Arcadia Care On The Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Illinois.
- Location
- 555 West Carpenter, Springfield, Illinois 62702
- CMS Provider Number
- 145160
- Inspections on file
- 47
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 30 (2 serious)
Citation history
Health deficiencies cited at Arcadia Care On The Hill during CMS and state inspections, most recent first.
A resident with diabetes, neuropathy, chronic foot ulcers, MRSA bacteremia, and a history of toe amputation experienced progressive worsening of a left plantar foot wound with exposed bone while in the facility’s care. Wound notes showed the lesion enlarging over time, and hospital and podiatry orders directed IV Daptomycin every 24 hours, twice‑daily saline wet‑to‑dry dressings, PICC assessments, lab monitoring, and pre‑surgical Hibiclens. MAR review revealed that ordered wound treatments were not documented for an extended period, multiple IV antibiotic doses were missed or given at inconsistent times, PICC checks and lab result faxing were omitted on several days, and a Hibiclens dose was not given. The podiatrist and clinic staff reported making numerous calls and sending orders to arrange urgent surgery due to exposed bone and osteomyelitis, but facility leadership did not return calls for about a week, and staff confirmed the podiatrist’s repeated, frustrated attempts to reach the DON. During this time, the facility had no wound care policy and had been without a wound nurse for about a month, with an LPN informally covering wound duties while also working the floor. Surgery was eventually performed, and more of the resident’s foot was amputated due to infection, which the podiatrist attributed to the delay in scheduling and incomplete coordination of ordered care.
A resident with a history of neurogenic bladder and multiple comorbidities did not have urinalysis and urine culture results sent promptly to the urologist, resulting in delayed treatment for a UTI. The resident experienced pain, was transferred to the ER, and developed sepsis requiring intensive interventions. Additionally, two residents were not properly assessed or documented during changes in condition, with missing current vital signs and incomplete evaluations prior to hospital transfers. Facility staff did not follow policies for timely communication of lab results and thorough documentation during changes in condition.
A resident with a history of multiple vertebral fractures and recent falls was admitted without documented fall prevention interventions in the care plan or admission assessment. The resident experienced two unwitnessed falls, resulting in skin tears and a hospital transfer for IV fluids and pain management. Facility staff did not document or implement interventions to prevent future falls, despite established fall prevention protocols.
A nurse failed to properly respond to a diabetic emergency by not administering the ordered Baqsimi (Glucagon) for hypoglycemia, instead incorrectly assembling and nasally administering epinephrine using a Narcan nasal spray cap. The error was discovered when EMS arrived to find the resident unresponsive, requiring IV glucose. The incident revealed a lack of competency in medication administration and failure to follow physician orders.
A resident with diabetes and other chronic conditions experienced a hypoglycemic crisis and did not receive the prescribed Glucagon due to a medication error by an RN, who instead administered epinephrine nasally after assembling it incorrectly with a nasal spray cap. The error was facilitated by another nurse who provided the wrong medications from the emergency kit. The resident's blood sugar dropped further, requiring emergency medical intervention and ICU admission. The incident involved failure to follow physician orders and standard medication administration protocols.
A resident with hemiplegia, reduced mobility, and a documented fall risk was left unattended on the toilet by a CNA, who stepped out to provide privacy and relied on the family to alert staff when assistance was needed. The resident subsequently fell, despite facility policy requiring staff to remain with residents needing assistance during toileting.
A resident with a known history of wandering and elopement risk, who was cognitively intact, was able to remove his wander guard and leave the facility without staff awareness. The resident obtained alcohol and was later found by police and transported to the hospital. Staff interviews and documentation revealed that monitoring practices and interventions in place were insufficient to prevent the resident's unsupervised exit.
A facility failed to notify a resident's POA of a change in condition when the resident was treated for pneumonia with antibiotics. The POA was only informed when the resident was sent to the hospital. The facility's policy requires notifying the legal representative of significant health changes, which was not adhered to in this case.
The facility failed to properly store, label, and date food items, including raw poultry, and did not adequately sanitize dishware due to a malfunctioning dishwashing machine. Thawed chicken was improperly stored, and undated food items were found in refrigerators. The dishwashing machine was not dispensing chlorine, and the facility lacked a manual dishwashing policy.
The facility failed to follow its water management policy, risking waterborne illnesses by not documenting monthly pipe flushing in unoccupied rooms. Additionally, two CNAs did not adhere to Enhanced Barrier Precautions (EBP) by providing care to a resident with severe cognitive impairment without wearing required PPE, despite clear signage. The facility's policies require weekly maintenance documentation and PPE use during high-contact care activities, which were not followed, potentially affecting all 109 residents.
The facility failed to accommodate the smoking needs of four cognitively intact residents, who expressed dissatisfaction with the current policy allowing only one cigarette per break and a six-minute limit. One resident, with a nicotine addiction, was unable to smoke due to a broken wheelchair, while others felt restricted by the policy. The administrator acknowledged the policy but cited practical and financial limitations.
The facility failed to provide adequate incontinent care for several residents, including those with cognitive impairments and mobility issues. Observations revealed that staff did not change gloves or perform hand hygiene between tasks, leading to contamination and incomplete cleaning. Residents were left in soiled briefs for extended periods, and staff did not follow facility policies for thorough cleaning and drying, increasing the risk of infection.
A resident with multiple medical conditions, including dysphagia and gastrostomy, received tube feeding that was not properly labeled, and the feeding rate was incorrect. Additionally, during peri-care, the resident's head of bed was lowered without stopping the tube feeding, contrary to facility policy. This resulted in a deficiency in the care provided, as staff failed to adhere to established protocols for tube feeding management.
A resident with intracerebral bleed, Alzheimer's, and atrial fibrillation was administered an incorrect dosage of Seroquel at bedtime over several days, receiving 37.5mg instead of the prescribed 25mg. This error was identified by the Assistant Director of Nursing during a review, and confirmed by the DON, indicating a failure to follow the facility's medication administration policy.
A resident with an indwelling catheter experienced a delay in UTI treatment due to poor communication and follow-up by the facility staff. Despite the urologist's orders for better catheter care, the facility failed to act promptly on urinalysis results, leading to the resident's hospitalization for septic shock.
A resident with a left knee prosthesis infection did not receive physician-ordered Oxycodone-Acetaminophen for several days due to a lapse in prescription refills and delayed pharmacy delivery. The resident reported severe pain, and alternative pain management was inadequate.
Failure to Coordinate Wound Care, IV Antibiotics, and Timely Surgery for Diabetic Foot Wound
Penalty
Summary
The deficiency involves the facility’s failure to coordinate and provide ordered wound care, IV antibiotics, and timely surgical scheduling for a resident with a complex left foot diabetic wound and MRSA bacteremia. The resident had multiple diagnoses including infective myositis of the left foot, abscess of the tendon sheath, osteomyelitis, MRSA infection, non‑pressure chronic foot ulcer with muscle involvement, neuropathy, COPD, type 2 DM with foot ulcer, prior right great toe amputation, weight loss, hypertension, and anemia. The resident was cognitively intact per MDS and required supervision or touching assistance for most ADLs. Care plan entries noted chronic wounds/infection, risk for skin impairments related to diabetes and impaired mobility, and that the resident had a history of removing dressings and unplugging the wound vac without notifying staff. Wound notes documented progressive worsening of the left plantar foot wound from 2/10/2026 through 4/7/2026, with increasing size, presence of exudate, and visible bone. The facility did not consistently follow physician orders for wound care and IV antibiotic therapy after the resident’s hospitalization for left foot MRSA infection. Hospital discharge instructions included Daptomycin 500 mg IV every 24 hours until 4/17/2026 with weekly labs, and wound care orders from the podiatrist specified saline wet‑to‑dry dressing changes twice daily. The March MAR showed that an order to cleanse the left foot, leave the Restrada graft in place, and apply wet‑to‑dry dressings and ABD wrap when the wound vac was not available was not documented as completed from 3/13/2026 to 3/31/2026. The April MAR showed missed doses of Daptomycin on 4/8/2026, 4/9/2026, and 4/12/2026, and administration times that did not follow the every‑24‑hour order on five days. The April MAR also showed missed Hibiclens pre‑surgical dose, missed PICC/midline assessments on specified dates, and missed faxing of lab results on multiple days. The DON and ADON acknowledged that if care or medications were not documented on the MAR, they were not done, and the Medical Director stated he expected all physician orders to be followed and no doses to be missed. The facility also failed to effectively coordinate and prioritize scheduling of the resident’s needed foot surgery despite repeated contacts from the podiatrist and his clinic. The podiatrist documented on 3/31/2026 that the left foot wound was worsening, with exposed bone and need for repeat debridement and left first ray amputation, and stated he faxed orders to the facility and called multiple times without return calls. He reported calling the facility over six times, leaving messages that the resident needed surgery STAT due to exposed bone and osteomyelitis, and that no one called him back until the ADON eventually responded in April. The podiatry clinic RN reported attempts to contact the facility on multiple consecutive days to schedule surgery after insurance approval, with successful contact only after about a week. The CNA/receptionist and an LPN corroborated that the podiatrist had called repeatedly, was upset that the DON was not returning calls, and threatened to contact Public Health. Facility leadership, including the Administrator, DON, and ADON, stated they were initially unaware of issues or delays with scheduling the surgery, and staff reported that the facility had been without a wound nurse for about a month, during which time wound responsibilities were informally covered by an LPN while also working the floor. Ultimately, the resident underwent surgery and had more of the left foot amputated due to infection, with the podiatrist stating he believed more of the foot had to be removed because surgery was not scheduled earlier and that the facility had not coordinated care or returned calls in a timely manner. On physical observation shortly before surgery, the resident’s left foot showed a large plantar wound with visible bone and a red streak across the foot, with the area larger than a fifty‑cent piece. Staff interviews indicated that the wound had been present and problematic for at least a year, and that bone visibility was not noted that far back. Wound notes from late March and early April documented that the wound was advancing, increasing in size, with serosanguinous exudate and visible bone. The facility had no wound care policy, and the Administrator stated they expected physician orders to be followed. The Physician‑Family Notification policy required timely communication with the physician and family when there was a need to alter treatment significantly, and the Medication Administration policy required medications to be administered in accordance with physician orders and documented on the MAR. Despite these policies, the record review, interviews, and observations showed that the facility did not ensure consistent implementation of ordered wound care, IV antibiotic therapy, lab monitoring, PICC assessments, and timely coordination of surgical intervention for this resident’s worsening foot wound. The DON reported limited RN staffing for a census of 118 residents and stated that while they were doing the best they could, it was not enough at times. Staff also reported that the facility had been without a designated wound nurse for about a month, and that wound care duties were being informally covered by an LPN who was also assigned to floor duties. The podiatrist and his clinic staff described multiple unsuccessful attempts to reach facility leadership to arrange surgery, and internal staff accounts confirmed that calls were routed to the DON without response for a period of time. The combination of missed and improperly timed antibiotic doses, incomplete wound treatments, inconsistent lab faxing and PICC assessments, lack of a wound care policy, absence of a wound nurse for a period, and failure to respond promptly to the podiatrist’s repeated efforts to schedule surgery all contributed to a delay in surgical intervention for the resident’s left foot wound, culminating in a more extensive amputation due to the spread of infection.
Failure to Communicate Lab Results and Assess Changes in Condition Leads to Delayed Treatment and Hospitalization
Penalty
Summary
The facility failed to provide timely communication of urinalysis and urine culture results to a resident's urologist, which resulted in a significant delay in treatment for a urinary tract infection (UTI). The resident, who was nonverbal and had a complex medical history including hemiplegia, stroke, neurogenic bladder, and prostate cancer, had a physician's order for increased fluid intake and monitoring for UTI symptoms. However, there was no documentation that the order was followed or reflected in the care plan, and the urinalysis and urine culture results were not promptly sent to the urologist as required. The urologist did not receive the results until ten days after they were available, which led to a lack of timely antibiotic treatment and escalation of the resident's condition. The resident subsequently experienced a decline, including pain, discomfort, and ultimately required transfer to the emergency room, where he was diagnosed with a UTI and sepsis. He received IV hydration, antibiotics, and underwent invasive procedures such as a PICC line insertion and intubation. Documentation revealed that staff failed to reassess the resident for warning signs of sepsis after readmission and did not complete change in condition documentation, including current vital signs and assessments, on multiple occasions prior to the resident's deterioration. The lack of timely and thorough assessment and communication contributed to the resident's progression to septic shock and cardiac arrest, necessitating emergent CPR. A second resident was also identified as not having proper assessment or documentation during a change in condition, specifically lacking current vital signs and respiratory assessment prior to hospital transfer for pneumonia. Facility policies required prompt reporting of diagnostic results and thorough documentation during changes in condition, but these were not followed. Interviews with facility staff, including the DON and NP, confirmed expectations for timely communication and documentation, which were not met in these cases.
Failure to Implement and Document Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement and document fall prevention interventions for a newly admitted resident with a documented history of multiple vertebral fractures and recent falls. Upon admission, the resident's hospital discharge plan and baseline care plan both indicated a significant risk for falls, including recent compression and burst fractures, low back pain, abnormal gait, muscle wasting, and lack of coordination. Despite these risk factors, no specific goals or interventions to prevent falls were documented in the resident's baseline care plan or admission assessment. Following admission, the resident experienced two unwitnessed falls within the facility. The first fall resulted in a skin tear to the left elbow, and the second fall led to a skin tear on the right elbow and post-fall lethargy, requiring transfer to the emergency department. The resident received IV fluids and narcotic pain medication at the hospital. Nursing notes and fall reports for both incidents did not document any interventions implemented to prevent future falls, nor were any changes made to the care plan after these events. Interviews with facility staff, including the Director of Nursing, confirmed that interventions should have been documented for residents with a history of falls. The facility's Fall Prevention Program requires individualized assessment and implementation of appropriate interventions at admission and after any fall, but these measures were not followed for this resident. The lack of documented interventions and failure to update the care plan after repeated falls constituted the deficiency.
Failure to Ensure Nursing Competency in Emergency Medication Administration
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to demonstrate competency in responding to a resident experiencing severe hypoglycemia. The resident, who had a history of diabetes mellitus, end-stage renal disease, and other chronic conditions, was found lethargic with a blood glucose level of 49, which later dropped to 33. Instead of following the physician's order to administer Baqsimi (Glucagon) nasal spray for low blood sugar, the RN incorrectly assembled and administered an epinephrine auto-injector with a nasal spray cap, intended for Narcan, and delivered it nasally to the resident. The RN did not verify the medication before administration and was unfamiliar with the emergency medications in the facility's E-Kit. The incident was witnessed by another nurse, who assisted in retrieving the emergency kit and observed the incorrect assembly and administration of the medication. The RN initially misrepresented the events but later admitted to not checking the medications and being unfamiliar with their use. Documentation and interviews confirmed that the resident did not receive the ordered Glucagon, and the error was only discovered after emergency medical services arrived and found the epinephrine pen with the nasal spray cap in the resident's bed. The resident was unresponsive when EMS arrived and required intravenous glucose administration to stabilize blood sugar levels. The physician and medical director were not initially informed of the medication error, only of the hypoglycemic episode and hospital transfer. The facility's investigation and staff interviews revealed a lack of competency in medication administration and failure to follow professional standards and physician orders, resulting in a significant medication error affecting the resident's care.
Removal Plan
- All nurses were educated on the use of Emergency Medications by DON.
- Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.
- DON, LPN, and RN, ADON reviewed the incident.
- 100% Nursing staff has been educated on the signs and symptoms of hypoglycemia and hyperglycemia by DON and RN, ADON.
- Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.
- NP was notified of the change in condition and MD notified of the resident being hypoglycemia and being sent to ER.
- V6 and V27 educated on ensuring right medication and dose prior to medication administration by DON.
- The monthly refresher will begin at our all-staff meeting.
- All nursing staff educated on the 5R's of medication administration by DON.
- V6 and V27 were educated and completed competent in medication administration on Narcan, Epinephrine, and Baqsiumi.
- 100% of nursing staff was educated on medication administration.
- DON or Designees will audit medication administration 2 times a week for 3 months.
- DON or Designee will audit 3 residents 2 times weekly to ensure blood sugar are within normal limit per MD orders for 3 months.
- DON or designee will perform an audit to ensure all emergency was handled correctly. This will be ongoing for 3 months and reviewed in our QA meeting.
- The emergency kits and the cart will be audit weekly to ensure educational material is in place. This will be ongoing for 3 months and review in our QA meeting. This will be monitored by ADON or designee.
- ADHOC QA completed with IDT regarding Policy and procedure.
- QA to review policy and procedure as part of Quality Assurance Process.
- This will be ongoing for 3 months.
Failure to Administer Correct Emergency Medication During Hypoglycemic Crisis
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) failed to administer the correct medication to a resident experiencing a hypoglycemic crisis. The resident, who had a history of diabetes mellitus, end-stage renal disease, and other chronic conditions, was found to have a critically low blood glucose level. Despite having a physician's order for Baqsimi (Glucagon) nasal powder to be administered in such situations, the RN did not provide the prescribed medication. Instead, the RN mistakenly assembled and administered an epinephrine auto-injector with a nasal spray cap, believing it to be Glucagon, and delivered it nasally to the resident. This error was compounded by the involvement of another nurse who assisted in retrieving the emergency kit and handing the incorrect medications to the RN. The resident did not receive the ordered Glucagon, and his blood sugar continued to drop, necessitating emergency medical intervention and subsequent transfer to the hospital, where he was admitted to the intensive care unit. Interviews and documentation revealed that the RN was unfamiliar with the emergency medications and did not verify the medication before administration. The incident was further complicated by initial inaccurate reporting by the RN regarding the medications given. The facility's medication administration policy and the standard nursing practice of verifying the five rights of medication administration were not followed, resulting in the resident not receiving the appropriate treatment for hypoglycemia.
Removal Plan
- All nurses were educated on the use of Emergency Medications by DON.
- Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.
- Nursing staff has been educated on the signs and symptoms of hypoglycemia and hyperglycemia by DON and ADON.
- Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.
- NP was notified of the change in condition and MD notified of the resident being hypoglycemic and being sent to ER.
- V6 and V27 educated on ensuring right medication and dose prior to medication administration by DON.
- All nursing staff educated on the 5R's of medication administration by DON.
- V6 and V27 were educated and completed competency in medication administration on Narcan, Epinephrine, and Baqsimi.
- Nursing staff was educated on medication administration.
- DON or Designees will audit medication administration 2 times a week for 3 months.
- DON or Designee will audit 3 residents 2 times weekly to ensure blood sugars are within normal limit per MD orders for 3 months.
- The emergency kits and the cart will be audited weekly to ensure educational material is in place. This will be ongoing for 3 months and reviewed in our QA meeting. This will be monitored by ADON or designee.
- ADHOC QA completed with IDT regarding Policy and procedure.
- QA to review policy and procedure as part of Quality Assurance Process.
- This will be ongoing for 3 months.
Failure to Provide Adequate Supervision During Toileting Results in Resident Fall
Penalty
Summary
A resident with diagnoses including hemiplegia, hemiparesis following cerebral infarction, lack of coordination, and reduced mobility was identified as being at risk for falls and dependent for toileting. The resident's care plan and fall risk assessment documented these risks and the need for staff assistance. On the date of the incident, the resident was being assisted with toileting by a CNA, who stepped out of the room to provide privacy while the resident was on the toilet, leaving the resident unattended. The resident's family was present in the room at the time. The resident subsequently fell off the toilet and was found lying on the bathroom floor by staff after being alerted by the family. The facility's Fall Prevention Program Policy states that residents requiring staff assistance should not be left alone after being assisted to bathe, shower, or toilet. Despite this policy, the CNA left the resident unattended, resulting in a fall. Interviews with facility staff confirmed that the CNA left the room and relied on the family to notify staff when the resident was finished, contrary to facility policy.
Failure to Prevent Elopement and Provide Adequate Supervision for At-Risk Resident
Penalty
Summary
A deficiency occurred when a cognitively intact resident, identified as an elopement risk, left the facility unsupervised, obtained alcohol, and was subsequently found by police and transported to the hospital. The resident was known to have a history of wandering and exit-seeking behaviors, as documented in multiple risk assessments and care plans. Despite these known risks, the resident was able to remove his wander guard device and exit the facility without staff knowledge. Staff interviews revealed that the resident was last seen in the building around 1 PM, and the facility did not become aware of his absence until contacted by police several hours later. The facility's policy required frequent monitoring and the use of electronic alert systems for residents at high risk of elopement. However, staff reported that rounds were made every two hours, and there was no formal policy on the frequency of these rounds. The resident's care plan included interventions such as a wander guard, door alarms, and structured routines, but these measures were not effective in preventing the resident from leaving. Staff also noted that the resident had previously removed his wander guard and had a pattern of wandering and exit-seeking, yet he was able to leave undetected. Documentation showed that the resident was alert and oriented at the time of the incident, and his medical records indicated a history of alcohol use and elopement risk. The facility's elopement policy focused primarily on cognitively impaired residents and did not clearly address procedures for cognitively intact individuals with elopement risk. The lack of effective supervision and monitoring allowed the resident to leave the facility, obtain alcohol, and require emergency medical evaluation.
Failure to Notify POA of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) of a change in condition for one resident who was being treated for pneumonia. The POA was not informed that the resident was placed on an antibiotic until the resident was being sent to the hospital. This lack of communication was confirmed by the POA and the facility's administrator, who acknowledged that the registered nurse did not notify the POA of the change in the resident's condition. The resident's medical records indicated a positive chest x-ray for pneumonia and a new order for Doxycycline, but there was no documentation of the POA being notified. The facility's policy requires that the resident's legal representative or family be informed of significant changes in the resident's health status. This policy was not followed, leading to the deficiency noted in the report.
Improper Food Storage and Dish Sanitization
Penalty
Summary
The facility failed to properly store, label, and date raw poultry and other food items, as well as failed to properly sanitize dishware, cups, and silverware. During an inspection, a zip lock bag with thawed chicken was found on the top shelf of a refrigerator, with cups of juice underneath, and a sandwich dated from ten days prior. Another refrigerator contained undated fruit bowls and cups of a red, jelled substance. The dishwashing machine was found to be malfunctioning, with a chlorine test strip reading zero, indicating no sanitization was occurring. The machine was also leaking water, and its temperature gauge was broken. The dietary consultant, V15, acknowledged the issues with the food storage and the dishwashing machine, stating that the chlorine was not being dispensed properly. The administrator, V1, confirmed that the thawed chicken should have been dated and stored correctly. The facility's policies require all food to be labeled and dated, and for raw animal foods to be stored separately from ready-to-eat foods. The dishwashing machine should not be used if it is not functioning properly, and manual dishwashing procedures should be followed if necessary. However, the facility did not have a policy for manual dishwashing at the time of the inspection.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to its water management policy, which is designed to prevent potential waterborne illnesses such as Legionella. The Maintenance Director, identified as V20, admitted to flushing the pipes in unoccupied rooms on the 1st and 4th floors only once a month without documenting the procedure. This is contrary to the facility's policy, which requires weekly verification and documentation of preventative maintenance activities, including flushing eyewash stations and ensuring water temperatures are within specified ranges. The Administrator, V1, acknowledged the ongoing construction on the 4th floor and the need for a log to document these procedures. Additionally, the facility did not follow its Enhanced Barrier Precautions (EBP) policy, which is intended to reduce the transmission of multidrug-resistant organisms. A resident, identified as R58, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was not provided care in accordance with EBP. Two Certified Nursing Assistants (CNAs), V25 and V26, entered R58's room and performed peri-care without wearing the required personal protective equipment (PPE), despite a sign on the door indicating the need for EBP. The CNAs admitted to forgetting to wear gowns, and the Licensed Practical Nurse (LPN), V28, was unaware of the CNAs' actions. The facility's policy on Enhanced Barrier Precautions mandates the use of gloves and gowns during high-contact resident care activities, especially for residents with indwelling medical devices such as feeding tubes. The Administrator, V1, confirmed the expectation that all staff should wear appropriate PPE when entering a resident's room under EBP. The failure to comply with these infection control measures has the potential to affect all 109 residents residing in the facility.
Failure to Accommodate Residents' Smoking Needs
Penalty
Summary
The facility failed to accommodate the smoking needs of four residents, all of whom were cognitively intact and expressed dissatisfaction with the current smoking arrangements. Resident R14, who has a physical and psychological addiction to nicotine, was unable to smoke due to a broken wheelchair that limited his mobility, forcing him to stay in bed all day. This resident typically receives three smoke breaks a day, each lasting six minutes, which he feels is insufficient. The care plan for R14, initiated in 2020, acknowledges the potential for physical and psychosocial disturbances due to disruptions in his smoking routine. Other residents, R47, R61, and R97, also reported dissatisfaction with the smoking policy, which allows only one cigarette per break and limits the time to six minutes. These residents expressed feelings of being restricted and desired more time or additional cigarettes during their breaks. Observations confirmed that residents were given one cigarette and were taken back inside after six minutes, despite their requests for more. The facility's smoking schedule indicates designated times for smoking breaks, but the administrator acknowledged that residents are allowed more than one cigarette, although practical limitations and financial considerations were cited as reasons for the current policy.
Inadequate Incontinent Care and Hygiene Practices
Penalty
Summary
The facility failed to provide timely and complete incontinent care for several residents, as observed during the survey. Resident R25, who has multiple diagnoses including Multiple Sclerosis and is frequently incontinent, reported waiting extended periods before being cleaned after incontinence episodes. Observations revealed that staff did not change gloves or perform hand hygiene between tasks, and contaminated clean water by using soiled gloves. This resulted in inadequate cleaning and potential risk of infection. Resident R58, who is severely cognitively impaired and always incontinent, also received inadequate care. Staff were observed using the same gloves throughout the cleaning process, contaminating clean water, and failing to thoroughly clean the peri area. This incomplete cleaning process was not in line with the facility's policies, which require thorough cleaning and drying of the resident's skin. Similar deficiencies were noted with residents R4 and R97. Staff failed to cleanse and dry all necessary areas during incontinent care, leaving soap suds on the skin and not addressing all soiled areas. These actions were contrary to the facility's policies, which emphasize the importance of thorough cleaning and drying to prevent skin breakdown and infection.
Deficiency in Tube Feeding Protocols
Penalty
Summary
The facility failed to adhere to its policy regarding tube feeding for a resident, identified as R58, who was admitted with multiple medical conditions including cerebral infarction with monoplegia, dysphagia, and gastrostomy. The care plan for R58 required specific interventions such as checking tube placement, maintaining the head of the bed (HOB) at a 45-degree angle during and after feeding, and proper labeling of feeding bottles. However, observations revealed that the tube feeding bottles were not consistently labeled with the resident's name, date, and time, and the feeding rate was incorrect on one occasion. During the survey, it was observed that an unlabeled bottle was used for R58's tube feeding, which was not in compliance with the facility's policy. The bottle was spiked and hung without proper labeling, and it was used for feeding despite the lack of identification. Additionally, the feeding rate on the unlabeled bottle was noted to be 65 ML/hour, which was not in accordance with the physician's order of 55 ML/hour. This discrepancy in labeling and feeding rate was not addressed by the staff, leading to a deficiency in the care provided to R58. Furthermore, during peri-care, the CNAs lowered R58's HOB without stopping the tube feeding, contrary to the facility's policy that required the feeding to be paused during such care. The CNAs were unaware of the need to inform the nursing staff to stop the feeding, and the LPN was not informed of the care being provided. This lack of communication and adherence to protocol contributed to the deficiency in the resident's care, as the tube feeding continued while the resident's position was altered, potentially compromising their safety.
Medication Administration Error
Penalty
Summary
The facility failed to administer medications according to the physician's orders for a resident diagnosed with intracerebral bleed, Alzheimer's, and atrial fibrillation. The resident was prescribed Seroquel 25mg, with instructions to take half a tablet every day and a full tablet at bedtime. However, the facility's records indicated that the resident was administered both a half tablet and a full tablet of Seroquel at bedtime, resulting in a total of 37.5mg being given instead of the prescribed 25mg. This medication error occurred over several days, from the 6th to the 10th of July, before being identified by the Assistant Director of Nursing during a review of consents. The error was acknowledged by both the Assistant Director of Nursing and the Director of Nursing, who confirmed that the resident received an incorrect dosage of Seroquel at bedtime, which was not in accordance with the doctor's orders. The facility's policy on medication administration requires adherence to doctor's orders, which was not followed in this instance.
Failure to Timely Treat UTI Leads to Septic Shock
Penalty
Summary
The facility failed to timely treat a urinary tract infection (UTI) for a resident (R3) who had an indwelling catheter due to obstructive uropathy. Despite the care plan indicating the need to monitor and report signs and symptoms of a UTI, the facility did not act promptly on the urinalysis results. R3's urinalysis, collected on 4/7/2024, indicated a UTI, but there was a delay in communication and follow-up with the urologist's office, resulting in a delay in antibiotic therapy and catheter change. This delay contributed to R3's condition worsening, leading to septic shock and admission to the intensive care unit (ICU). The urologist had ordered Bactrim, monthly catheter changes, and bladder irrigations, but these orders were not promptly executed by the facility staff. R3's medical history included a right femoral head fracture, obstructive uropathy, and chronic Foley catheter use. The urologist's progress note from 3/27/2024 indicated that R3's bladder was loaded with debris and the catheter tubing was very dirty, suggesting poor care at the facility. Despite the urologist's orders for better catheter care, the facility failed to follow through in a timely manner. The urinalysis results were not promptly communicated to the urologist, and there were multiple attempts by the urologist's office to contact the facility without success. This lack of timely communication and follow-up led to a significant delay in R3 receiving the necessary antibiotic treatment and catheter care. On 4/23/2024, R3 was admitted to the local hospital's emergency room with symptoms of septic shock, including suprapubic pain, weakness, decreased oral intake, and abnormal lab results. The hospital's emergency room notes documented that R3 had a history of UTIs and was found to have acute kidney injury, severe anemia, lactic acidosis, and sepsis secondary to a UTI. The delay in antibiotic therapy and improper catheter care at the facility were significant factors contributing to R3's deteriorating condition and subsequent hospitalization.
Failure to Provide Physician-Ordered Pain Medication
Penalty
Summary
The facility failed to provide the physician-ordered pain medication for a resident (R3) who was admitted with an infection and inflammatory reaction due to an internal left knee prosthesis. Despite having a physician's order for Oxycodone-Acetaminophen to be administered every four hours as needed for chronic pain, R3 did not receive the medication from 3/23/24 to 3/25/24. The resident reported severe pain during this period, rating it as a 30 on a 0-10 pain scale. The delay in medication was due to the prescription running out of refills and the subsequent order not being delivered until 3/26/24, despite being placed as a STAT order on 3/25/24. The resident's pain was not adequately managed with alternative medications, as he refused Tylenol offered by the nursing staff. Interviews with the nursing staff and the Director of Nurses revealed that the issue was identified on 3/25/24, but the pharmacy's cut-off time delayed the delivery of the new prescription until the following day. The staff noted that the resident often complained of pain but did not exhibit obvious signs of distress. The Director of Nurses acknowledged the lapse in medication management and the failure to ensure timely delivery of the pain medication. The facility was unable to locate the pharmacy policy at the time of the survey, indicating a potential gap in procedural adherence and documentation.
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A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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