years, was observed and acknowledged by the Maintenance Director to be rusted, not sealed correctly, and allowing a noticeable draft into the dining room. Residents consistently reported that the dining room was extremely cold, that they had to wear multiple layers and blankets, and that it was uncomfortable to eat under these conditions. Several residents stated they had stopped going to the dining room or left meals early because of the cold, with one resident reporting developing a sore throat and another stating they did not finish breakfast due to the temperature. On-site observation on the survey date confirmed an immediate temperature drop when entering the dining room from the hallway and a cold draft from the unsealed door. The Maintenance Director’s phone application showed a low temperature of 57°F in the dining room over a recent 24-hour period, and spot checks during the survey showed temperatures in the high 60s°F while approximately 25 residents sat in the dining room wearing coats and blankets before lunch. The Administrator initially stated being unaware of the cold conditions and later stated not being involved with the heating issue because the Maintenance Director was handling it with corporate, despite multiple prior grievances about heat issues documented in the facility’s grievance logs without recorded resolution or follow-up notification.
Failure to Protect Resident From Verbal Abuse by Agency CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a staff member. According to the facility’s abuse prevention and reporting policy, the facility affirms residents’ rights to be free from abuse and prohibits abusive behavior, including verbal abuse. Despite this, an agency CNA (V8) engaged in a verbal altercation with a resident (R1), who was a short-term rehabilitation patient with altered cognitive deficits (BIMS score 12/15) and diagnoses including a right femur fracture and COPD. During a transfer, V8 swore at the resident and disregarded the resident’s reported hip pain, demonstrating a poor attitude and impatience. The incident was witnessed by the resident’s spouse (V14), who observed that the CNA was very rude and impatient with the resident. Staff, including a registered nurse (V4) and the administrator (V1), reported that the CNA was cussing at and berating the resident in the presence of the spouse. The CNA’s employee file documented termination for verbally abusing a resident but did not contain documentation of abuse training, despite the facility’s CNA job description requiring safeguarding residents’ health, safety, and welfare, demonstrating tact with residents and families, and knowledge of public health regulations. These circumstances show that the resident was subjected to verbal abuse by a staff member, contrary to facility policy and job expectations.
Failure to Maintain Safe Transportation Van for Resident Travel
Penalty
Summary
The facility failed to ensure its transportation van was properly maintained and safe for resident transport, resulting in use of a vehicle with non-functioning headlights and broken windshield wipers during resident trips after dark and in the rain. The transportation driver reported that when he started employment in early November 2025, the van’s headlights were already not working properly and that he had been instructed to drive with the bright lights on because the regular headlights were very dim. He described a late appointment in November and a subsequent nighttime hospital transport around Christmas, both over an hour away, during which he and the Maintenance Director drove in the dark with improperly functioning headlights and nearly struck three deer. The driver stated the van had almost 300,000 miles and dashboard warning lights that remained illuminated, and that he continued to drive the van but did not want to drive it after dark. For a later appointment involving one resident (R3), the driver transported the resident and the resident’s daughter more than an hour away and returned in the dark while it was raining, using the same van with non-functioning headlights and broken windshield wipers. The driver reported having to drive approximately 40 miles per hour on the interstate due to these conditions and described the trip as very scary for both himself and the resident’s daughter. A CNA confirmed that upon return from this van ride, the resident and the daughter were very upset, and the daughter was crying. The Maintenance Director acknowledged that the transport van’s headlights were burnt out, stated he had been notified after the daughter complained, and indicated he had attempted but was unable to replace the headlights himself. He also could not provide maintenance records for the van. The facility’s grievance tracking logs documented issues with the headlights but did not include a resolution date or follow-up notification.
Failure to Maintain Adequate Housekeeping, Laundry, and Maintenance Resulting in Unsanitary Environment and Equipment Issues
Penalty
Summary
The deficiency involves the facility’s failure to employ and schedule sufficient maintenance, custodial, laundry, and housekeeping staff to maintain a safe, clean, comfortable, and homelike environment for all 58 residents. The facility assessment referenced support staff such as plant operations, custodians, housekeeping, and maintenance, but did not include an addendum specifying the staffing plan or number of staff needed for maintenance, housekeeping, and laundry services. Housekeeping/laundry schedules showed that only one laundry aide worked eight hours on 12 of 15 days reviewed, and only one housekeeper worked eight hours on 7 of 15 days, leaving large portions of time and shifts without coverage. Staff interviews consistently reported that there were not enough housekeepers or laundry staff, especially on second and third shifts, and that CNAs did not have time to perform laundry duties. As a result of this inadequate staffing and scheduling, the facility was not kept clean and free of odors, and there were persistent shortages of clean linens and mechanical lift slings. Multiple clean linen storage rooms were observed to be dirty, with floors covered in brown staining, trash, and debris, sinks with rust or white buildup, missing floor tiles, and overflowing trash cans. Linens stored in these rooms, including towels and sheets, were stained a light brown color and smelled of feces, and there were no clean washcloths or bed pads available in some areas. Staff and residents reported that linens frequently arrived stained, dirty, or smelling of feces, and that clean washcloths, bed pads, towels, and slings were routinely unavailable in the mornings. CNAs and nurses stated they often had to use towels instead of washcloths to clean residents, dig through dirty laundry to find the “least dirty” sling, or encountered “clean” washcloths with feces still on them. The lack of adequate housekeeping and maintenance also led to resident rooms and bathrooms not being cleaned daily and to physical plant disrepair. Observations showed resident rooms with scattered debris, overflowing trash cans, stained cubicle curtains, missing chunks of drywall, exposed unpainted drywall patches, cracked and bulging drywall above heating/cooling units, and a flickering over‑bed light that had been ongoing for weeks. Residents reported that their rooms and floors were always dirty, that their trash was always full, and that housekeepers were not able to clean their rooms every day. Several residents described toilets that overflowed into their rooms for weeks before being fixed, resulting in water and feces (“turds”) on their floors. One resident stated their sheets always smelled like feces, that they had purchased their own washcloths because they refused to use the facility’s, and that they had not had a housekeeper clean their room since early in the month. In addition, the facility failed to ensure that mechanical lifts and related equipment were adequately maintained and available. The manufacturer’s manual specified that the emergency red button is used when the control unit is not functioning and that a person can be lowered by pulling the red quick release lever in a power failure. During demonstration, the mechanical lift’s emergency button was found to be missing, and the lift’s legs were covered in debris and brown stains. The maintenance supervisor acknowledged not realizing the emergency button was missing and was unsure who was responsible for cleaning the lift, while a CNA reported that residents had been stuck in the air when batteries died and that there were not enough batteries to keep the lift functioning. Staff also reported that one of two full mechanical lifts had been broken for about a month, leaving only one working lift for multiple residents who required mechanical lift transfers, and that showers and transfers were missed when slings and clean linens were unavailable. Environmental observations further showed that the facility did not provide a homelike environment. On the memory care unit, two dining room windows lacked blinds or curtains and instead had see‑through bed sheets tacked up unevenly, covering only part of the windows. A concern form from a visitor described sheets hanging on dining room windows as “very tacky” and noted the absence of pictures on the walls. Another resident reported never having curtains and therefore hanging a bedspread over the window to block the sun. These conditions, combined with the dirty linen rooms, stained and foul‑smelling linens, unclean resident rooms, and unrepaired fixtures, demonstrate that the facility did not honor residents’ rights to a safe, clean, comfortable, and homelike environment and did not provide treatment and supports for daily living in a safe and sanitary manner.
Failure to Ensure Adequate Direct Care Staffing, Hydration, Hygiene, and Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate direct care staffing and to operationalize a facility assessment that specified the number of direct care staff needed daily to meet resident needs. The facility’s assessment tool referenced an addendum for direct care staffing needs, but no such addendum existed, leaving the facility without a defined staffing plan for direct care staff. The Director of Nursing later stated that specific numbers of CNAs were needed on each shift to meet resident needs, and confirmed that the facility was unable to staff those minimum numbers on multiple days. Review of CNA schedules and time sheets for selected dates showed that the number of CNAs actually working on day and night shifts was below the stated minimums. The facility also failed to provide scheduled showers and basic hygiene as outlined in residents’ care plans and facility policies. Multiple residents had care plans and MDS assessments indicating dependence on staff for showers and personal hygiene, as well as preferences or schedules for showers on specific days. Documentation showed missed showers on scheduled days, including one resident whose shower report explicitly cited lack of staff as the reason a scheduled shower was not given. Another resident submitted a written concern stating they were not getting showers and that it had been another whole week without one. During observations, residents were noted with long, jagged fingernails and reported not receiving showers or nail care as expected. The facility further failed to follow its hydration policy requiring fresh cold ice water to be provided to each resident at least three times daily. During tours of all four hallways, no residents were observed with fresh ice water at the bedside, and several residents reported they did not receive fresh ice water every shift or at all, and that they had to save water from meals to have water in their rooms. Residents also reported that call lights often remained on for long periods, sometimes over an hour, before being answered. Multiple CNAs, LPNs, and RNs consistently reported that there were not enough CNAs on various shifts, that showers and ice water passes were frequently not completed, and that call lights could not be answered promptly due to low staffing, including reports of nights with only one or two CNAs for the entire building. These observations, interviews, and record reviews collectively show that the facility did not ensure adequate numbers of direct care staff to complete daily ADLs such as showers, nail care, hydration, and timely response to call lights for the 58 residents in the building. The failures occurred despite facility policies requiring at least weekly bathing and a minimum of three daily fresh ice water passes, and despite care plans directing staff to encourage oral fluids and maintain fresh ice water at the bedside for residents with urinary alterations and risk for dehydration.
Failure to Protect Resident's Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report notes that there was a failure to safeguard a resident's personal property or funds, resulting in unauthorized or inappropriate use. Specific actions or omissions by facility staff led to this breach, directly impacting the resident's rights and property. No additional details about the resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Quarterly Financial Statements to Residents and Representatives
Penalty
Summary
The facility failed to provide quarterly financial statements to residents and their representatives as required by its own policies and procedures. Record review and interviews revealed that neither residents nor their representatives received these statements, with one resident's Power of Attorney and another resident both confirming they had never received such documentation. The prior Business Office Manager admitted to not sending out quarterly statements during her tenure, citing workload issues, and the current Business Office Manager, who had recently started, also had not sent out any statements. The facility's administrator acknowledged that the previous Business Office Manager was terminated in part for not fulfilling this responsibility. At the time of the survey, 44 residents resided in the facility, all potentially affected by this deficiency.
Failure to Provide Updated Admission Agreements After Change of Ownership
Penalty
Summary
The facility failed to promptly provide updated admission agreements or contracts to all residents and/or their representatives following a change in facility ownership. Record review showed that, as of the date of ownership change, 34 residents were residing in the facility, but none received the updated admission agreement within 30 days. The Business Office Manager's job description and policy required ensuring that resident admission contracts are signed and appropriately filed, but this was not carried out in a timely manner. Interviews confirmed that residents and their representatives did not receive or sign the updated admission contracts immediately or within the required timeframe after the change of ownership. For example, a resident's guardian stated that the admission contract was not signed until months after the new ownership took effect. The Administrator also verified that none of the residents' admission contracts were provided or signed within the expected period following the ownership transition.
Failure to Timely Refund Resident Trust Funds After Death
Penalty
Summary
The facility failed to refund unused resident funds to a resident's representative within 30 days of the resident's death, as required by guidelines. Record review showed that a resident was transferred to the hospital and subsequently passed away. The resident had $420 remaining in the facility's trust fund account, which had not been spent or used for several months prior to death. Despite repeated requests from the resident's Power of Attorney, the facility had not refunded the remaining funds as of the time of the survey. The Regional Director of Operations confirmed that there was no facility policy specifying when trust funds should be distributed, but acknowledged that the funds should have been returned within 30 days according to CMS guidelines.
Failure to Maintain Sanitary and Homelike Resident Restrooms
Penalty
Summary
The facility failed to maintain a sanitary and orderly environment for residents by not providing disposable or cloth hand towels in resident restrooms and by not ensuring the cleanliness of certain resident bathrooms. Observations revealed that nine residents did not have access to disposable or cloth hand towels or washcloths in their restrooms. Multiple residents reported that they had been without paper towels for several days, leading some to dry their hands on their clothes or simply shake their hands dry. Additionally, two residents' bathrooms were found to be unclean, with one commode bowl described as black-tinged with debris and another with a raised seat riser and surrounding area covered in black and brown debris, which a resident believed to be mold. Interviews with residents confirmed the ongoing lack of hand towels, with several stating that the dispensers had not been refilled for days and that they sometimes had to request towels without success. One resident, who serves as the Resident Council President, noted the absence of towels and the presence of urine and debris on the bathroom floor. Housekeeping staff confirmed the lack of paper towels on their supply carts, and the main supply closet was found to be out of stock. The Housekeeping/Maintenance/Laundry Supervisor acknowledged the shortage, attributing it to a delayed shipment and the recent holiday weekend, and verified that some rooms had not been restocked. Facility documentation, including the Resident Rights policy, Housekeeper job description, and Facility Assessment, all require the maintenance of a clean, safe, and homelike environment, as well as the provision of body cleansing products and hand hygiene supplies. Despite these requirements, supply purchase records showed only one recent order for paper towels, and the administrator was unaware of the extent of the shortage until it was brought to their attention. The deficiency was further compounded by the inexperience of the staff member responsible for ordering supplies, who was new and managing multiple departments.
Failure to Follow Physician Orders and Provide Basic Nail Care
Penalty
Summary
The facility failed to follow physician orders and provide basic care for a resident with multiple medical conditions, including chronic kidney disease, osteoarthritis, repeated falls, muscle disorder, abnormal gait, anemia, zoster, major depressive disorder, and dementia. The physician order sheet specified that compression stockings were to be applied to both lower extremities in the morning and removed at night to address edema. However, during multiple observations, the resident was found with swollen legs exhibiting moderate pitting edema and was not wearing the prescribed compression stockings. The resident confirmed that staff were not applying the stockings as ordered. Additionally, the resident's care plan required staff assistance with personal hygiene, including checking, trimming, and cleaning fingernails on bath days and as necessary. Despite this, shower records did not indicate that nail care was provided, and the resident was observed with long fingernails containing a moderate amount of black dry debris. The resident stated that their nails had not been cleaned, and the administrator verified the presence of debris, acknowledging that nail care should have been performed during the most recent shower.
Failure to Maintain Required RN Staffing Levels
Penalty
Summary
The facility failed to maintain the required staffing levels by not having a Registered Nurse (RN) on duty for eight hours a day, seven days a week, which is a regulatory requirement. This deficiency potentially affects all 46 residents in the facility. The facility's assessment, updated on March 1, 2025, indicated an average daily census of 40 residents and documented the need for RN coverage on the day shift. However, the State Payroll Based Journal Staffing Data Report for the quarter from October 1 to December 31, 2024, showed no RN hours on multiple dates, including weekends and a holiday. Additionally, daily staffing sheets for January through March 2025 confirmed the absence of RN coverage on several dates. The facility employs ten nurses, of which only two are RNs, including the Director of Nursing (DON) and another RN. The DON confirmed that there are three nursing vacancies and that no RNs are available through agencies. The facility relies on Licensed Practical Nurses (LPNs) to cover weekend shifts when the sole RN does not work. The DON also verified that she does not cover the RN shifts on weekends. The facility's administrator stated that the current management took over the nursing home on November 1, 2024, which coincides with the start of the documented staffing deficiencies.
Lack of Certified Dietary Staff in Facility
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills in the food and nutrition service department, as evidenced by the absence of a Certified Dietary Manager (CDM) and certified staff. During the survey, it was observed that the facility's Dietary Manager (DM) did not possess a valid CDM certificate and had an expired food handler certificate. Additionally, the facility was unable to provide food handler certificates for any of the dietary staff, including dietary aides and cooks, indicating a lack of compliance with required certifications. The deficiency was further highlighted during a meal delivery service where dietary staff, including the DM and dietary aides, were observed preparing and serving food without the necessary certifications. The facility's job descriptions for dietary roles emphasize the need for compliance with federal, state, and local standards, yet the lack of certified staff suggests a failure to adhere to these standards. This deficiency has the potential to affect all 46 residents residing in the facility, as it compromises the quality and safety of nutritional services provided.
Insufficient Staffing During Meal Service
Penalty
Summary
The facility failed to provide sufficient staff during meal service, affecting the timely delivery of meals to residents. On March 18, 2025, during the 11:00 AM meal service, staff were observed filling meal carts for residents who eat in their rooms and subsequently left the dining room unattended to serve these meals down the hallways. This left no staff available to serve the residents who were seated in the dining room, resulting in delays. The Dietary Manager confirmed that room trays are prioritized, and due to insufficient staffing, residents in the dining room have to wait for their meals. During a resident council meeting on March 19, 2025, five residents expressed concerns about the delays in receiving their meals in the dining room. They reported that the staff is occupied with serving room trays first, which leads to insufficient staff available for dining room service. The residents noted that attempts to serve the dining room first were unsuccessful, and they emphasized the need for a solution to the staffing issue during meal times.
Food Storage and Labeling Deficiency
Penalty
Summary
The facility failed to comply with its food storage policy, which requires all foods to be covered, labeled, and dated. During a kitchen tour, it was observed that a bag of frozen zucchini and multiple loaves of bread lacked a delivery, use-by, or expiration date. The Dietary Manager acknowledged the oversight, noting that the bread was expected to have a date and that the zucchini had been removed from its box that day. This deficiency has the potential to affect all 46 residents residing in the facility, as proper food labeling is crucial for ensuring food safety and quality.
Failure to Complete PASARR Screening for Resident
Penalty
Summary
The facility failed to ensure that a PASARR Level I screening and/or Level II referral were completed for a resident reviewed for PASARR screenings. The facility's policy requires that all potential admissions undergo a PASARR Level I screening to determine if the individual meets the criteria for a mental disorder or intellectual disability. If the Level I screening indicates such conditions, a Level II screening must be requested before admission. However, the facility did not have documentation of a PASARR screening for the resident, who was admitted with diagnoses including unspecified psychosis, COPD, alcohol dependence, and other conditions. The Minimum Data Set/Care Plan Coordinator acknowledged the absence of the required PASARR documentation and noted that the facility had undergone a change in ownership, which may have contributed to the missing records. The coordinator was unable to locate the Level I screening that should have been completed prior to the resident's admission and recognized that a Level II screening referral should have been made due to the resident's psychosis diagnosis. The coordinator expressed intent to follow up with the relevant agency to verify if the screenings were conducted and to obtain copies.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate assistance for activities of daily living (ADL) related to hygiene and scheduled baths for a dependent resident, identified as R4. The facility's policy mandates that residents should be offered a shower, tub bath, or bed/sponge bath at least once a week or according to their preference. However, R4, who requires assistance due to hemiplegia/hemiparesis following a stroke, did not have a scheduled shower day or time documented. The facility's records showed that R4 only received bed baths and no showers were documented during the period reviewed. Observations and interviews revealed that R4 had not received a proper shower since before Christmas, despite expressing a desire to get out of bed and into the shower. The Corporate Regional Nurse Consultant admitted that R4's showers were scheduled for midnight, leading to documentation of refusals and resulting in R4 not receiving any showers. This lack of proper hygiene assistance was evident as R4 was observed with unkempt and oily hair, indicating a failure to maintain the resident's cleanliness and dignity as per the facility's policy.
Failure to Maintain Proper Orders and Labeling for Respiratory Equipment
Penalty
Summary
The facility failed to maintain proper orders and labeling for respiratory equipment for three residents. One resident had an order for oxygen at 3 liters via nasal cannula, with instructions to change the oxygen tubing weekly. However, the oxygen tubing was dated from February, and the nebulizer tubing was not dated, indicating a failure to adhere to the facility's policy of changing and labeling respiratory equipment. Another resident had a BiPAP machine in use every night, but there were no medical orders documented for its use, which is a critical oversight in ensuring proper respiratory care. Additionally, a third resident had a CPAP machine, nebulizer, and oxygen at 4 liters via nasal cannula, with orders to change the oxygen tubing and humidifier weekly. However, the nebulizer and oxygen tubing were not dated, and the nebulizer was not stored in a bag as required. These deficiencies highlight a lack of compliance with the facility's own policies regarding the maintenance and documentation of respiratory equipment, potentially compromising the quality of care provided to the residents.
Failure to Provide Timely Specialized Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services to a resident, identified as R191, who was admitted with a medical diagnosis of Polymyalgia Rheumatica and Congestive Heart Failure. Upon discharge from the hospital, R191 was recommended to receive physical therapy 1-2 times per day, Monday through Friday, for two weeks. The treatment plan included gait training, mobility, transfers, strength, range of motion exercises, education, family training, and balance activities. However, despite the physician's orders for occupational, physical, and speech therapy evaluations and treatments as indicated, R191's physical therapy evaluation and plan of treatment did not commence until 3/14/25, which was ten days after the resident's admission. During an interview on 3/21/25, R191 expressed disappointment and frustration over the delay in starting therapy, stating that they did not receive therapy for two weeks and were considering leaving the facility. The resident began receiving therapy on 3/17/25, with sessions documented on 3/17, 3/18, 3/20, and 3/21/25. The delay in initiating the prescribed therapy services resulted in a failure to meet the resident's rehabilitative needs as outlined in the hospital discharge plan, which was a contributing factor to the deficiency identified by the surveyors.
Inaccessible State Survey Binder
Penalty
Summary
The facility failed to make the state survey book or binder readily accessible to residents, family members, and legal representatives, and did not accurately post the location of the survey book. This deficiency was identified during a resident council meeting where five residents expressed that they were unaware of the survey binder's location. Upon investigation, the survey binder was found outside the Administrator's office, obscured by other binders, with its label not visible. Additionally, a note on a communication board incorrectly indicated that the survey book was located at the nurses' desk. The Administrator later confirmed the binder's location outside their office at the front entrance. This oversight has the potential to affect all 46 residents residing in the facility.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily staffing information, including the total number of actual hours worked by both licensed and unlicensed nursing staff. This deficiency was observed on two separate occasions, where the staffing information posted at the front entrance was outdated, showing a date of 3/15/25, despite the observations being made on 3/19/25 and 3/21/25. Additionally, the posted staffing sheet lacked the total hours worked for the date of 3/15/25. The Director of Nursing (DON) confirmed the oversight and acknowledged that the staffing information should have been updated daily, with the night nurse being responsible for posting the next day's staffing information. This failure potentially affects all 46 residents residing in the facility, as documented in the Department of Health and Human Services Centers for Medicaid and Medicare Services Form 671.
Failure to Implement Effective Fall Interventions for Resident
Penalty
Summary
The facility failed to implement resident-specific fall interventions for a resident with a history of falls, resulting in multiple injuries requiring hospital treatment. The facility's Fall Prevention Program Policy mandates assessing individual resident needs and implementing appropriate interventions, but this was not adequately followed for the resident in question. The resident, who has a history of traumatic brain injury, cognitive impairment, and mobility issues, experienced several falls, some resulting in lacerations and hospital visits. The resident's care plan acknowledged the risk factors, including decreased mobility and impaired cognitive function, but did not document specific interventions for each fall. Despite multiple incidents, the interventions remained largely unchanged and ineffective, such as encouraging the resident to use a call light, which was not within reach during observations. The resident's roommate and staff acknowledged the frequent falls and the inadequacy of the interventions. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, revealed an awareness of the resident's impulsive behavior and the ineffectiveness of the current interventions. The staff admitted that the interventions were not appropriate for the resident's needs, indicating a lack of proper assessment and adjustment of fall prevention strategies as required by the facility's policy.
Lack of Resident-Centered Activities Due to Vacant Activity Director Position
Penalty
Summary
The facility failed to ensure that ongoing resident-centered activity programs were being offered, affecting all 40 residents. The facility's Resident Rights Policy emphasizes the importance of providing services that promote residents' quality of life, including participation in social and community activities. However, observations on multiple occasions revealed that no scheduled activities were being conducted. Interviews with residents confirmed the absence of activities, with several expressing their desire to participate in activities such as Bingo and music, which were not available. The lack of activities has been ongoing for over a week, as noted by the Resident Council President and other residents. The deficiency was further compounded by the absence of an Activity Director. The Social Service Director, who recently started working at the facility, confirmed that the previous Activity Director had quit over a week ago, leaving the position vacant. The Administrator in Training verified the lack of an Activity Director or a full-time Activity Assistant, acknowledging the sudden departure of the former Activity Director. As a result, the Social Service Director was assigned to take on the responsibilities of the Activity Director, despite the lack of activities being conducted for the residents.
Misappropriation of Resident Funds by Business Office Manager
Penalty
Summary
The facility failed to protect the rights of 74 out of 75 residents from the misappropriation of their property by the Business Office Manager (BOM), identified as V4. Over a period of eight months, V4 stole $11,815 from the residents' pooled trust account without their knowledge. This misappropriation involved forging signatures on checks, cashing them, and then depositing the funds into V4's personal bank account. The facility did not monitor the residents' pooled trust account monthly, which allowed V4 to continue these fraudulent activities. The facility's policies required dual signatures on all banking transactions and monthly oversight by the Administrator, but these measures were not enforced. V3, the Administrator in Training, admitted to not monitoring the monthly trust fund account or ensuring that residents received their quarterly statements. Additionally, V4 kept a resident's pre-paid social security card and made unauthorized charges, further violating the residents' rights. Interviews with residents and staff revealed that several residents did not receive receipts for purchases made on their behalf, and some residents' signatures were forged on withdrawal logs. The facility's audit confirmed a deficit of $11,815 in the residents' trust funds, and the trust fund withdrawal logs for several months were missing. The facility's lack of oversight and failure to adhere to its own policies allowed the misappropriation to occur, resulting in an Immediate Jeopardy situation.
Removal Plan
- The facility staff have interviewed all cognitive residents to identify those residents who allowed the facility to manage their monies and who had given V4/Business Office Manager monies for items and never got items, receipts, or monies back.
- V1 notified all resident's/responsible parties of discharged residents of misappropriation of funds.
- V2 was in serviced by V1/Regional director on the facility's Abuse Policy and Procedures.
- V2 was educated by V1 on how the resident trust fund is supposed to work and procedures on handling the resident's cash.
- V20 was thoroughly trained by V1 on the resident trust.
- A deposit was made in the amount of 11,815.00 to the resident's new trust fund account. This amount was the amount audited and determined by V7 to be missing from the resident's pooled trust fund account.
Failure to Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to adhere to its Abuse Policy by not immediately reporting allegations of misappropriation of residents' funds to the local police department, the state agency, and the residents or their representatives. This failure affected all 75 residents reviewed in the sample. The issue began when a resident reported to the Prior Administrator-In-Training that the Business Office Manager was making fraudulent charges from her debit card. This allegation was not reported to the state agency. Subsequently, the Prior Administrator was informed by a bank manager of suspected fraudulent withdrawals from the residents' trust fund, but the police and state agency were not notified until eight days later, leaving the residents' accounts vulnerable. An audit revealed a deficit of $11,815 missing from the residents' pooled trust fund account. Further investigation showed that the Business Office Manager had been forging signatures and writing checks to cash, then depositing the funds into her personal account. Residents reported unauthorized withdrawals and fraudulent charges on their accounts, and many were not informed by the facility about the misappropriation of their funds. The facility's failure to report these allegations promptly and to notify the residents or their representatives resulted in an Immediate Jeopardy situation. The facility's Abuse Prevention Program policy requires immediate reporting of any potential mistreatment, exploitation, neglect, or abuse to a supervisor and the administrator, and further reporting to the state agency and law enforcement as per state law. However, the facility did not follow these procedures, leading to significant financial losses for the residents and a breach of trust. The facility's inaction and lack of communication with the affected residents and their representatives contributed to the severity of the deficiency.
Removal Plan
- V4/Business Office Manager was suspended and has not worked at the facility since.
- V2 (AIT) was educated by V1 (Regional Director) on the Abuse Policy and Procedures with an emphasis on two-hour reporting window to (State Agency), notifying the responsible party, doctor, and local police.
- V2 (AIT) and V20 (Business Office Manager/Social Service Director) were both in-serviced by V1 (Regional Director) on how the resident trust fund is supposed to work and procedures on handling the resident's cash.
- The facility completed all measures on the abatement plan, including providing in-servicing to all the staff on abuse policy and procedures and notifying all responsible parties of the residents in the facility of the misappropriation of funds.
Failure to Investigate Misappropriation of Funds
Penalty
Summary
The facility failed to adhere to its Abuse Policy by not thoroughly investigating allegations of misappropriation of funds and not removing the alleged perpetrator, the Business Office Manager (BOM), from contact with residents and their funds during the investigation. This failure affected all 75 residents reviewed for protection against abuse. The issue began when a resident reported to the Administrator-In-Training (AIT) that they suspected the BOM of making fraudulent charges on their debit card. Despite this report, no investigation was initiated, and the BOM was not suspended, leaving residents' funds unprotected. Further allegations arose when the Bank Manager informed the Prior Administrator of suspicious activities involving the BOM, who was allegedly making unauthorized withdrawals from the residents' trust fund for personal use. Despite being notified, the Prior Administrator did not suspend the BOM or initiate an investigation immediately. The BOM continued to have access to the residents' pooled trust fund account, resulting in a significant deficit of over $11,000 due to unauthorized withdrawals. Another resident reported that the BOM had taken their pre-paid social security card and made fraudulent charges. This allegation was not immediately investigated, and the state agency was not notified promptly, allowing further fraudulent charges to occur. The facility's failure to act on these allegations and protect residents' funds resulted in an Immediate Jeopardy situation, highlighting significant lapses in following established abuse prevention protocols.
Removal Plan
- V4 (Business Office Manager) was suspended and has not worked at the facility since.
- V2 (AIT) was educated by V1 (Regional Director) on the Abuse Policy and Procedures with an emphasis on two-hour reporting window to (State Agency), notifying the responsible party, doctor, and local police.
- V2 (AIT) and V20 (Business Office Manager/Social Service Director) were both in-serviced by V1 (Regional Director) on how the resident trust fund is supposed to work and procedures on handling the resident's cash.
- The facility completed all measures on the abatement plan, including providing in-servicing to all the staff on abuse policy and procedures and notifying all responsible parties of the residents in the facility of the misappropriation of funds.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to develop and implement adequate pressure ulcer prevention and care interventions for a resident, leading to the development of a facility-acquired unstageable pressure ulcer on the right heel and a stage three pressure ulcer on the right buttock. The resident was admitted with a femur fracture and no existing pressure ulcers. Initial assessments indicated the resident was at risk for pressure ulcers, but the care plan did not include specific interventions to address this risk. Despite being identified as high risk for pressure ulcers, the facility did not perform daily skin checks or implement necessary interventions such as heel protectors or proper turning and repositioning. The resident reported not having pressure-relieving boots or sufficient staff assistance to reposition, which contributed to the development of the pressure ulcers. The facility's policy required these interventions for high-risk residents, but they were not documented or executed. The resident's care plan lacked individualized goals and interventions to treat and prevent the worsening of the pressure ulcers. Observations and staff interviews confirmed that the necessary preventive measures were not in place, and the resident's pressure ulcers developed and worsened while in the facility's care. The facility's failure to adhere to its pressure sore prevention guidelines resulted in significant harm to the resident.
Failure to Conduct Resident Council Meetings
Penalty
Summary
The facility failed to conduct Resident Council Meetings for five out of twelve months in the past year, affecting all 36 residents. The absence of these meetings was attributed to the lack of an Activity Director, who was responsible for organizing and facilitating the meetings. Residents expressed concerns about not being invited to Care Plan Meetings, a shortage of essential supplies like towels and linens, and a lack of knowledge about formal grievance procedures. They also reported feeling unheard when raising issues and were unaware of the existence or importance of a Survey Book. Residents expressed dissatisfaction with the lack of activities and the cessation of meetings since February. They felt that the meetings provided a platform to voice concerns and discuss improvements, which was no longer available. Specific grievances included long wait times for call lights, cold meals, and inadequate staffing, among others. The Administrator in Training acknowledged the absence of meetings and was unaware of the complaints raised during previous meetings. The facility's documentation showed repeated grievances without evidence of resolution, indicating a systemic issue in addressing resident concerns.
Inadequate Linen Supply and Moldy Shower Curtain
Penalty
Summary
The facility failed to provide an adequate supply of washcloths and towels, as well as maintain a clean shower curtain, affecting the quality of care for all 36 residents. Observations and interviews revealed that staff members, including CNAs, were forced to use alternative items such as pillowcases, bath blankets, and paper towels for resident hygiene due to the lack of washcloths and towels. Multiple residents expressed dissatisfaction with the situation, noting the absence of basic hygiene supplies and the use of inappropriate substitutes for personal care. Additionally, the main shower room's curtain was found to be in poor condition, with a thick black, musty-smelling substance covering a significant portion of it. Staff and residents reported that the moldy condition of the shower curtain had persisted for an extended period, with one CNA stating it had been an issue for two years. The Administrator-In-Training acknowledged awareness of the moldy shower curtain and the shortage of linens but had not yet taken action to resolve these issues.
Failure to Address Resident Grievances and Inform Residents of Grievance Process
Penalty
Summary
The facility failed to ensure that residents were aware of the grievance process, including how to submit grievances and who the grievance official is. This deficiency was identified through observations, interviews, and record reviews, revealing that residents were not informed about the grievance procedures and that complaints raised during resident council meetings were not being addressed. Specifically, residents expressed that they were unaware of what a grievance was, where to find grievance forms, or who the grievance official was. Additionally, residents reported that their complaints, such as the desire for church services and outings, had been repeatedly voiced in resident council meetings over several months without resolution. The facility's grievance policy outlines that grievances should be reported to the Social Service Director, who serves as the grievance official, and that these should be addressed in daily Quality Assurance meetings. However, the facility did not have an activity director to submit resident council concerns, and the Administrator-In-Training admitted to being unaware that residents could submit grievances themselves. This lack of awareness and action resulted in unresolved complaints, such as the absence of church services and outings, affecting all 36 residents in the facility.
Lack of Resident Activities and Engagement
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the physical, mental, and psychosocial well-being of its residents. Observations and interviews revealed that no activities were offered to residents on several days, and there was a lack of activity calendars or postings throughout the facility. The facility had not employed any staff in the activity department for over two months, resulting in no scheduled activities on the second shift or weekends. This lack of activities was confirmed by multiple staff members, including CNAs and the Social Service Director, who stated that the facility had not provided activities consistently for several months. Residents expressed dissatisfaction with the lack of activities, stating that they were bored and had nothing to do outside of their rooms. Several residents, including those with cognitive impairments and mental health diagnoses, reported that they had not been offered activities such as bingo, church services, or outings, which they had previously enjoyed. The Resident Council Meeting Minutes documented repeated requests for church services and outings, which had not been addressed by the facility. Interviews with residents and their family members highlighted the negative impact of the inactivity on their well-being, with some residents expressing feelings of depression and boredom. The facility's failure to assess and update residents' activity preferences and care plans further contributed to the deficiency. Several residents' medical records lacked Activity Preferences Assessments or Quarterly Reviews of Activity Participation, and their care plans did not address their activity goals or interests. This oversight affected residents' participation in activities, as evidenced by the low attendance recorded in their Activity Tracking Logs. The absence of an activity director and the lack of staff to facilitate activities were cited as reasons for the deficiency, leaving residents without meaningful engagement or opportunities for social interaction.
Lack of Activity Director Leads to Deficiency in Resident Activities
Penalty
Summary
The facility failed to employ a full-time Activity Director to plan, schedule, and implement an ongoing program of activities, affecting all 36 residents. The facility's policy requires the Activity Director to plan and coordinate activities to meet the physical, mental, and psychosocial needs of each resident, including completing assessments and participating in care plan development. However, observations and interviews revealed that the facility has not had an Activity Director since March 12, 2024, after the previous director resigned. As a result, no scheduled activities, activity calendars, or resident council meetings have been provided for several months. During the survey, it was observed that no activities were offered to residents on multiple days, except for a brief bingo session. Residents expressed concerns about the lack of activities, and the Social Service Director confirmed the absence of scheduled activities and staff to conduct them. The Administrator-In-Training acknowledged the vacancy in the Activity Director position since March 2024, contributing to the deficiency in providing an adequate activities program for the residents.
Inadequate Nursing Staff Leads to Delayed Care
Penalty
Summary
The facility failed to ensure adequate nursing staff was available to meet the needs of all 36 residents, as evidenced by observations, interviews, and record reviews. The facility's Daily Census confirmed the presence of 36 residents, and the Facility Assessment Tool emphasized the necessity for sufficient nursing staff with appropriate competencies to ensure resident safety and well-being. However, the Nurse Master Schedule revealed multiple dates where staffing was insufficient, specifically on 5-11-24, 5-12-24, 5-25-24, 5-26-24, 5-31-24, 6-1-24, and 6-2-24, during the 6am to 6pm shifts. On 6-2-24, an LPN was observed administering medications from 7:10 AM to 10:45 AM, despite the scheduled medication pass time being 8:00 AM. The LPN reported that the facility required two full-time nurses on both day and evening shifts to complete all tasks, including wound treatments and timely medication administration. During a resident council meeting, several residents expressed concerns about the lack of morning nursing staff, resulting in delayed medication administration. The Resident Care Coordinator confirmed the staffing requirements and acknowledged the staffing shortages on the specified dates.
Deficiency in RN Coverage and Lack of DON
Penalty
Summary
The facility failed to provide Registered Nurse (RN) services for eight hours daily and did not employ a Director of Nursing (DON) to oversee the Nursing Department, affecting the quality of care for all 36 residents. The facility's policy mandates RN services to be available every day, but the Nurse Master Schedule revealed multiple days without RN coverage. Specifically, there was no RN coverage on several dates in May and June, and no DON was present on multiple days in early June. The absence of a DON has persisted since February, following the departure of the previous DONs. Interviews with facility staff confirmed the lack of RN coverage on the specified dates. The Administrator-In-Training acknowledged the absence of a DON since February, and the Resident Care Coordinator confirmed the lack of RN coverage on the listed dates. The facility's Facility Assessment Tool also highlighted the need for a DON to support and care for the resident population, indicating a systemic issue in maintaining adequate nursing leadership and coverage.
Absence of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a Certified Dietary Manager, which is a requirement for managing the food and nutrition services effectively. The job description for the Food Service Manager outlines responsibilities such as managing food service personnel, ensuring residents receive physician-ordered diets, and maintaining sanitation and safety standards. However, since August 2023, the facility has not had a Dietary Manager, and the tasks have been divided among the existing dietary staff, who are already understaffed. This situation has the potential to affect all 36 residents living in the facility. During an observation on June 2, 2024, it was noted that the dietary aides were managing the kitchen operations without a designated manager. They expressed challenges in handling additional responsibilities due to the lack of sufficient staff. The Administrator in Training confirmed the absence of a Dietary Manager, citing difficulty in filling the position. The facility's daily census documented 36 residents, indicating that the deficiency could impact the entire resident population.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food storage and sanitation practices, which were observed during a kitchen tour. Two pans containing shredded ham were left unrefrigerated overnight, and several food items were found without proper labeling or dating. Additionally, the refrigerator was leaking fluid onto food containers, potentially contaminating the food. The facility also failed to discard outdated food, as evidenced by luncheon meat that had been pulled from the freezer on a previous date. The storage room door was left open, and the outside door was also open, compromising the safety and sanitation of the food storage area. The kitchen environment was not maintained in a clean and safe condition. There was a buildup of grime on the base of the can opener, dust on the hood and baffles over the range, and gaps in ceiling tiles and around pipes. The ceiling vents and returns were covered in dust and grime, and floor tiles were missing under the sink area. Additionally, bags of water softener salt and boxes of paper goods were improperly stored on the floor. The lighting in the food preparation room was inadequate, with several lights out and one light cover cracked. These deficiencies have the potential to affect all 36 residents living in the facility.
Deficiencies in Staffing, Infection Control, and Resident Care
Penalty
Summary
The administration of the facility failed to address ongoing resident complaints and ensure adequate resources and staffing were available. Residents reported not receiving church services and desired more activities like bingo. The facility lacked a full-time Director of Nursing, Activity Director, and Dietary Manager, which contributed to the absence of daily activities and unresolved resident grievances. Additionally, the facility did not conduct monthly resident council meetings, and residents were unaware of the grievance process. The facility was also deficient in maintaining adequate infection control practices. Several residents with indwelling urinary catheters and wounds were not placed in enhanced barrier precautions, and staff were observed not wearing appropriate protective gear while providing care. The facility's infection preventionist was unaware of the enhanced barrier precautions policy, indicating a lack of training and implementation of up-to-date infection control measures. Furthermore, the facility struggled with staffing and resource management. There were insufficient nursing staff on multiple occasions, and the facility lacked adequate linens, with reports of only one or two washcloths available for all residents. The dietary department faced challenges with broken equipment, such as a non-functional convection oven and a rusted freezer door, which hindered meal preparation. The facility also failed to provide required annual in-service training for CNAs, including abuse prevention, Alzheimer's dementia management, and QAPI training.
Failure to Employ Licensed Administrator
Penalty
Summary
The governing body of the facility failed to employ a licensed administrator to oversee and manage the everyday operations, which has the potential to affect all 36 residents residing within the facility. Observations and interviews revealed that the designated administrator, V1, has not been present at the facility regularly, with staff reporting that V1 visits only about once a week. The facility's job description for the administrator position requires the individual to hold a current, unencumbered Nursing Home Administrator's license or meet the state's licensure requirements, which V1 possesses but is not fulfilling the role's responsibilities. Instead, V2, an Administrator-In-Training, has been managing the facility since November 2023 without holding an administrator's license or the necessary education to obtain a temporary license. Staff members, including LPNs and CNAs, confirmed that V2 is the only administrator they have seen managing the facility, and they have not seen V1 in months. This situation indicates a lack of proper oversight and management as required by the facility's governing body, potentially impacting the quality of care provided to the residents.
Facility Fails to Implement QAPI Plans and Address Multiple Deficiencies
Penalty
Summary
The facility failed to develop and implement Quality Assurance and Performance Improvement (QAPI) plans to address several deficiencies, including the lack of follow-up to resident complaints, insufficient nursing staff, and inadequate training on QAPI, dementia care, infection control, and abuse prevention. The facility also did not have department heads such as the Director of Nursing, Activity Director, and Dietary Manager, which contributed to the lack of an ongoing program of activities and unresolved resident complaints. Additionally, the facility did not conduct resident council meetings consistently, and there was a lack of required employees attending QAPI meetings. Observations revealed that residents were not placed in enhanced barrier precautions despite having conditions that warranted such measures, and staff were not wearing appropriate protective gear while providing care. The facility's equipment was in disrepair, with a broken convection oven and a rusted freezer door, affecting dietary operations. The facility also faced a shortage of linens, with reports of insufficient washcloths and towels for resident care. Furthermore, there was no activity calendar for several months, and activities were not offered consistently, leaving residents without meaningful engagement. Interviews with staff and residents highlighted the lack of awareness and resolution of grievances, with residents expressing dissatisfaction with the absence of church services and delayed medication administration due to staffing shortages. The facility's administrator confirmed the absence of a Director of Nursing since February and acknowledged the lack of required training for staff. The facility also restricted access to QAPI meeting minutes and had not developed or implemented corrective plans to address these issues.
Deficiency in Quality Assurance Meetings Attendance
Penalty
Summary
The facility failed to have a Director of Nursing (DON) or the required number of members present at the quarterly Quality Assurance Meetings, which is a deficiency that could potentially affect all 36 residents living in the facility. The document titled 'Members of Quality Assessment and Assurance' lists the required members, including the Administrator, Administrator in Training, Resident Care Coordinator, Social Services Director/Business Office Manager, Medical Director, Therapy, and Pharmacy. However, the review of the Quality Assurance quarterly sign-in sheets for the past twelve months revealed that a DON was not present at any of the meetings. Specifically, the meeting on January 19, 2024, had five members, while the meetings on October 19, 2023, and July 21, 2023, each had four members. During an interview on June 6, 2024, the Administrator in Training confirmed the absence of a DON at these meetings, stating that the number of members able to attend signed the attendance sheets. The facility's daily census as of June 2, 2024, documented 36 residents currently residing within the facility.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment, impacting the ability to prepare and serve meals safely and efficiently to all 36 residents. Observations and interviews revealed that several large appliances, including the convection oven, range oven, steam table, and large hood with baffles, were not functioning properly. The convection oven had been broken for months, and one of the range ovens could only be used as a warmer, failing to reach the correct temperature for cooking. Additionally, a broken pipe in the steam table and a non-functional large hood with baffles were reported. Staff members stated that they had informed the Administrator about these issues six or seven months ago, but no repairs had been made, and there was no formal work order process in place. Further inspection showed that the door to the outside freezer was severely rusted, with the inner door material and insulation exposed. Staff indicated that attempts to repair the door had been unsuccessful, and there was no plan to replace it. The Administrator in Training was unaware of these equipment failures, highlighting a lack of communication and oversight in addressing maintenance issues. The facility's Maintenance and Environmental Policy emphasizes the importance of a well-maintained environment for safe and effective care, yet the failure to repair critical kitchen equipment contradicts this policy.
Latest citations in Illinois
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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