Arcadia Care Toulon
Inspection history, citations, penalties and survey trends for this long-term care facility in Toulon, Illinois.
- Location
- 700 E Main St, Toulon, Illinois 61483
- CMS Provider Number
- 145442
- Inspections on file
- 37
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Arcadia Care Toulon during CMS and state inspections, most recent first.
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.
A resident with dementia and gait abnormalities had a documented history of an unwitnessed fall after slipping from a vinyl or leather recliner. The IDT identified the need for non-skid material on the recliner seat, and this intervention was added to the resident’s fall care plan. However, during surveyor observation, the recliner lacked the required non-skid material. A CNA reported never having seen non-skid material on the chair, and the DON acknowledged that the recliner seat should have had it, demonstrating that the care-planned fall prevention intervention was not implemented.
The facility failed to maintain a safe, functional, and comfortable environment, with widespread physical plant disrepair and unsafe conditions throughout multiple halls and rooms. Surveyors observed missing floor tiles, loose baseboards, chipped paint, exposed and damaged drywall, exposed metal screws, and multiple resident room doors with scratched and chipped wood. Several rooms had exposed electrical cable wires running from wall vents to the ceiling, and long electrical cords were hanging from outlets onto walking pathways in more than one hall. A wall-mounted heating/cooling unit had its cover removed and lying outside on the ground amid debris, and other units had crumbling, discolored drywall and missing wood framing. The main dining room had exposed drywall without baseboards, and visitor bathrooms for men and women were posted as out of order during the survey period. The facility lacked available maintenance work orders for an extended period, and leadership acknowledged that many repairs were needed.
The facility failed to provide timely meals in accordance with posted meal times, resulting in several residents receiving breakfast and lunch trays significantly later than scheduled and interfering with at least one resident’s ability to attend an activity. Staff were observed delivering a large number of unserved room trays well past the designated meal periods, and residents reported that their trays had just been delivered while they were eating much later than the scheduled times. Facility documentation noted concerns about meal trays not being picked up from rooms and the need for CNAs to return trays promptly, while staff acknowledged that the kitchen was far behind and that there were too many room trays being delivered late.
Two residents with dementia-related diagnoses were involved in a physical altercation when one, known for aggressive behaviors, struck another in the eye while assisting with post-meal cleanup. Despite existing care plans and staff presence, the incident occurred in the Memory Care Unit, and both residents were assessed with no injuries noted. The event was reported according to policy, but the facility did not prevent the physical abuse.
A resident who consistently felt cold was deprived of his personal jacket by a CNA, who removed it in response to the resident's exit-seeking behaviors. The jacket was not returned, leaving the resident to use a blanket for warmth and causing ongoing discomfort. Staff and the DON were aware of the situation, but no further investigation was conducted, and the jacket was never recovered.
A resident's family and Power of Attorney observed the resident was cold and missing his jacket, which a CNA admitted to withholding to prevent the resident from leaving. The incident was documented, but the DON delayed notifying the Administrator, and the allegation was not reported to the state agency as required by policy.
A resident's family and Power of Attorney reported that the resident was left without his jacket and was cold after a CNA took it away due to exit-seeking behaviors, stating she would not return it. Despite the facility's policy requiring investigation of all abuse allegations, no investigation was documented, and the administrator confirmed that none was conducted.
Three residents with significant mobility impairments and care plans requiring full mechanical lift transfers were not consistently transferred using the required equipment. Staff manually transferred a resident when no clean slings were available, and others used alternative methods such as sit-to-stand lifts, despite documentation specifying full mechanical lift use. Staff interviews revealed confusion about transfer requirements and inconsistent communication regarding care plan updates.
A resident was transferred twice to the ER for a leg rash later diagnosed as cellulitis, but the facility failed to complete a thorough and accurate assessment before the second transfer. The LPN used outdated vital signs and did not document current observations, evaluations, or notifications to the physician and family, as required by facility policy. The Assistant DON confirmed these documentation gaps.
A resident identified as at risk for falls did not have the required non-slip material in her wheelchair, as specified in her care plan. Observation confirmed the absence of this intervention, and an LPN verified that the non-slip material was not in place, despite the resident's history of being found in a position suggestive of a fall risk.
Four cognitively impaired residents were involved in two separate incidents of resident-to-resident physical abuse. In one case, a resident with a history of aggression placed his hands around another resident's neck and squeezed, while in another, a resident struck a peer in the face. Both aggressors had documented behavioral issues and prior aggressive episodes, but the facility did not prevent these altercations despite known risks.
A resident with a history of paraplegia, ESBL resistance, and urine retention did not have a urine sample collected in a timely manner as ordered by a physician. The DON completed a lab requisition but did not enter the order into the system, resulting in staff not being alerted to collect the specimen. The urine sample was collected several days late, despite the facility's policy requiring prompt entry of physician orders.
A resident with multiple diagnoses, including Dementia and Schizoaffective Disorder, was physically abused by an agency CNA in a LTC facility. The incident occurred when the resident became combative, and the CNA reflexively struck the resident on the head. The facility's administrator was notified, and the CNA was suspended pending investigation. The incident was reported to the police, and the resident was sent to a hospital for evaluation.
The facility failed to resolve resident grievances in a timely manner, with issues such as unchecked smoke detectors and CNAs using phones while feeding residents repeatedly documented in Resident Council Minutes. The Resident Council President noted that grievances are often unresolved, affecting all 64 residents.
The facility did not schedule a Registered Nurse (RN) for at least eight consecutive hours on specific days, as required by their staffing policy. Instead, only Licensed Practical Nurses (LPNs) were on duty, which was confirmed by the Administrator. This deficiency potentially affects the well-being of all 64 residents in the facility.
The facility did not inform residents that signing an arbitration agreement was not a condition of admission and that they could rescind the agreement within 30 days. This was confirmed through a review of agreements for two residents and an interview with a staff member, affecting all 64 residents.
The facility did not ensure the QAA Committee had the required members or met quarterly. The Administrator, employed for seven months, acknowledged no meetings occurred due to a lack of training. The Medical Director did not attend meetings, and there was no Infection Preventionist since January 2024, potentially affecting all 64 residents.
The facility failed to implement an Antibiotic Stewardship Program, affecting all 64 residents. Despite having a policy, the program was not executed, and there was no monitoring of infections. Two residents had antibiotic orders, but the Regional Director confirmed the absence of a stewardship program, infection monitoring, an Infection Preventionist, and necessary logs.
The facility failed to designate a qualified Infection Preventionist, impacting its ability to manage infection control for all 64 residents. Despite ongoing antibiotic treatments for infections in two residents, the facility lacked documentation for infection monitoring and tracking, and has not had an Infection Preventionist since January 2024.
The facility failed to provide influenza vaccines to eligible residents during the flu season, as required by their policy and state guidelines. Despite having physician orders for annual flu vaccines, no vaccines were administered, and none were available in the medication rooms. The Regional Director of Operations confirmed that an outside company contracted to provide the vaccines had not done so, and the facility had not ordered any vaccines.
A facility failed to complete a PASARR screening for a resident admitted with cerebral infarction, anxiety disorder, and major depressive disorder. The resident's medical record lacked the required screening, which the administrator and Business Office Manager acknowledged was not conducted prior to admission, as the hospital also did not perform it.
The facility did not update care plans for two residents as required. One resident's care plan lacked documentation of hospice services, while another's did not reflect a stage 2 pressure wound despite having wound care orders. The Regional Director of Operations confirmed these omissions.
Two residents were inappropriately prescribed Quetiapine, an antipsychotic medication, without proper indications. One resident with unspecified dementia and a BIMS score indicating cognitive intactness was prescribed Quetiapine for dementia, which is not an appropriate diagnosis for the medication. Another resident was prescribed Quetiapine for sleep, which is also inappropriate. The facility failed to adhere to guidelines for the use of psychotropic medications.
The facility failed to follow its Enhanced Barrier Precaution policy, leading to deficiencies in care for two residents. Staff members, including a registered nurse and CNAs, did not wear gowns during high-contact activities, and a LPN did not use appropriate PPE during wound care. The staff lacked training on EBP, and the facility did not provide accessible gowns, as acknowledged by the Director of Operations.
A resident with anxiety and dementia did not receive 15 doses of prescribed Lorazepam due to unavailability. Several LPNs failed to notify the physician or obtain the medication from the emergency supply, and they incorrectly documented that the medication was administered. The facility did not adhere to its policy requiring physician notification of medication errors.
A resident with anxiety and cognitive impairments did not receive 15 doses of prescribed Lorazepam due to unavailability. LPNs failed to request the medication from the Emergency Box or notify the physician, and they inadvertently documented that the medication was administered. This resulted in a significant medication error.
A resident at high risk for pressure ulcers developed a stage three ulcer due to the facility's failure to implement preventive measures and perform required skin checks and treatments. The resident's care plan lacked necessary interventions, and staff did not consistently reposition the resident or use pressure-relieving devices. Communication issues and the absence of key coordinators contributed to these deficiencies.
A resident in a LTC facility fell out of bed and sustained a femur fracture due to the bed being left in a high position and personal items out of reach. Additionally, the resident fell forward out of a wheelchair in a facility van due to improper securing, resulting in neck and shoulder pain. The facility failed to follow its fall prevention and van usage policies, and did not document or investigate the incidents.
A resident's MDS assessments were inaccurately completed, failing to document a fall with major injury and a pressure ulcer. The facility lacked a dedicated MDS Coordinator, leading to discrepancies in the resident's medical records, as confirmed by the DON and Administrator-In-Training.
A cognitively intact resident was disrespected by an RN who made a rude comment while the resident was on the phone with his mother. The resident felt disrespected, and the incident was confirmed by the facility's Administrator-In-Training.
The facility failed to revise a Comprehensive Care Plan for a resident at risk for wandering and elopement. Despite staff interventions and the resident's documented risk, the Care Plan did not include necessary goals or interventions, as confirmed by the Administrator and DON.
The facility failed to provide adequate supervision for a resident with severe cognitive impairment and a history of falls, leading to the resident's unsupervised exit and fall. All CNAs were in the dining room during mealtime, and no one was assigned to monitor the halls, contrary to the facility's policies.
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.
Failure to Implement Care-Planned Fall Prevention Intervention
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall prevention intervention for a resident identified as being at risk for falls. The facility’s Fall Prevention Policy dated 01/26 states that residents at risk for falls will have appropriate safety interventions implemented based on individual assessment, and that accident/incident reports involving falls will be reviewed by the Interdisciplinary Team (IDT) to ensure appropriate care and services. The resident, an individual with dementia and abnormalities of gait, had an unwitnessed fall on 2/24/26, after slipping out of a vinyl or leather recliner while attempting to get up. Following this incident, the IDT identified the root cause as slipping from the recliner and determined that non-skid material should be applied to the recliner seat as an intervention. The resident’s current care plan documented that non-skid material was to be applied to the recliner to reduce the risk of sliding out of the chair. However, during an observation on 4/30/26, the resident’s recliner, located to the right side of the bed, did not have any non-skid material on the seat as required by the care plan. A CNA confirmed that the recliner did not have non-skid material and stated they had never seen such material on the resident’s recliner seat. The DON also stated that the recliner seat should have non-skid material, confirming that the planned fall prevention intervention had not been implemented as documented.
Widespread Environmental Disrepair and Unsafe Conditions Throughout Facility
Penalty
Summary
The facility failed to provide a functional, safe, clean, and comfortable environment for residents, staff, and the public, affecting all 71 residents in the building. The Maintenance Director job description required planning, organizing, and directing maintenance operations, repairing facility and resident property, coordinating outside vendors when needed, maintaining supplies and equipment for a safe environment, promptly reporting damage to the Administrator, and conducting weekly inspections to ensure quality control. Despite these requirements, the former Maintenance Director was terminated for incompetence, substandard productivity, and unsatisfactory job performance, including failure to complete tasks related to facility environment issues identified during a health survey. Additionally, the Administrator in Training was unable to provide maintenance work orders for a period of over six weeks, indicating a lack of documented maintenance follow-through. Surveyor observations throughout multiple halls and rooms showed widespread physical plant deterioration and unsafe conditions. These included missing floor tiles at the entry to Hall A; loose and peeling baseboards; chipped paint and exposed drywall in several rooms; exposed metal screws; and multiple resident room doors with scratched, missing paint and chipped wood. In Hall B, rooms had chipped drywall, exposed black, white, and green electrical cable wires running from wall vents to the ceiling, and a wall-mount heating/cooling unit with its cover off and lying on the ground outside, covered with leaves and debris. Electrical cords approximately six feet long were hanging from outlets onto walking pathways in Halls B and D. Additional deficiencies included large exposed drywall patches, multiple drywall holes and scratches, crumbling and discolored drywall around heating/cooling units, missing wood framing, and exposed drywall without baseboards in the main dining room. The men’s and women’s visitor bathrooms were posted as out of order over two consecutive survey days, and the AIT acknowledged that the building needed many repairs and that the visitor bathrooms were not operational.
Delayed Meal Service and Tray Management Issues
Penalty
Summary
The deficiency involves the facility’s failure to provide meals and snacks at appropriate times in accordance with residents’ needs and the posted meal schedule. The facility’s dietary menu for the week indicated set meal times of 8:00 a.m. for breakfast, 12:00 p.m. for lunch, and 5:00 p.m. for dinner. Despite this, surveyors observed multiple residents receiving and consuming meal trays significantly later than these scheduled times. One resident reported still finishing breakfast at 11:09 a.m. and stated they missed a 10:00 a.m. activity because their breakfast tray was delivered late. Another resident was just beginning to eat a lunch tray at 2:11 p.m. and stated they had just received their lunch. Additional residents were observed eating lunch trays around 2:07–2:08 p.m. and reported that their trays had just been delivered. The facility’s own documentation reflected concerns with tray management and timeliness. A concern/compliment form noted that trays were not being picked up from rooms at night and that staff did not always pick up a specific resident’s meal tray. An in-service sign-in sheet documented training for CNAs emphasizing that breakfast, lunch, and dinner trays needed to be collected and returned to the kitchen and not left in residents’ rooms. During the survey, staff were observed pushing a dietary meal tray cart containing 13 unserved room trays, and the activity staff stated the kitchen was “really far behind” that day. The Administrator in Training acknowledged there were too many room trays and that residents should not be receiving trays so late, confirming the pattern of delayed meal service and tray pickup for multiple residents.
Failure to Prevent Resident-to-Resident Physical Abuse in Memory Care Unit
Penalty
Summary
The facility failed to prevent physical abuse between residents in the Memory Care Unit, specifically involving two residents with dementia-related diagnoses. One resident, who had a documented history of verbal and physical aggression, was assisting with cleaning after a meal and attempted to remove another resident's lunch tray. The second resident reached out as the tray was being removed, and the first resident responded by striking the second resident in the eye. Staff interviews and record reviews confirmed that the incident occurred in the dining area, and that the aggressive resident had a care plan in place addressing behavioral issues, including interventions to minimize disruptive behaviors. At the time of the incident, staff were present in the unit, and an LPN reported hearing a loud noise and observing the aftermath, with the victim covering his eyes and stating he was hurt. Both residents were assessed following the altercation, and no physical injuries were noted. The facility's policies affirm residents' rights to be free from abuse, and the event was reported to the state agency as required. However, the incident demonstrates a failure to effectively implement interventions and supervision to prevent resident-to-resident physical abuse.
Resident Deprived of Personal Jacket Due to Exit-Seeking Behaviors
Penalty
Summary
The facility failed to protect a resident from abuse by depriving him of his personal jacket, which he relied on for warmth due to his constant feeling of being cold. The resident's jacket was taken by a Certified Nursing Assistant (CNA) because the resident was exhibiting exit-seeking behaviors, and the CNA believed that having the jacket increased these behaviors. The jacket was placed in the shower room and not returned to the resident, despite his repeated requests and complaints of being cold. The resident was observed using a blanket to keep warm in the absence of his jacket, and both the resident and his family reported his ongoing discomfort and distress due to the missing jacket. Multiple staff members, including the Director of Nursing (DON) and other CNAs, were aware that the jacket had been taken and that the resident was left without it for several weeks. The facility's policy prohibits the deprivation of goods or services necessary for residents' well-being, yet no further investigation was conducted by the DON after being notified of the incident. The resident's family and Power of Attorney also raised concerns about the deprivation, but the jacket was never recovered, and the resident continued to experience discomfort as a result.
Failure to Immediately Report Alleged Abuse to Administrator and State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was immediately reported to the Administrator and the State Agency, as required by facility policy. According to documentation, a family member and a Power of Attorney visiting a resident noticed the resident was without his jacket and was cold. A Certified Nursing Assistant informed them that she had taken the resident's jacket and placed it in the shower room because the resident wanted to leave the facility, and she was not going to return it. The concern was documented on a facility form, but the Director of Nursing did not notify the Administrator until the following day. Additionally, as of the date of the survey, there was no documentation that the allegation of potential abuse had been reported to the state agency, contrary to the facility's policy requiring immediate reporting.
Failure to Investigate Allegation of Potential Abuse
Penalty
Summary
The facility failed to investigate an allegation of potential abuse involving one resident. According to the facility's own Abuse Prevention and Reporting policy, any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property requires an investigation. On 6/15/2025, a resident's family member and Power of Attorney observed that the resident did not have his jacket and was cold, and were informed by a Certified Nursing Assistant that she had taken the jacket because the resident was exhibiting exit-seeking behaviors and intended to keep it from him. This incident was documented on a Concern/Compliment Form, but as of 9/17/2025, there was no documentation of any investigation into the allegation. The facility administrator confirmed that no investigation had been conducted regarding this potential abuse.
Failure to Use Required Mechanical Lifts for Dependent Residents
Penalty
Summary
The facility failed to ensure that three residents who required a full mechanical lift for transfers were consistently transferred using the appropriate equipment, as specified in their care plans and facility policy. Observations, interviews, and record reviews revealed that these residents were either manually transferred by staff or transferred using alternative equipment, such as a sit-to-stand lift, instead of the required full mechanical lift. Staff reported that on at least one occasion, a resident was manually transferred by two CNAs because there were no clean slings available for the mechanical lift, and the resident did not have a sling under her, making the lift unusable at the time of transfer. The care plans and Kardex sheets for the three residents clearly documented the need for a full body mechanical lift for all transfers. Despite this, staff interviews indicated a lack of consistent adherence to these documented requirements. Some CNAs stated they relied on verbal instructions from therapy staff or other CNAs rather than the written care plans or Kardex, leading to confusion and inconsistent transfer practices. Additionally, there was a lack of communication among staff regarding changes in transfer status, with some staff unaware of where to find the correct information in the electronic charting system. The residents involved had significant medical conditions affecting their mobility, including dementia, muscle wasting, orthopedic issues, and hereditary spastic paraplegia. All were dependent on staff for transfers and used wheelchairs for mobility. At the time of the deficiency, observations confirmed that these residents did not have full mechanical lift slings under them, and staff acknowledged using manual or alternative transfer methods contrary to the care plan. The facility's own investigation confirmed that the failure to use the mechanical lift as required was due to a lack of proper equipment setup and communication lapses among staff.
Failure to Accurately Assess and Document Resident Condition Prior to Hospital Transfer
Penalty
Summary
The facility failed to thoroughly assess and accurately document the condition of a resident who was transferred to the emergency room for a rash on the leg, later diagnosed as cellulitis. The facility's policy requires comprehensive assessment and documentation during incidents and significant status changes, including reviewing previous notes, documenting findings, and notifying relevant parties. However, the Change in Condition Evaluation form completed by an LPN on the day of the second transfer lacked updated vital signs, relevant observations, and a summary of the nurse's evaluation and recommendations. The vital signs and notification times recorded were from the previous day, and the most recent blood glucose value was several months old. Additionally, the form did not indicate whether the condition had occurred before, incorrectly marking it as "Unknown" despite the same issue prompting a hospital visit the previous day. There was also no documentation of updated notifications to the primary care clinician or the resident's healthcare power of attorney regarding the second transfer. These omissions were confirmed by the Assistant Director of Nursing, who acknowledged the lack of accurate and current assessment and notification documentation for the resident's second emergency room transfer.
Failure to Implement Fall Prevention Intervention for At-Risk Resident
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in its Fall Prevention Program for one resident identified as at risk for falls. The program requires individualized assessment and the use of appropriate interventions, including assistive devices, for residents at risk. Documentation showed that a non-slip material was to be added to the resident's wheelchair as a fall prevention measure. However, during observation, the resident was seen propelling herself in the dining room without the required non-slip material in her wheelchair. This was confirmed by a Licensed Practical Nurse present at the time. Additionally, nurse's notes indicated that the resident had previously been found sitting half-upright near her bed, further indicating a risk for falls.
Failure to Prevent Resident-to-Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect four cognitively impaired residents from abuse, specifically failing to prevent resident-to-resident physical abuse. Two separate incidents occurred involving residents with severe cognitive impairment and documented behavioral issues. In the first incident, one resident with a history of aggressive and combative behavior placed both hands around another resident's neck and forcefully squeezed, requiring staff intervention to separate them. The aggressor had a documented pattern of aggression towards staff and peers, including previous episodes of hitting, scratching, and resisting care. Both residents involved were unable to recall the incident due to their cognitive status. In the second incident, another resident with dementia and a history of behavioral problems struck a peer in the face with a closed fist. The aggressor was observed by staff walking quickly toward the victim, calling her by an incorrect name, and then hitting her. The victim complained of pain and had visible redness on her face. Both residents involved in this incident were also severely cognitively impaired and unable to recall the event during subsequent assessments. Staff interviews and record reviews revealed that both aggressors had known histories of aggression and behavioral disturbances, including prior physical altercations and resistance to care. Despite these known risks, the facility did not implement effective interventions to prevent these incidents. The facility's abuse policy affirms residents' rights to be free from abuse and outlines the responsibility to prevent such occurrences, yet the events described demonstrate a failure to uphold these protections for the residents involved.
Failure to Timely Obtain Ordered Urine Sample
Penalty
Summary
The facility failed to follow a physician's order to obtain a urine sample in a timely manner for a resident with a history of paraplegia, depression, ESBL resistance, and urine retention. The resident was on enhanced barrier precautions and required straight catheterization every four hours while awake, with additional catheterization as needed at night. The care plan identified the resident as being at risk for urinary tract infection (UTI) due to their diagnoses and catheterization needs, and noted the presence of a colonized multi-drug resistant organism (ESBL) in the urine. A physician's order for bloodwork and urinalysis (UA) was received after concerns were raised about the resident's behavior and fatigue. Despite the order, the Director of Nursing (DON) completed a laboratory requisition form and provided it to the floor nurse but did not enter a laboratory order into the system, which would have alerted staff to collect the specimen. As a result, staff failed to obtain the urine sample for several days, missing the appropriate collection window. The urine specimen was eventually collected several days after the order was received, and laboratory results showed abnormal findings. The facility's policy required that telephone orders be entered into the resident's chart under the order tab, but this was not done in this instance, leading to the delay.
Failure to Prevent Staff Physical Abuse of Resident
Penalty
Summary
The facility failed to prevent staff physical abuse for a resident, identified as R1, who was at high risk for mistreatment due to a history of previous incidents. R1, who has diagnoses including Dementia, Schizoaffective Disorder, Major Depressive Disorder, Anxiety Disorder, and Generalized Idiopathic Epilepsy, was involved in an incident where a Certified Nursing Assistant (CNA) from an agency allegedly struck R1 on the head. The incident occurred when R1 became combative during assistance, leading to the CNA's reflexive action of hitting R1. This incident was reported by an LPN to the facility administrator, and the CNA was immediately suspended pending investigation. The investigation revealed that the CNA admitted to hitting R1, describing it as a reflexive action after being punched by R1. The facility's social service assistant conducted interviews with staff and residents, confirming the CNA's admission. The incident was reported to the police, and R1 was sent to a local hospital for evaluation. The facility's administrator took immediate action by notifying the staffing agency and ensuring the CNA was placed on a do-not-return list. Despite these actions, the facility's failure to prevent the abuse and protect R1 from harm constitutes a deficiency in their care standards.
Failure to Resolve Resident Grievances Timely
Penalty
Summary
The facility failed to ensure that resident grievances were resolved in a timely manner, as evidenced by repeated unresolved issues documented in the Resident Council Minutes over several months. The facility's policy encourages residents to voice grievances without fear of reprisal and mandates that the Administrator promptly resolve these complaints. However, the Resident Council Minutes from May to October document ongoing issues, such as the need for smoke detectors to be checked and concerns about CNAs using their phones and eating while feeding residents. These grievances were repeatedly brought up in meetings without resolution. The Resident Council President confirmed that grievances are often filed on behalf of the facility but remain unresolved, leading to their recurrence in subsequent meetings. The facility's policy requires the Social Service Director to notify residents and their representatives of the resolution, but this follow-up appears to be lacking. The failure to address these grievances affects all 64 residents residing in the facility, as indicated by the facility's Long Term Care Facility Application for Medicare and Medicaid.
Failure to Schedule Registered Nurse Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least eight consecutive hours each day, which is a requirement for maintaining the highest practical physical, mental, and psychosocial well-being of each resident. This deficiency was identified through a review of the facility's undated Nurse Staffing Policy and untitled daily assignment sheets for specific dates. The policy mandates that a minimum of 10% of nursing and personal care time should be provided by RNs. However, on the dates of 10/02/24, 10/09/24, and 10/16/24, all nurses working were Licensed Practical Nurses (LPNs), with no RNs scheduled. This was confirmed by the facility's Administrator, who acknowledged the lack of RN coverage on these days. The facility's application for Medicare and Medicaid, dated 10/29/24, indicates that 64 residents currently reside in the facility.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that residents were informed that signing an arbitration agreement was not a condition of admission and that they had the right to rescind the agreement within 30 days of signing. This deficiency was identified through a review of the arbitration agreements for two residents, dated 05/09/23 and 07/06/23, which lacked language notifying residents of these rights. An interview with a staff member confirmed that the arbitration agreements did not include documentation stating that signing was not a condition of admission or that the agreement could be rescinded within 30 days. This oversight has the potential to affect all 64 residents currently residing in the facility.
Failure in QAA Committee Meetings and Membership
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) Committee had the required number of members and did not meet at least quarterly as mandated. The facility's Quality Assurance Plan, dated August 1, 2017, specifies that the QAA Committee should conduct quarterly meetings at a minimum. However, the Administrator, who has been employed for seven months, admitted that no quarterly QAA meetings had occurred during her tenure. She attributed this to a lack of education and training on conducting the meetings. Additionally, the Medical Director had not attended any meetings, and there was no Infection Preventionist at the facility since January 2024. This oversight has the potential to affect all 64 residents residing in the facility.
Lack of Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an Antibiotic Stewardship Program, which is essential for promoting the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This deficiency potentially affects all 64 residents in the facility. The facility's policy, dated 12/12/18, outlines the purpose of the program, but it was not put into practice. Specific instances include a resident with a physician's order for Doxycycline for skin wounds and another resident with an order for Clindamycin for a left toe infection. Despite these orders, the Regional Director of Operations confirmed that there was no Antibiotic Stewardship Program, no monitoring of infections, no Infection Preventionist, and no Infection/Antibiotic logs or Infection Prevention and Control Program in place.
Lack of Infection Preventionist in Facility
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) responsible for the Infection Prevention and Control Program, which is crucial for assessing, developing, implementing, monitoring, and managing infection control measures. This deficiency potentially affects all 64 residents in the facility. The facility's policy, dated December 7, 2018, mandates routine surveillance and monitoring to ensure compliance with infection control practices and requires at least a part-time Infection Control Preventionist. However, the facility was unable to provide documentation or logs for infection monitoring and tracking, indicating a lapse in adherence to its own policy. The report highlights specific cases involving two residents receiving antibiotics for infections. One resident was administered Doxycycline for skin wounds, while another received Clindamycin for a left toe infection. Despite these ongoing treatments, the facility lacked an Infection Preventionist since January 2024, as confirmed by the Administrator and the Regional Director of Operations. This absence of a designated IP raises concerns about the facility's ability to effectively manage and control infections, as there is no individual responsible for overseeing these critical functions.
Failure to Administer Influenza Vaccines
Penalty
Summary
The facility failed to provide influenza vaccinations to residents eligible for the vaccine during the flu season, as required by their own policy and state guidelines. The facility's policy, dated 10/10/22, mandates the administration of the influenza vaccine throughout the flu season, from the receipt of the vaccine until March 1. However, the facility did not have any influenza vaccines available in their medication rooms as of 10/31/24, and no vaccines had been administered to residents or staff since the start of the flu season. This failure affected five residents, all of whom had physician orders indicating they could receive the annual flu vaccine with consent unless contraindicated. Each of these residents last received the influenza vaccine on 10/03/23, indicating a lapse in the current flu season's vaccination efforts. The Regional Director of Operations confirmed that the facility had not provided influenza vaccines for residents or staff and that an outside company contracted to administer the vaccines had not done so. The director was unaware of when the vaccines would be administered and stated that the facility had not ordered any influenza vaccines. This lack of action and preparation resulted in the facility's inability to minimize the risk of acquiring, transmitting, and suffering complications from influenza for the residents reviewed.
Failure to Complete PASARR Screening for Resident
Penalty
Summary
The facility failed to ensure a PASARR (Pre-Admission Screening and Resident Review) screening was completed for one of the five residents reviewed for PASARR screenings. The resident, identified as R28, was admitted to the facility with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of the basilar artery, generalized anxiety disorder, and major depressive disorder, recurrent, moderate. Upon review, it was found that R28's medical record did not include a completed PASARR screening. The facility's administrator acknowledged that the screening was not done and stated that all residents should have a screening prior to admission. The Business Office Manager also confirmed that the resident was supposed to be screened before admittance and admitted that the facility failed to conduct the screening after the hospital did not perform it prior to the resident's admission.
Failure to Revise Care Plans for Hospice and Pressure Wound
Penalty
Summary
The facility failed to revise care plans for two residents, which was identified during a review of 16 residents for care plan revisions. According to the facility's policy on Comprehensive Care Planning, care plans should be revised when the needs or problems of a resident change. However, the care plan for one resident, who was placed on hospice services per a physician's order, did not include hospice care. Another resident with a stage 2 pressure wound on the coccyx had wound care orders, but the care plan was not updated to reflect this condition. The Regional Director of Operations confirmed that the care plans for these residents were not revised as required.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to provide an appropriate indication for the use of antipsychotic medications for two residents. The first resident, identified as R6, was diagnosed with unspecified dementia without behavioral, psychotic, or mood disturbances. Despite this, R6 was prescribed Quetiapine, an antipsychotic medication, for dementia, which is not an appropriate diagnosis for this medication. The resident's mental status was assessed as cognitively intact, with a BIMS score of 15, and the care plan noted behaviors of hoarding and paranoia, but these did not justify the use of Quetiapine. The second resident, R14, also diagnosed with unspecified dementia without behavioral disturbance, was prescribed Quetiapine for sleep, which is not an appropriate use of the medication. R14's BIMS score also indicated cognitive intactness, and the care plan documented a history of wandering near exits as the only behavior. The Director of Operations confirmed that the use of Quetiapine for sleep was inappropriate, highlighting the facility's failure to adhere to guidelines for the use of psychotropic medications.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precaution (EBP) policy, which aims to reduce the transmission of multidrug-resistant organisms (MDRO). This deficiency was observed in the care of two residents. The first resident, who had a supra pubic indwelling catheter and a jejunostomy tube, did not receive care in accordance with EBP guidelines. A registered nurse and two certified nursing assistants provided care without wearing gowns, which are required during high-contact activities to prevent MDRO transmission. The staff members involved were not aware of the EBP requirements and had not received training or in-service education on the policy. Additionally, the facility lacked accessible gowns for staff use, and the Director of Operations acknowledged the failure to implement EBP throughout the facility. In another instance, a licensed practical nurse performed wound care for a resident with a coccyx wound without wearing the necessary enhanced barrier personal protective equipment, specifically a gown. The nurse stated that she was not required to wear gowns during wound treatment, indicating a lack of understanding or training regarding the facility's EBP policy. The facility's failure to provide adequate training and resources for staff to follow EBP guidelines contributed to these deficiencies.
Failure to Notify Physician of Medication Omission
Penalty
Summary
The facility failed to notify a physician of a medication error/omission for a resident diagnosed with Anxiety Disorder, Panic Disorder, Dementia, and Alzheimer's Disease. The resident had an order for Lorazepam 0.5 milligrams to be administered three times a day. However, the medication was not available between specific dates, and the doses were not administered as required. Despite the unavailability of the medication, several Licensed Practical Nurses (LPNs) inadvertently signed off that the medication had been administered when it had not. The facility's policy required that the physician be notified of any medication errors or omissions, but this was not done. The incident investigation revealed that the LPNs involved did not notify the physician or request the medication from the emergency supply when it was unavailable. The Director of Nurses confirmed that the resident missed 15 doses of the scheduled medication and that there was no documentation of physician notification during this period. The failure to notify the physician and the incorrect documentation of medication administration were identified as deficiencies in the facility's adherence to its medication administration policy.
Significant Medication Error Due to Unavailability and Misdocumentation
Penalty
Summary
The facility failed to ensure that a resident received prescribed medication for anxiety as per the physician's order, resulting in a significant medication error. The resident, who has diagnoses including Anxiety Disorder, Panic Disorder, Dementia, and Alzheimer's Disease, was prescribed Lorazepam (Ativan) 0.5 milligrams to be taken three times daily. However, the medication was not administered as prescribed between September 15 and September 20, 2024, due to unavailability. Despite the lack of medication, several LPNs inadvertently signed off that the medication had been administered, which was not the case. The incident investigation revealed that the medication was not available in the building, and the LPNs did not request the medication from the Emergency Box or notify the physician about the unavailability. The Director of Nurses confirmed that the resident missed 15 doses of the scheduled medication during this period. The failure to administer the medication as prescribed and the incorrect documentation of its administration constituted a significant medication error, as the facility did not adhere to its policies regarding medication administration and physician notification.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to develop and implement appropriate pressure ulcer prevention and care interventions for a resident identified as high risk for pressure ulcers. The resident, who was admitted with conditions including paraplegia and wheelchair dependence, was assessed with a high risk for pressure ulcers using the Braden Scale. However, the facility did not conduct further Braden Scale assessments after admission, nor did they include pressure ulcer risks or interventions in the resident's care plan. This oversight contributed to the development of a stage three pressure ulcer on the resident's right medial ankle. The facility also failed to perform daily skin checks and physician-ordered wound treatments as required. Despite a physician's order for skin checks every shift and specific wound care treatments, the facility only conducted weekly skin checks and did not consistently apply the prescribed treatments. The resident's medical records lacked documentation of the pressure ulcer's stage and size when it was first identified, and there was no evidence of a care plan update to address the ulcer and prevent further skin breakdown. Interviews with staff and family members revealed that the resident was not repositioned as needed, and pressure-relieving devices were not used consistently. The facility lacked a Care Plan Coordinator or MDS Coordinator, which contributed to the absence of necessary assessments and care plan updates. The Director of Nursing was unaware of the wound clinic's orders for daily skin checks, indicating a communication breakdown within the facility regarding the resident's care needs.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure a resident's bed was kept in the lowest position, which led to the resident falling out of bed while reaching for his cell phone. The resident's bed was left in a high position, and personal items, including the cell phone and bed remote, were not within reach. This resulted in the resident sustaining a left femur fracture. The resident's family member reported that the staff consistently left the bed in a high position despite being informed of the need to keep it low. Additionally, the resident's call light was not within reach, and there was a delay in staff response when the resident called for help after the fall. The facility also failed to ensure the resident was secure while being transported in the facility van. The maintenance assistant, who was not trained in securing residents in wheelchairs, transported the resident to a wound clinic. During the trip, the assistant had to brake suddenly, causing the resident to fall forward out of the wheelchair and hit his head. The resident experienced neck and shoulder pain and was taken to the emergency room for assessment. The incident was not documented in the resident's medical record, and no investigation into the root cause or implementation of new fall interventions was conducted. The facility's policies on fall prevention and van usage were not adequately followed. The fall prevention policy required immediate assessment and documentation of falls, as well as discussion in quality assurance meetings and updates to care plans. However, these steps were not taken following the resident's falls. Similarly, the van usage policy required securing seat belts and ensuring residents were safely secured, which was not adhered to, leading to the resident's fall in the van.
Inaccurate MDS Assessments for Resident with Fall and Pressure Ulcer
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for a resident, identified as R1, who experienced changes in condition. The MDS Coordinator/Care Plan Coordinator was responsible for ensuring the timely and accurate completion of these assessments. However, R1's MDS assessments did not reflect the resident's actual medical conditions. Specifically, R1 had a fall on July 19, 2023, which resulted in a major injury, but this was not documented in the MDS assessment. Additionally, R1 had a pressure ulcer on the right ankle since September 10, 2023, which was not recorded in the MDS assessments dated December 28, 2023, and March 25, 2024. The inaccuracies in the MDS assessments were confirmed through interviews with the Director of Nursing and the Administrator-In-Training. The facility did not have a dedicated MDS Coordinator, and the Corporate MDS Coordinator was responsible for completing the assessments. The failure to accurately document R1's fall and pressure ulcer in the MDS assessments indicates a deficiency in the facility's assessment process, as these conditions were present and should have been recorded. This oversight highlights a lapse in the facility's responsibility to maintain accurate and up-to-date resident assessments.
Failure to Treat Resident with Respect
Penalty
Summary
The facility failed to ensure a staff member treated a resident with respect. The incident involved a cognitively intact resident who was restricted to one cigarette due to tornado warnings. When the resident called his mother to discuss the situation, the RN made a disrespectful comment, asking the resident what he was 'tattling' about. The resident felt disrespected by the RN's harsh and rude tone. The resident's mother also reported hearing the RN's disrespectful comment during the phone call. The facility's Administrator-In-Training confirmed the incident and acknowledged that the RN did not treat the resident with respect.
Failure to Revise Comprehensive Care Plan for Resident at Risk of Wandering
Penalty
Summary
The facility failed to revise a Comprehensive Care Plan for a resident identified as R1, who was at risk for wandering and elopement. Despite R1's Wandering-Elopement Evaluation Scale indicating a score of 10, which classifies the resident as 'At risk to wander/exit seek,' the current Care Plan did not document any goals or interventions addressing these concerns. Interviews with staff, including a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), confirmed that R1 exhibited behaviors such as expressing a desire to go home or leave the facility, and staff had to intervene daily to redirect her. However, these behaviors were not reflected in the Care Plan as required by the facility's policy. The facility's Comprehensive Care Plan Policy mandates that Care Plans be revised as necessary to reflect the resident's current needs and conditions. Both the Administrator and the Director of Nursing (DON) acknowledged that R1's Care Plan should have been updated to include her wandering and elopement risks. The failure to update the Care Plan was identified during a review of R1's records and confirmed through staff interviews, highlighting a lapse in adhering to the facility's policy for maintaining accurate and up-to-date Care Plans for residents.
Failure to Provide Adequate Supervision Leading to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident identified as R1, who had a history of falls and was at risk for wandering. On the evening of the incident, R1 was in the dining room for supper but left unassisted and exited through the A-Hall door, falling onto the cement outside. The door alarm was triggered, and staff responded immediately, finding R1 on the ground. Interviews with staff revealed that all CNAs were in the dining room feeding residents, and no one was assigned to monitor the halls during mealtimes. The LPN was also in the dining room passing medications at the time of the incident. The facility's policies on fall prevention and resident monitoring were not effectively implemented, as R1 was not adequately supervised despite being identified as a high risk for falls and wandering. R1's medical records indicated severe cognitive impairment, a history of falls, and a high risk for wandering. The resident's care plan documented the need for supervision due to dementia, impaired decision-making, and other risk factors. Despite these documented needs, the facility did not ensure that staff were monitoring residents who were not in the dining room during mealtimes. The Director of Nursing and the Administrator acknowledged that one CNA should have been monitoring the halls, but this protocol was not followed, leading to R1's unsupervised exit and subsequent fall.
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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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