Axiom Gardens Of Nashville
Inspection history, citations, penalties and survey trends for this long-term care facility in Nashville, Illinois.
- Location
- 485 South Friendship Drive, Nashville, Illinois 62263
- CMS Provider Number
- 146043
- Inspections on file
- 36
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 13 (4 serious)
Citation history
Health deficiencies cited at Axiom Gardens Of Nashville during CMS and state inspections, most recent first.
A resident with severe dementia and a history of aggressive behaviors, including hitting other residents and staff, was known to exhibit disruptive physical and verbal behaviors that significantly interfered with others. Despite care plan interventions such as medication review, redirection, and frequent visual checks, another cognitively impaired resident with multiple psychiatric and neurologic diagnoses, who was not care planned as being at risk for abuse, became involved in a confrontation in a TV room doorway. During this altercation, one resident grabbed the other and used a derogatory term, and the other resident responded by punching the resident in the face, knocking off glasses and causing facial redness, demonstrating a failure to protect the resident from physical abuse.
A facility failed to prevent accidents by not completing or implementing fall risk assessments, not ensuring required alarms and safety devices were in use, and not performing safe transfers. A resident with severe dementia and high ADL needs was admitted without a documented fall risk assessment and later sustained an unwitnessed fall with a hip fracture while attempting to toilet herself. Another resident with vascular dementia and a history of falls had multiple unwitnessed wheelchair falls with head lacerations and LOC, despite being care planned for chair and bed alarms and close visual supervision; surveyors observed her repeatedly without alarms connected and out of staff view. Two residents requiring full-body mechanical lift transfers were lifted while their wheelchairs were left unlocked, and one high fall risk resident had no fall mat in place. A cognitively intact bilateral amputee who smoked was documented on assessments as not smoking and safe to smoke unsupervised, yet staff provided her cigarettes and a lighter and she reported smoking at will, with burn marks noted on her clothing. Exit door alarms were found turned off or malfunctioning, with staff stating alarms were disabled so residents could go outside and the administrator acknowledging ongoing alarm issues despite policies requiring functional elopement systems.
Multiple residents with bowel and bladder incontinence, including one with an indwelling Foley cath and history of UTIs, did not receive complete perineal care or proper infection control during toileting and incontinence care. CNAs were observed wiping only limited areas (such as the anal area or buttocks) without cleansing the full peri, groin, inner thigh, or labial/genital regions, and in one case not cleansing the anal area at all. Staff used wet cloths without soap or peri-cleaner, reused soiled gloves from contaminated tasks to clean residents and handle clothing, linens, and equipment, and failed to perform hand hygiene before donning gloves, between glove changes, and after glove removal. These actions did not follow the residents’ care plans or the facility’s policies on incontinence care, glove use, and hand hygiene.
The facility failed to prevent two separate abuse incidents despite having an abuse prevention policy. In one case, a severely cognitively impaired resident with multiple comorbidities was sexually abused when a staff member kissed the resident on the lips in the resident’s room, an act later admitted by the staff member and substantiated by the facility’s investigation. In another case, a cognitively intact resident with serious medical conditions was verbally harassed outside by another resident, who later threw coffee on the resident as he walked past the aggressor’s room, prompting the victim to push the aggressor in the chest; the incident was witnessed and no injuries were found.
A resident with multiple complex wounds did not receive timely and appropriate wound care as ordered by the NP, including delays and omissions in dressing changes and skin assessments. The low air loss mattress intended to provide pressure relief was not maintained in working order, resulting in the resident experiencing significant pain and worsening wounds. These failures led to multiple infections, hospitalizations, and surgical interventions.
A resident with significant risk factors for skin breakdown developed new and worsening pressure ulcers after staff failed to complete regular skin assessments, ensure wound care supplies were available, and perform wound treatments as ordered. The resident was left in a wheelchair for extended periods without adequate repositioning, and new wounds were only identified by a nurse practitioner during rounds, not by facility staff. Documentation showed repeated lapses in wound care and missed assessments, despite no evidence of the resident refusing care.
Two residents with cognitive impairment and identified elopement risks were able to repeatedly exit the facility unsupervised due to staff failing to monitor or respond to door alarms, doors being left unalarmed or cracked open, and inadequate supervision. One resident was found outside in unsafe conditions, including in the middle of the road and in a visitor's van, while another was found outside in cold weather without proper clothing. Staff interviews confirmed awareness of the risks and repeated incidents, but monitoring and timely responses were inconsistent.
A resident with multiple pressure ulcers and complex medical needs experienced extreme pain due to a malfunctioning low air loss mattress that repeatedly lost inflation, leaving her on a hard bed frame. Staff and family reported the issue, and photographic evidence confirmed the mattress was not maintained in safe working order, despite care plan requirements and facility policy.
A facility-wide assessment was not updated to include required elements such as identification of current Administrator and DON, resources for care during routine and emergency operations, evaluation of staffing needs, resident population details, physical environment, assistive technology, staff training programs, and risk assessments. The Administrator confirmed no additional information or policy was available for the facility assessment, affecting all 60 residents.
The facility did not ensure CNAs received the required 12 hours of annual education, including dementia care and abuse prevention training. Review of records showed that several CNAs received significantly fewer hours than required, and there was no documentation of dementia training or timely training after hire, as mandated by facility policy. This deficiency has the potential to impact all residents in the facility.
A resident with severe cognitive impairment and multiple medical conditions was found outside the facility on several occasions. Although staff documented the incidents and returned the resident safely, there was no evidence that the resident's legal representative was notified as required by facility policy. The representative confirmed she was not informed by the facility about these events.
A resident with a coccyx wound and diagnoses of HIV and Hepatitis B was placed on enhanced barrier precautions, but an LPN failed to follow infection control protocols during wound and incontinence care. The LPN did not change gloves or perform hand hygiene after handling soiled materials and touched multiple surfaces, including the medication cart, before eventually using hand sanitizer. Contaminated dressings and PPE were not disposed of in biohazard bags as required by facility policy.
A resident with multiple comorbidities and high risk for pressure ulcers developed a stage 3 ulcer on the left heel after abnormal findings were repeatedly documented without timely assessment, treatment orders, or completion of physician-ordered care. Facility staff confirmed gaps in documentation and treatment, and the facility's policy for skin breakdown assessment and intervention was not followed.
A facility failed to prevent verbal and mental abuse for four residents, resulting in psychosocial harm. A CNA, identified as V3, refused to assist a resident with dressing in her room, forcing her to dress in the bathroom, leaving her exposed and cold. Another resident was dismissed by V3 when requesting help to get out of bed. Additionally, V3 yelled at two residents with Alzheimer's for not dressing properly and for having an accident. The facility's investigation confirmed V3's actions constituted abuse or neglect.
The facility failed to implement proper infection control measures for COVID-19 positive residents. Staff lacked access to necessary PPE, such as N95 masks and eye protection, and isolation signage was missing. Additionally, a resident exposed to a COVID-positive roommate was not documented as tested, and staff were unaware of proper rooming arrangements. These deficiencies highlight lapses in adhering to the facility's infection control policies.
The facility did not have a qualified Infection Control Preventionist (ICP) working full-time, affecting all 59 residents. The Administrator admitted the absence of an ICP and ongoing hiring efforts. Residents with COVID-19 were present, and the DON, off with a COVID infection, was unaware of the current situation, highlighting a lack of infection control oversight.
The facility failed to maintain a safe environment for three cognitively impaired residents on the dementia unit. A broken window and an unlocked door were observed, posing potential hazards. One resident was seen sitting in the dining room near the broken window, while another walked past the room with broken glass. A third resident, requiring supervision, became confused and agitated near the Alzheimer's unit door. Maintenance staff were unaware of the need for repairs, and the administrator believed the room was locked.
The facility failed to implement progressive fall interventions for two residents, resulting in injuries. One resident, with conditions like cognitive decline, experienced multiple falls with injuries requiring ER visits, yet no new interventions were documented. Another resident sustained a bruise from a mechanical lift incident, with staff unaware of the event. Facility policies on safe lifting and fall prevention were not effectively followed.
A resident with Alzheimer's and other conditions experienced severe weight loss due to the facility's failure to implement nutritional interventions. Despite documented interventions to provide supplements, the resident lost 15.7% of body weight over six months. The RD did not document or communicate dietary recommendations effectively, and the facility's documentation of meal and supplement intake was minimal. Observations showed the resident appeared very thin, and there was poor communication between staff regarding the resident's nutritional needs.
The facility failed to ensure an RN was on duty for at least 8 consecutive hours a day, 7 days a week, as required. Staffing schedules showed no RN coverage on nine specific days, and the facility's administrator acknowledged the shortage. The deficiency potentially affects all 56 residents, with the facility's PBJ Report indicating a one-star staffing rating.
The facility did not post nurse staffing information in a clear and accessible manner, affecting all 56 residents. During a facility tour, it was found that no nursing information was available for review. The PBJ report showed insufficient RN coverage, leading to a 1-star staffing rating. Interviews revealed a lack of awareness about the posting requirement, with the Business Office Manager unsure if staffing information was posted under new management. The facility's assessment and staffing policy highlighted the need for adequate staffing, but no updated assessment was provided.
The facility failed to store and prepare food in a manner preventing contamination, affecting all 56 residents. Observations included a greasy fryer basket, unlabeled and undated food items in the refrigerator, and significant ice buildup in the freezer affecting various food products. The Dietary Manager acknowledged the labeling requirements, and the Maintenance Man was aware of the freezer issues but had not resolved them.
The facility did not ensure its Facility Assessment was current and reviewed annually, potentially affecting all 56 residents. The Administrator confirmed the most recent assessment was from July 2023, and no updated version was provided. The DON stated there was no policy on Facility Assessment.
The facility failed to document the organisms causing UTIs in several residents, despite prescribing antibiotics. Additionally, an LPN did not follow proper hand hygiene during a dressing change for a resident with pressure ulcers, indicating lapses in infection control practices.
The facility did not have a qualified Infection Control Preventionist (ICP) working full-time, potentially affecting all 56 residents. The DON, acting as the ICP, had not completed the required training and lacked oversight. The facility's policy outlines the ICP's responsibilities, including monitoring antibiotic use and providing staff education, but these may not be adequately fulfilled due to the lack of a qualified ICP.
A resident with an indwelling urinary catheter experienced embarrassment due to the facility's failure to cover the catheter bag, compromising their dignity. The resident expressed frustration about the situation, and CNAs acknowledged the need for a dignity bag. The facility's policy emphasizes treating residents with dignity, which was not upheld in this case.
A resident with a sore on her lower left leg did not have a physician's order for treatment documented in her EHR. Despite the resident's cognitive intactness and medical history, the sore was dressed without an order, and the facility's policy for notifying physicians was not followed. The DON confirmed the lack of an order, and an LPN noted the sore's condition and planned to contact the doctor.
A resident with Alzheimer's Dementia fell from their wheelchair, leading to an incident where an LPN became angry, yelled, and physically handled the resident inappropriately. Multiple staff witnessed the mistreatment, and the facility's investigation substantiated the abuse allegations, resulting in the LPN's termination.
A facility failed to monitor a resident requiring dialysis and paracentesis. The resident's care plan noted risks related to end-stage renal disease, but there was no documentation of monitoring for fluid overload. Post-paracentesis instructions from a hospital were not recorded in the resident's records. LPNs checked the dialysis access site but did not document these checks unless issues arose. No dialysis and paracentesis policy was provided.
A resident with dysphagia was fed by a unit aid who lacked state-approved training and supervision by an RN or LPN. The facility did not have a policy on feeding assistance, and the unit aid's job description did not include feeding duties. The Director of Nursing confirmed that unit aids should not feed residents, especially those at high risk for choking.
A resident with Alzheimer's and dementia eloped from a memory care unit due to inadequate supervision and monitoring. Despite being identified as an elopement risk, the resident was not equipped with an electronic monitoring bracelet and was able to leave the facility undetected. Staffing was insufficient, with only one CNA present when the LPN was administering medications on other halls, leaving residents unsupervised. The resident was found by a passerby in a field near a hospital.
The facility failed to provide adequate staffing for a memory care locked unit, affecting 11 residents with dementia and Alzheimer's disease. Staff interviews revealed that only one CNA was often left to supervise the unit while the assigned nurse attended to other halls, leaving residents unsupervised during 1:1 care. The facility's staffing policy was not met, leading to the deficiency.
The facility failed to secure and control medications for several residents, leading to deficiencies in medication management. A cognitively intact resident had unauthorized medications at bedside, while a severely cognitively impaired resident had medications left unattended on a dining table. Another resident had medications left out of reach, and a confused resident had topical gel on her bedside table without a self-administration assessment. The facility's policy on self-administration of medications was not followed.
Failure to Protect Resident From Physical Abuse During Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and protection from physical abuse for a resident who was punched in the face by another resident. One resident (R1) had multiple neurocognitive and psychiatric diagnoses, including psychosis, dementia, altered mental status, and poor impulse control, and was care planned as having the potential to be physically aggressive, including punching and hitting. R1’s MDS documented severe cognitive impairment (BIMS score of 03) and behavioral symptoms such as physical and verbal behaviors directed toward others, as well as other disruptive behaviors that significantly interfered with her own participation in activities and significantly intruded on and disrupted the care and living environment of others. Prior to the incident with R2, R1 had a documented pattern of aggressive and disruptive behaviors toward staff and other residents. On multiple dates, R1 was involved in altercations, including punching another resident in the shoulder, rummaging through a staff purse and hitting staff with her fist, grabbing residents, hitting another resident, and throwing orange juice on another resident and hitting staff. The care plan interventions initiated in response to these behaviors included medication review for physical behaviors, securing staff personal belongings, redirecting R1 away from other residents during grabbing or hitting behaviors, redirecting her away from confrontations, and supervising her with visual checks every 30 minutes. R2, who was later punched by R1, had diagnoses including vascular dementia, delirium due to a known physiological condition, major depressive disorder, panic disorder, and anxiety disorder, and also had a BIMS score of 03, indicating severe cognitive impairment. R2’s care plan did not include a focus area for being at risk for abuse. During the incident in question, a CNA witnessed R2 grabbing R1 in the doorway of the TV room and calling R1 a derogatory name, after which R1 swung and hit R2 in the face, knocking R2’s glasses to the floor and causing slight redness to R2’s forehead. Staff and family interviews confirmed that R1 punched R2 in the face and that R1 had a history of frequent behavioral issues, while R2 was unable to recall the incident due to cognitive impairment. The facility’s abuse prevention policy affirmed residents’ rights to be free from abuse and mistreatment, but the events described show that R2 was not protected from physical abuse by another resident.
Failure to Prevent Falls, Ensure Safe Transfers, Smoking Safety, and Maintain Exit Door Alarms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment free from accident hazards and to provide adequate supervision and assistance to prevent accidents, particularly related to falls, transfers, smoking safety, and exit door alarms. One resident with severe dementia, osteoarthritis, and high assistance needs for ADLs was admitted without a documented admission fall risk assessment, despite transfer paperwork indicating she was high risk for falls and required 1:1 observation. Her care plan later identified her as at risk for falls and wandering, but the fall risk evaluation and precautions were not initiated on admission. She experienced an unwitnessed fall in her room while attempting to toilet herself after removing her non-skid socks, complained of right hip pain, and was subsequently found to have a right hip fracture requiring hospital transfer and surgical repair. Later observation showed her call light attached to the bed sheet and out of her reach. Another resident with vascular dementia, a history of falls, fractures, restlessness, and incontinence was care planned for multiple fall interventions, including bed pad and chair alarms, placement near the nurse’s station, and keeping her within staff’s visual field when up in a wheelchair. She had an unwitnessed fall from her wheelchair in a common bathroom, sustaining a laceration above her right eye that required repair in the ER. She later had another unwitnessed fall from her wheelchair in a dining area, with reported loss of consciousness and multiple forehead lacerations requiring ER treatment. Despite these events and her care-planned interventions, surveyors repeatedly observed her in her wheelchair without the chair alarm connected, with the alarm monitor left on the bed and the pull cord on the back of the wheelchair, and at times placed in her room out of staff view. Staff interviews confirmed that the alarm was not consistently used when family was present. The facility also failed to provide safe mechanical lift transfers for multiple residents. One cognitively intact resident with a history of falls, fractures, weakness, and high fall risk was care planned to require two staff and a full-body mechanical lift for transfers, with a fall mat and other fall-prevention measures. During observation, CNAs transferred her from wheelchair to bed using a full-body lift while the wheelchair was left unlocked, and no fall mat was present or placed afterward. Another resident with severe cognitive impairment, dementia, and high fall risk was similarly transferred from a geriatric chair to bed with a full-body lift while the wheelchair remained unlocked. Smoking safety practices and exit door alarm management were also deficient. A cognitively intact bilateral above-knee amputee with a documented history of smoking and burn concerns was care planned as a smoker, but her smoking safety risk assessments twice documented that she did not currently smoke, and one assessment concluded she was safe to smoke unsupervised. Observations showed CNAs assisting her into a wheelchair, providing her with a burn-marked smoking gown, handing her cigarettes and a lighter from her bedside, and the resident reporting that she could smoke whenever she wanted, usually without staff outside. At the same time, the facility’s smoking policy required a smoking safety assessment to determine supervision needs and noted that burning clothing or being generally careless while smoking jeopardizes independent privileges. In addition, exit door alarms were not consistently activated or effectively audible. A surveyor opened the 200 hall exit door and found that the alarm did not sound until a CNA used a key to activate it; the CNA stated the alarm was often left off so residents could go out for fresh air and that keeping it on was considered a restraint. On another unit, an exit alarm sounded continuously for over ten minutes, and the administrator was unsure which door was alarming and acknowledged existing issues with door alarms, including a memory care unit exit alarm not functioning properly. The facility’s elopement device policy required regular inspection and documentation of exit door security systems and staff placement at malfunctioning doors, but survey findings showed alarms not being kept on and alarms that were difficult for staff in other areas to hear.
Failure to Provide Complete Perineal Care and Proper Hand Hygiene During Incontinence and Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to provide complete incontinence and catheter-related care, including appropriate perineal cleansing and hand hygiene, for multiple residents with bowel and bladder incontinence and/or indwelling catheters. One resident with a history of UTIs, an indwelling Foley catheter placed for pressure ulcers, cognitive impairment, and total dependence for toileting was observed after a bowel incontinence episode. Two CNAs assisted the resident to her side and used wet washcloths to wipe only the anal area, then repositioned and covered her without cleansing the entire buttocks or performing full incontinent care as outlined in her care plan and facility policy. Another resident, cognitively intact but frequently incontinent of urine and always incontinent of bowel, and dependent on staff for toileting, was assisted from a wheelchair to a bedside commode. Staff exposed a heavily urine-soaked brief, seated the resident on the commode, and later applied a clean brief. During cleansing, a CNA used a wet washcloth to clean only the buttocks before the brief and pants were pulled up. The staff did not cleanse the entire buttocks, perineal area, groin, inner thighs, or labia, despite the resident’s care plan directing assistance with toileting every two hours and as needed. A third resident with multiple chronic conditions, moderate cognitive impairment, frequent bowel and bladder incontinence, and dependence for ADLs was provided incontinent care while in a wheelchair using a sit-to-stand device. CNAs donned gloves without performing hand hygiene, removed a wet brief, and one CNA changed gloves without hand hygiene, then used only wet washcloths from the sink without soap or peri-cleaner to briefly wipe the front genital area and buttocks; the anal area was not cleaned. The same soiled gloves were then used to handle the resident’s clothing, equipment, and positioning. A fourth resident with severe cognitive impairment, total dependence for ADLs, and constant bowel and bladder incontinence was observed with a saturated, strong-smelling urine brief. A CNA, wearing the same soiled gloves used to remove the saturated brief, used wet cloths from a basin to wipe the vagina, buttocks, and anal area, then a dry cloth, and subsequently touched the resident’s pillows, sheets, and blanket without any glove change or hand hygiene. These practices were inconsistent with the facility’s written policies for incontinence care, glove use, and hand hygiene, which require thorough perineal cleansing, use of soap or peri-cleaner, changing gloves between contaminated and clean tasks, and performing hand hygiene after glove removal.
Failure to Prevent Sexual Abuse by Staff and Physical Abuse Between Residents
Penalty
Summary
The facility failed to protect a severely cognitively impaired resident from sexual abuse by an employee. The resident, who had vascular dementia with behavioral disturbance and multiple other medical conditions, required substantial to maximal assistance with transfers. According to the facility’s abuse investigation reports, an activity director reported to the administrator that a unit aide kissed this resident on the mouth/lips in her room. The aide admitted in his statement that he kissed the resident once on the lips. The facility’s investigation, including interviews with staff and residents, concluded that the incident did occur and substantiated that the resident was subjected to sexual abuse. The facility also failed to prevent physical abuse between residents when one resident threw a cup of coffee on another resident. One resident, who was cognitively intact, independent with ADLs, and had diagnoses including end stage renal disease, COPD, major depressive disorder, diabetes, and anxiety disorder, reported that another resident had previously harassed him. On the day of the incident, the aggressor resident went outside, yelled at the cognitively intact resident, then returned to his room. When the cognitively intact resident came back inside and passed the aggressor’s room, the aggressor opened his door and threw coffee on him, after which the cognitively intact resident pushed the aggressor in the chest with open hands. The incident was witnessed, residents were separated and assessed, and no injuries were noted. These events occurred despite the facility’s written policy affirming residents’ rights to be free from abuse and describing measures intended to prevent abuse and mistreatment.
Failure to Implement Wound Care Orders and Maintain Pressure Relief Equipment
Penalty
Summary
The facility failed to follow and implement wound care orders from the Wound Nurse Practitioner (NP) in a timely manner for a resident with multiple complex wounds, including stage 3 pressure ulcers and chronic skin conditions. Orders for wound dressings, specialty equipment such as a low air loss mattress, and heel float boots were not promptly initiated or maintained as directed. Documentation shows that wound care treatments were delayed, incorrect treatments were applied, and there were multiple instances where dressing changes and skin assessments were either not performed or not documented as completed according to the NP's orders. The resident's low air loss mattress, which was ordered to provide pressure relief and prevent further skin breakdown, was not maintained in proper working order. Staff, family members, and the resident reported that the mattress frequently lost air, leaving the resident lying on a hard surface, which caused significant pain and discomfort. The mattress was described as being held together with duct tape, with hoses repeatedly disconnecting and the air pump malfunctioning. Despite repeated notifications to facility leadership and maintenance, the issues with the mattress persisted for an extended period before a replacement was provided. As a result of these failures, the resident experienced worsening of wounds, which became infected with multiple organisms including MRSA, Pseudomonas, Enterococcus faecalis, and ESBL E. coli. The infections led to several hospitalizations, surgical debridement, and the need for intravenous antibiotics. The facility's lack of timely and appropriate wound care, failure to maintain essential equipment, and inadequate documentation directly contributed to the deterioration of the resident's condition and the escalation of her wounds.
Removal Plan
- Facility wound care policy was reviewed by President of Operations and was found to be in compliance with state and federal regulations.
- Director of Nursing or designee initiated in-servicing for all nursing staff on the wound care policy and procedures.
- Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on wound care policy and procedures.
- Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant to ensure that all wound orders are carried out and all interventions are in place.
- Director of Nursing or designee will conduct audits of all wound care orders and interventions weekly.
- The Director of Nursing or designee will interview 3 staff members, 3 times weekly to ensure that staff understand wound care policies and procedures.
- Maintenance Director checked all Low Air Loss (LAL) mattresses to ensure proper functioning.
- Maintenance will perform checks of LAL mattresses weekly to ensure proper functioning.
- IDT team (Admin, DON, SSD, MDS, DM) reviewed all residents with wounds to ensure all orders have been processed and treatments are being done correctly.
- R2's mattress was replaced with a new mattress.
Failure to Prevent and Manage Pressure Ulcers Due to Missed Assessments and Treatments
Penalty
Summary
The facility failed to implement and document new care plan interventions to prevent new or worsening pressure ulcers for a resident with multiple risk factors, including diabetes, peripheral vascular disease, and immobility. The staff did not consistently complete skin assessments, ensure the availability of wound care supplies, or perform wound treatments as ordered. As a result, the resident developed a stage II pressure ulcer on the right buttock, a stage III pressure ulcer on the left buttock, and experienced worsening of an existing right heel wound, which required antibiotic treatment. These wounds were discovered by a nurse practitioner during rounds, not by facility staff, indicating a lack of timely identification and intervention. Observations and record reviews revealed that the resident was left in a wheelchair for extended periods without adequate repositioning, and incontinent care was delayed, as evidenced by a full brief with bowel movement upon being returned to bed. Documentation showed repeated lapses in wound care, with multiple entries indicating that treatments were not completed due to unavailable supplies or lack of documentation. There were also missed or delayed skin assessments, including after hospital readmission, and no evidence that new wounds were promptly identified or addressed by staff. Behavioral tracking did not indicate that the resident refused care or treatments during the relevant period. Interviews with facility leadership and clinical staff confirmed expectations that nurses should follow up on treatment changes, document assessments, and notify supervisors if supplies are lacking. However, the nurse practitioner and administrator acknowledged that these processes were not followed, and new wounds were only discovered during external wound care rounds. The facility's own policy required regular skin inspections, timely repositioning, and the use of appropriate pressure-relieving equipment, but these measures were not consistently implemented for the resident in question.
Removal Plan
- Facility pressure ulcer prevention policy was reviewed by President of Operations and was found to be in compliance with state and federal regulations.
- R1 was seen by Wound Care Provider and received new treatment orders, LAL (low air loss) mattress ordered, and wheelchair cushion replaced.
- Director of Nursing or designee initiated in-servicing for all facility and Agency nursing staff to include RNs, LPNs and CNA's, on the pressure ulcer prevention policy and procedures.
- In-servicing will be completed by the start of each staff member's next shift.
- Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant on pressure ulcer prevention.
- Facility Administrator and Director of Nursing were in-serviced by Regional Nurse Consultant to ensure that all newly acquired pressure wounds are identified timely and addressed immediately by reviewing shower sheets daily and ensuring all skin assessments are completed timely and thoroughly.
- Director of Nursing or designee will in-service all facility and Agency nursing staff to include RNs, LPNs and CNA's on identifying all newly acquired pressure areas timely by completing assessments timely and accurately.
- All nursing staff will be educated by the beginning of their next shift.
- Director of Nursing or designee will conduct audits of skin assessments weekly to ensure all new skin conditions are identified timely and addressed accurately as part of the QA process.
- The Director of Nursing or designee will interview 3 staff members weekly x4 weeks to ensure that staff are completing assessments and addressing any new pressure areas.
- Director of Nursing and or designees will conduct skin assessments on all to ensure that any pressure areas are being identified and addressed.
- The staff members responsible for not completing assessments or wound treatments as ordered have been disciplined.
- The DON or designee will review all new admissions to ensure that all assessments are completed.
- The DON or designee educated all facility and agency nurses of how and when to complete skin assessments.
- All facility and agency nurses will be educated by the beginning of their next shift.
- R1 has had a full skin assessment performed by the ADON to ensure all areas of concern have been identified and addressed appropriately.
- All facility and Agency nursing staff to include RNs, LPNs and CNA's, educated by DON or designee that all residents need to be turned and repositioned at least every two hours and as needed.
- All in-servicing will be completed by the beginning of the staff member's next scheduled shift.
- IDT team (Admin, DON, SSD, MDS, DM) reviewed all residents to determine if they are at risk for potential for impaired skin integrity.
- IDT team ensured all skin assessments have been done timely, all new skin areas have been identified and addressed accordingly including care plan review.
Failure to Prevent Elopement Due to Inadequate Supervision and Non-Functioning Door Alarms
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents, specifically related to elopement risks. Multiple observations revealed that door alarms were either not functioning, turned off, or not responded to in a timely manner. On several occasions, doors leading to the outside were found cracked open or could be opened without triggering an alarm, and staff were observed not checking on residents who were at risk of elopement. These lapses allowed a severely cognitively impaired resident, who was identified as an elopement risk, to repeatedly leave the facility unsupervised, including incidents where the resident was found outside in unsafe conditions such as in the middle of the road or inside a visitor's van. The resident in question had a history of alcohol-induced dementia, Wernicke's encephalopathy, and chronic kidney disease, and was documented as being ambulatory and prone to wandering. Despite being placed on frequent checks and having a wander guard, the resident was able to exit the facility multiple times. Staff interviews confirmed that the resident was able to find ways to leave the building, sometimes with the assistance of visitors or by exploiting malfunctioning or inaudible alarms. Documentation also indicated that staff were aware of the resident's repeated elopements, but there was a lack of consistent monitoring and timely response to alarms, and the resident's legal guardian was not notified of these incidents. Another resident, also identified as an elopement risk with cognitive impairment and mobility limitations, was able to exit the facility on multiple occasions. This resident was found outside in inclement weather, inadequately dressed, and required staff intervention to be brought back inside. Staff interviews and progress notes indicated that alarms did not always sound when doors were opened, and there was uncertainty about how long the resident had been outside. The facility's own logs did not consistently document these incidents, and staff acknowledged that some doors were routinely left unalarmed for convenience, further contributing to the risk.
Removal Plan
- Facility Elopement Policy was reviewed by Regional Director of Operations and was found to be in compliance with state and federal regulations.
- Facility Administrator or designee initiated in-servicing for all staff on the elopement policy and procedures. In-servicing will be completed by the start of each staff members next shift.
- Facility Administrator or designee initiated in-servicing for all staff on ensuring all staff are monitoring door alarms and responding immediately. In-servicing will be completed by the start of each staff members next shift.
- Maintenance Director or designee will conduct an audit of all facility door alarms and to be completed weekly to ensure they are adequately functioning and audible to staff areas.
- Administrator or designee to conduct Elopement Drill weekly x4 weeks to ensure monitoring and compliance.
- The Administrator or designee will interview 3 staff members, 3 times weekly x4 weeks to ensure that staff understand elopement policies and procedures.
- IDT team (Admin, DON, SSD, MDS, DM) has assessed R4 and care plan updated to reflect new interventions for R4 being placed on the locked unit.
- IDT team (Admin, DON, SSD, MDS, DM) reviewed all residents for the potential to elope and care plans updated to reflect interventions to protect residents from elopement.
- R4 was placed on the locked unit.
- All facility exit door keys were removed and placed in secured location.
- Facility Administrator or designee initiated in-servicing for all staff to not turn off door alarms. In-servicing will be completed by the start of each staff members next shift.
- Maintenance Director replaced the door lock to 300 Hall door to courtyard and is functioning properly.
Failure to Maintain Low Air Loss Mattress in Safe Working Condition
Penalty
Summary
The facility failed to ensure that a low air loss mattress was maintained in proper working order for a resident with multiple pressure ulcers and complex medical conditions. The resident, who was cognitively intact and required substantial assistance for mobility, had a care plan that included the use of a low air loss bariatric mattress for pressure reduction due to her high risk for skin breakdown and existing stage 3 pressure ulcers. Despite this, the mattress provided to her was not functioning correctly, as the hose that kept the mattress inflated repeatedly disconnected, causing the mattress to deflate and leaving the resident lying on a hard metal bed frame. Multiple staff members, including a CNA and an LPN, confirmed that the mattress was not staying inflated and that the hose would frequently come off, sometimes requiring makeshift repairs such as duct tape to keep it in place. Family members also reported the issue to facility leadership, providing photographic evidence and written communication about the malfunctioning equipment. The resident herself described experiencing extreme pain, rating it as a 10 out of 10, particularly when the mattress lost air and she was left without adequate pressure relief for her wounds. Interviews with the wound care nurse practitioner and review of the resident's care plan confirmed that the use of a properly functioning low air loss mattress was a necessary intervention for her condition. The facility's own preventive maintenance policy required systematic inspection and timely repair or replacement of essential equipment, but the failure to maintain the mattress in working order resulted in the resident enduring significant pain and inadequate pressure relief for an extended period.
Facility Assessment Lacks Required Components and Updates
Penalty
Summary
The facility failed to ensure that its facility-wide assessment was updated to include all necessary components as required by current standards of practice. The assessment provided did not identify the current Administrator or Director of Nursing (DON), nor did it specify resources required to provide necessary care and services to residents during both routine operations and emergencies, including nights and weekends. Additionally, the assessment lacked an evaluation of the overall number of staff needed to ensure sufficient qualified personnel are available to meet each resident's needs as identified through assessments and care plans. The assessment also omitted pertinent information about the resident population, such as race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, preferred language, health literacy, or other factors affecting access to care and health outcomes related to health equity. Further deficiencies included the absence of information regarding the physical environment, assistive technology, individual communication devices, or other material resources needed to provide required care and services. The facility assessment did not evaluate the training program to ensure training needs are met for all staff, including managers, nursing and direct care staff, contracted service providers, and volunteers. There was also no evaluation of applicable policies and procedures, nor a facility-based and community-based risk assessment using an all-hazards approach to maintain continuity of operations and secure required supplies and resources during emergencies or natural disasters. When asked, the Administrator confirmed that the provided assessment was all the information available and stated there was no policy for the facility assessment. At the time of the survey, there were 60 residents residing in the facility.
Failure to Provide Required Annual CNA Education and Dementia Training
Penalty
Summary
The facility failed to ensure that Certified Nurse Assistants (CNAs) completed the required 12 hours of annual education, including mandatory training in dementia care and abuse prevention. Record review showed that six CNAs had received between 0 and 2.5 hours of education in the past year, far below the required amount. The Administrator confirmed that the in-service records provided were limited to short sessions, with most lasting only 30 minutes and only one session lasting an hour. Additionally, there was no documentation of dementia training for the year, and the Administrator admitted that dementia training within 60 days of hire, as required by facility policy, was not being conducted. The facility's Employee Education policy mandates a coordinated staff education plan, including both pre-service and annual requirements in key areas such as infection control, abuse prevention, and dementia care. Despite this, both the Administrator and the Director of Nursing acknowledged that the required education hours had not been met for the CNAs reviewed. The deficiency has the potential to affect all 60 residents currently residing in the facility, as documented in the daily census report.
Failure to Notify Resident Representative After Elopement
Penalty
Summary
The facility failed to notify a resident's representative after the resident, who was severely cognitively impaired and diagnosed with alcohol dependence with alcohol-induced persisting dementia, Wernicke's encephalopathy, and chronic kidney disease, was found outside of the facility on multiple occasions. Documentation showed that the resident was found by staff outside by the dumpster, sitting in a visitor van, and exiting through a back door with a broken lock. In each instance, staff responded by returning the resident to the facility and documenting the events in the progress notes, but there was no documentation that the resident's representative was notified of these incidents. Interview with the resident's family member, who is also the legal guardian, confirmed that she was not informed by the facility about the resident leaving the premises. The family member stated she only learned of one incident through her sister, not directly from the facility. Facility policy requires that the responsible party be notified in the event of a resident attempting to leave or leaving the premises, but this was not followed in the case of this resident. The administrator confirmed that staff are expected to notify the representative immediately and document the notification, which did not occur.
Failure to Follow Infection Control Standards During Wound and Incontinence Care
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for hand hygiene, wound dressing disposal, and contaminated linen disposal for one resident who was under enhanced barrier precautions due to a coccyx wound and diagnoses of asymptomatic HIV and chronic Hepatitis B. The resident was observed in a single occupancy room with clear signage indicating the need for enhanced barrier precautions, including hand hygiene before entering and upon leaving the room, and the use of gloves and gowns for high-contact care activities such as wound care. During an observation, an LPN donned appropriate personal protective equipment (PPE) before entering the resident's room. While assisting the resident, who had a bowel movement, the LPN used a disposable brief to clean the resident and disposed of it in a trash bag placed on the floor by the room door. Without changing gloves or performing hand hygiene, the LPN touched the trash bag, room door, door handle, door frame, and requested clean bedding from a CNA. The LPN continued to touch various surfaces, including the bathroom door and sink faucet, while still wearing the same soiled gloves. The LPN then removed the resident's soiled wound dressing, cleaned the wound area, and allowed the wound to come into contact with the bed linens. The soiled dressing and PPE were disposed of in the same trash bag, and the LPN exited the room, again without performing hand hygiene, and touched additional surfaces including the medication cart before eventually using hand sanitizer in the hallway. Interviews with facility staff, including the LPN, ADON/Infection Control Nurse, and DON, confirmed that the resident was on enhanced barrier precautions and that facility policy required proper disposal of items contaminated with blood or body fluids in red biohazard bags in the dirty utility room. The facility's policy and referenced infection control guidelines emphasized the importance of hand hygiene, appropriate glove use, and proper disposal of contaminated materials to prevent the transmission of infectious agents. However, these protocols were not followed during the observed care of the resident.
Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to obtain timely treatment orders and complete physician-ordered treatments for a resident with pressure ulcers. The resident, who had diagnoses including congestive heart failure, pneumonia, urinary tract infection, and type 2 diabetes, was identified as high risk for pressure ulcer development and had a care plan in place for skin breakdown prevention. Despite documentation of abnormal findings on the left heel on multiple shower sheets, there were no corresponding progress notes, treatments, or orders on those dates. The weekly wound evaluation did not document the left heel until it was identified as a stage 3 ulcer, and the treatment order for the left heel was not obtained until several days after abnormalities were first noted. Additionally, the treatment administration records showed that the ordered treatments for the left heel were not completed on the first two days after the order was written. Interviews with facility staff confirmed that documentation and treatment for the left heel were lacking, and that the wound was not addressed in a timely manner. The wound nurse stated that the left heel was not open prior to the treatment order, but there was no documentation of assessment or intervention when the area was first identified as abnormal. The facility's policy requires assessment and documentation of risk factors and skin breakdown, but this was not followed for the resident's left heel, resulting in a delay in treatment and incomplete documentation.
Failure to Prevent Verbal and Mental Abuse
Penalty
Summary
The facility failed to prevent verbal and mental abuse for four out of six residents, resulting in psychosocial harm. Resident 3, who was cognitively intact, required assistance with activities of daily living due to conditions such as atherosclerosis, unsteadiness, and a fractured humerus. On one occasion, a Certified Nursing Assistant (CNA), identified as V3, refused to help Resident 3 get dressed in her room, insisting she dress in the bathroom despite her objections. V3 was forceful and rushed, leaving Resident 3 feeling exposed and cold without a button-up shirt. Resident 4, also cognitively intact, required assistance with transfers due to conditions like heart failure and hemiplegia. V3 displayed a dismissive attitude towards Resident 4, refusing to help her out of bed and making her feel terrible. Resident 4 reported V3's behavior to the facility administrator, who acknowledged the inappropriate actions. Additionally, Resident 5 witnessed V3 yelling at Residents 6 and 7, who had Alzheimer's disease and required assistance with dressing and toileting. V3's behavior included yelling at Resident 6 for not dressing in the clothes laid out and at Resident 7 for having an accident. The facility's investigation confirmed that V3 engaged in behaviors constituting abuse or neglect. The facility's abuse policy emphasizes providing an environment free from abuse, neglect, and exploitation, defining abuse as actions causing physical harm, pain, or mental anguish. Despite the policy, V3's actions led to residents experiencing feelings of shame, embarrassment, and humiliation, highlighting a significant deficiency in the facility's ability to protect residents from abuse.
Inadequate Infection Control Measures for COVID-19
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place for residents who tested positive for COVID-19. Specifically, staff did not have ready access to or use appropriate personal protective equipment (PPE) such as N95 masks and eye protection when entering the rooms of COVID-positive residents. Isolation signage was also missing from the doors of these residents, which is crucial for indicating the type of isolation required. For instance, one resident was found in bed with the door open and no isolation signage, and the isolation cart outside the room lacked necessary PPE. Another resident was assisted by a CNA who wore inadequate PPE, and the CNA acknowledged the absence of N95 masks and face shields. The facility's medical records and supplies staff confirmed the availability of PPE, but it was stored in locked areas, making it inaccessible to staff when needed. Additionally, the facility did not document COVID testing for a resident who was exposed to a COVID-positive roommate. The facility's policy requires that only residents with the same respiratory pathogens be housed together, yet this was not adhered to. The Director of Nursing and other staff members were unaware of the reasons for the lack of isolation signage and the rooming arrangements. The facility's policy mandates that healthcare providers entering the room of a COVID-positive patient should wear a respirator with an N95 filter, gown, gloves, and eye protection, but this was not consistently followed, leading to a deficiency in infection control practices.
Absence of Qualified Infection Control Preventionist
Penalty
Summary
The facility failed to ensure the presence of a qualified Infection Control Preventionist (ICP) working full-time, which has the potential to affect all 59 residents. On the specified date, the Administrator acknowledged the absence of an ICP and mentioned efforts to hire one. During the same period, residents who tested positive for COVID-19 were residing in the facility. The Director of Nursing, who was off due to a COVID infection, expressed uncertainty about the current situation, indicating a lack of oversight and management in infection control practices.
Failure to Maintain a Safe Environment for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide a safe and hazard-free environment for three residents on the dementia unit, all of whom were severely cognitively impaired. Resident 4, who can walk independently, was observed sitting in the dining room, and it was noted that the window in the area was broken and the door was not locked. The activities staff member was unaware of the broken window and unlocked door. Resident 5, also able to walk independently, was seen walking up and down the hall, passing the room with broken glass. Resident 6, who requires supervision or assistance for walking, was observed returning from therapy and became confused and agitated near the Alzheimer's unit door. She was later seen at the nurses' station, unable to make sentences or answer questions. The room with the broken window was supposed to be locked, as confirmed by the maintenance staff, who stated they were not asked to repair it. The administrator was under the impression that the room was locked. The facility's policy on safety and supervision emphasizes maintaining an environment free from accident hazards, but this was not adhered to in this instance.
Failure to Implement Progressive Fall Interventions
Penalty
Summary
The facility failed to implement progressive fall interventions for two residents, resulting in injuries. One resident, admitted with conditions such as weakness, polyneuropathy, and cognitive decline, experienced multiple falls. On one occasion, the resident was found on the floor with lacerations requiring emergency room transfer and sutures. Despite being at high risk for falls, the resident's care plan and progress notes did not document any new interventions following these incidents. Interviews with staff confirmed the absence of documented progressive interventions for the falls. Another resident, diagnosed with vascular dementia and other conditions, sustained a bruise on the forehead after being bumped by a mechanical lift bar. The incident report noted the injury, but the social worker and registered nurse were unaware of the incident or the staff involved. The facility's policies on safe lifting and fall prevention were not effectively implemented, as evidenced by the lack of appropriate interventions and staff awareness.
Failure to Implement Nutritional Interventions Leads to Severe Weight Loss
Penalty
Summary
The facility failed to implement nutritional interventions to prevent significant weight loss in a resident diagnosed with Alzheimer's disease, anemia, and other conditions. The resident was admitted with a nutritional deficit, and interventions were documented to provide supplements as ordered. However, the resident experienced a severe weight loss of 15.7% over six months, indicating a failure to maintain adequate nutrition. The Registered Dietitian (RD) was responsible for recommending dietary changes, but there was a lack of documentation and communication regarding these recommendations. The RD did not document recommendations in the resident's progress notes for September and November, and the facility's Nutritional Care Form did not reflect the necessary dietary changes. The RD admitted to not seeing the resident in person and was unaware of the continued weight loss and refusal of supplements. The facility's documentation of meal and supplement intake was minimal, and the Director of Nursing acknowledged poor communication with the RD. Observations revealed that the resident appeared very thin with muscle and orbital wasting, and there was no meal tray or nutritional supplement provided at times. The Dietary Aid confirmed that the resident often refused supplements, and the Dietary Manager acknowledged the resident's poor intake of supplements. The facility's policy required monitoring and documentation of weight and dietary intake, but this was not effectively implemented, leading to the resident's significant weight loss.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified through a review of staffing schedules and interviews with facility staff. The staffing schedules for the past 14 days revealed that there were no RNs working on nine specific days, including 12/1/2024, 12/2/2024, 12/3/2024, 12/5/2024, 12/7/2024, 12/8/2024, 12/9/2024, 12/10/2024, and 12/15/2024. The facility's administrator acknowledged the shortage of RN coverage, and the Director of Nursing confirmed that the facility currently employed only two RNs, including herself, and efforts were being made to hire more RNs. The deficiency potentially affects all 56 residents living in the facility. The facility's PBJ Report for the 4th quarter indicated a one-star staffing rating, and the Facility Assessment dated 7/1/2023 outlined a staffing plan based on the current census, which was not met. The facility's staffing policy, revised in 2017, stated that sufficient numbers of staff with the necessary skills and competency should be available to provide care and services for all residents. However, the lack of RN coverage on the specified days indicates a failure to adhere to this policy, potentially impacting the quality of care provided to the residents.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information in a clear and readable format in a prominent place, which is required to be readily accessible to residents and visitors. During a tour of the facility, it was observed that no nursing information, including the facility name, current date, total number of actual hours worked by RNs, LPNs, CNAs, and resident census, was posted or available for review. The facility's PBJ report for the 4th quarter documented insufficient RN coverage for 8 consecutive hours per day, resulting in a 1-star staffing rating. Interviews with the Director of Nursing and the Business Office Manager revealed a lack of awareness regarding the requirement to post staffing information, with the Business Office Manager noting that staffing was previously posted by the door but was unsure if it had been posted under new management. The facility's assessment and staffing policy indicated the need for adequate staffing to meet resident care needs, but no updated assessment was provided.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a manner that prevents potential contamination, affecting all 56 residents. During an inspection, surveyors observed several deficiencies in the kitchen and storage areas. The fryer station next to the oven was found with a basket covered in old grease and crisp pieces floating in it, indicating a need for cleaning. In the walk-in refrigerator, there was a large container of unidentified meat with noodles in red sauce, and a tray with eight bowls of unidentified food, both without labels or dates. Additionally, there was an 18-quart container of white liquid and another of red liquid, both lacking labels and dates. The freezer also presented issues, with large chunks of ice on the floor and ice crystals dripping from the ceiling onto various food items, including ice cream cups, waffles, chocolate pies, meat, and bread. A large block of ice was covering a box of hamburger. The Dietary Manager acknowledged the requirement for all items to be dated and labeled, and the Maintenance Man, who was new to the facility, was aware of the ice buildup issue but had not yet resolved it. The facility's Food Receiving and Storage Policy, revised in July 2014, mandates that food be stored in compliance with safe handling practices, including proper labeling and dating, which was not adhered to in this instance.
Facility Assessment Not Current or Reviewed Annually
Penalty
Summary
The facility failed to ensure that its Facility Assessment was current and reviewed annually, which has the potential to affect all 56 residents living in the facility. On December 17, 2024, the Facility Assessment was requested and later provided by the Administrator, V1, with a revision date of July 1, 2023. When asked if this was the most up-to-date version, V1 confirmed it was. No other Facility Assessment was provided by the facility by December 18, 2024. Additionally, the Director of Nursing, V2, stated there was no policy on Facility Assessment. The facility's daily census sheets documented a total of 56 residents living in the facility.
Inadequate Infection Control Documentation and Practices
Penalty
Summary
The facility failed to maintain a comprehensive infection surveillance program, as evidenced by the incomplete documentation in the Monthly Infection Control Log for November. Several residents were diagnosed with urinary tract infections (UTIs) and prescribed antibiotics, but the logs did not document the organisms causing these infections. Specifically, residents were prescribed Cipro and Cephalexin for their UTIs, yet the causative organisms were not recorded, indicating a lapse in the facility's infection control documentation practices. Additionally, there was an observed breach in infection control practices by a Licensed Practical Nurse (LPN) during a dressing change for a resident with pressure ulcers. The LPN did not wash or sanitize hands after leaving and returning to the resident's room, nor did they sanitize hands between glove changes. This failure to adhere to proper hand hygiene protocols further highlights deficiencies in the facility's infection prevention and control measures.
Lack of Qualified Infection Control Preventionist
Penalty
Summary
The facility failed to ensure they had a qualified Infection Control Preventionist (ICP) working full-time, which has the potential to affect all 56 residents. The Administrator identified the Director of Nursing (DON) as the current ICP. However, the DON admitted to not having completed the required training for the role and stated there was no oversight in place. The facility's Antibiotic Stewardship Policy outlines responsibilities for the ICP, including monitoring antibiotic use and resistance, collaborating with the pharmacist, and providing education to nursing staff. Despite these outlined duties, the lack of a qualified ICP suggests these responsibilities may not be adequately fulfilled.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to maintain a dignified existence for a resident, identified as R11, who was cognitively intact and dependent on a wheelchair with an indwelling urinary catheter due to neurogenic bladder. The resident's catheter bag was observed uncovered on multiple occasions, which was a source of embarrassment for the resident. R11 expressed frustration about the lack of a cover for the catheter bag, stating it was embarrassing when people walked by the room. Certified Nursing Assistants (CNAs) acknowledged the need for a dignity bag to cover the catheter bag, especially when the resident was moving around the unit. The facility's Administrator and Director of Nursing also stated that they expected catheter bags to be covered. The facility's Resident Rights Policy emphasizes treating residents with kindness, respect, and dignity, which was not upheld in this instance, as the resident's dignity was compromised by the visible catheter bag.
Failure to Notify Physician and Obtain Treatment Order for Resident's Sore
Penalty
Summary
The facility failed to notify the physician and obtain an order for treating a non-pressure sore on a resident's lower left leg. The resident, who is cognitively intact and has a medical history including an acquired absence of the right leg above the knee and peripheral vascular disease, reported a sore on her leg that was leaking. Despite this, there was no documented order in the Electronic Health Record for the dressing applied to the sore. The nurse's note from the previous day indicated that the sore was dressed and covered with triple antibiotic ointment and a bandage, with no signs of warmth or redness, and the plan was to continue monitoring. The Director of Nursing confirmed the absence of a treatment order, and a Licensed Practical Nurse (LPN) noted the sore was scabbed over but had an open tip. The LPN cleansed the area, applied ointment and a bandage, and noted a new area on the leg that was not measured. The LPN stated she would call the doctor, and the physician confirmed being contacted but had not yet seen the resident. The facility's policy requires the charge nurse or supervisor to contact the attending physician for immediate discussion and management if a clinical situation necessitates it, which was not adhered to in this case.
Failure to Protect Resident from Abuse by LPN
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a cognitively severely impaired resident with Alzheimer's Dementia and other medical conditions. The incident occurred when the resident fell out of their wheelchair, and a CNA reported the fall to an LPN. The LPN became visibly angry, yelled at the resident, and was reported to have physically handled the resident inappropriately. Multiple staff members witnessed the LPN mistreating the resident, including aggressive talking and forcibly moving the resident's wheelchair. The facility's investigation substantiated the allegations of abuse, leading to the termination of the LPN's employment. The facility's policy on Abuse Prevention, revised in 2017, states that residents should be provided with an environment free from abuse, neglect, or misappropriation of property. Despite attempts to contact the involved staff for interviews, they were unavailable, and their written statements were included in the investigation.
Failure to Monitor Post-Dialysis and Paracentesis Care
Penalty
Summary
The facility failed to adequately monitor a resident, identified as R34, who required dialysis and paracentesis. R34's electronic health record documented diagnoses of end-stage renal disease, alcoholic cirrhosis of the liver with ascites, and dependence on dialysis. Despite these conditions, the facility did not document post-dialysis and post-paracentesis monitoring in the resident's records. The care plan for R34 indicated a risk for complications related to end-stage renal disease and dialysis, but there were no documented orders or evidence of monitoring for signs and symptoms of fluid overload in the electronic health record. Additionally, the facility did not document the post-paracentesis instructions provided by the local hospital, which included specific care instructions such as removing the bandage in 3 to 5 days and monitoring for redness or drainage. The Medication Administration Record and Treatment Administration Record lacked documentation of these instructions. Licensed Practical Nurses (LPNs) at the facility acknowledged checking the dialysis access site for thrill and bruit but did not document these checks unless issues were noted. Furthermore, there was no dialysis and paracentesis policy provided upon request, indicating a lack of formalized procedures for these critical care activities.
Improper Feeding Assistance by Untrained Staff
Penalty
Summary
The facility failed to ensure that residents who required assistance with feeding were attended to by properly trained staff under the supervision of a registered nurse (RN) or licensed practical nurse (LPN). This deficiency was identified during an observation where a unit aid, who had not completed a state-approved training class for assisting residents with feeding, was feeding a resident diagnosed with dysphagia and other digestive issues. The resident was on a pureed diet, and the feeding occurred without the presence of a nurse in the dining room. The unit aid's job description did not include feeding residents, and the Director of Nursing (DON) confirmed that unit aids were not supposed to feed residents, especially those at high risk for choking. The facility did not have any paid feeding assistants, nor did it have a policy on feeding assistance or residents needing assistance with feeding. The facility's existing policy required that paid feeding assistants complete a state-approved training course and be supervised by a registered dietitian and an RN, but this was not adhered to in practice.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent the elopement of a resident identified as R2, who was at risk due to her cognitive impairments. R2, who had been admitted to the facility with a diagnosis of Alzheimer's disease and dementia, was known to be confused, agitated, and frequently expressed a desire to leave the facility. Despite these known risks, R2 was able to elope from the facility undetected on the afternoon of 10/15/2024. On the day of the incident, R2 was last seen by staff at approximately 3:00 PM. She was later found by a passerby at around 4:30 PM, walking in a field near the local hospital. The facility's investigation revealed that a window in an unoccupied room on the memory care unit was found ajar, suggesting that R2 may have exited through it. Alternatively, it was suspected that she might have followed a visitor out of the secured door. The facility's staffing on the memory care unit was insufficient, with only one CNA present when the LPN was administering medications on other halls, leaving the residents unsupervised. R2's care plan and elopement risk assessments were not adequately updated or implemented. Although R2 was identified as an elopement risk upon admission, she was not equipped with an electronic monitoring bracelet, which could have alerted staff to her exit. The facility's failure to ensure that R2 was continuously monitored and that preventive measures were in place directly contributed to her elopement.
Removal Plan
- The issue has the potential to affect all memory care residents and any other residents within the facility that have been identified as an elopement risk.
- R2 was evaluated at local hospital following the elopement and again upon returning to the facility. No injuries were observed. R2's responsible party, attending physician, and State Survey Agency were all notified.
- All residents on the memory care unit were placed on 15-minute checks for a period. At the expiration of the period, residents were placed on a 2-hour check, with the exception of R2 who remained on 15-minute checks, and QA team will review to see if any changes need to be made.
- R2 care plan was reviewed and updated to assess exit seeking triggers and none were identified. The care plan was updated to include the use of an electronic monitoring device.
- The electronic monitoring device, which is present on all exterior doors of the facility, was tested and determined to be in working order. The electronic monitoring alert system was tested and determined to be functioning properly and the electronic monitoring bracelet was placed on the resident.
- The facility has conducted updated risk assessments on all current residents. This risk assessments included identifying exit seeking triggers, if any. No new elopement risks were identified.
- The facility's administrative and clinical teams, led by the administrator, met to review all elopement policies and procedures. Current policies and procedures were determined to be satisfactory, and no changes were proposed.
Inadequate Staffing in Memory Care Unit
Penalty
Summary
The facility failed to ensure adequate staffing for the memory care locked unit, affecting all 11 residents residing on the unit. These residents, who have dementia and Alzheimer's disease, require assistance with activities of daily living (ADLs) and are at risk of wandering and setting off door alarms. The staffing issue was observed during various shifts, where only one CNA was left to supervise the unit while the assigned nurse attended to residents on other halls. This left the CNA alone to manage high-acuity residents, which was deemed unsafe by multiple staff members. Interviews with staff, including LPNs, RNs, and CNAs, revealed that the current staffing pattern left the memory care unit inadequately supervised. Staff members reported that they were often required to leave the unit to care for residents on other halls, leaving only one CNA to manage the 11 residents. This situation was described as unsafe, particularly when the CNA had to provide 1:1 care, such as toileting, which left other residents unsupervised for extended periods. The Director of Nursing (DON) and the facility administrator acknowledged the staffing issues but did not have a clear understanding of the acuity of the memory care unit or the specific staffing assignments. The facility's staffing policy requires a minimum of 3.8 hours of nursing and personal care each day for residents needing skilled care, but the current staffing did not meet these requirements, leading to the deficiency noted in the report.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to secure and control the disposition of administered medications for several residents, leading to deficiencies in medication management. Resident 1, who was cognitively intact but required assistance with activities of daily living, was found with hydrocortisone cream in her wheelchair and diclofenac gel at her bedside without a documented order for medications at bedside. The registered nurse and licensed practical nurse were unaware of any assessments for residents to have medications at bedside, and the care plan nurse admitted there was no comprehensive assessment policy in place. Resident 7, who was severely cognitively impaired, had medications left unattended on a dining table for over half an hour. The licensed practical nurse left the medication cup on the table without continuous nursing observation. The care plan nurse acknowledged the lack of a comprehensive self-administration assessment for Resident 7, despite the expectation of nursing supervision and oversight of medications left for residents to administer. Resident 8, who was cognitively intact, also had medications left unattended on a dining table for nearly an hour. The licensed practical nurse left the medication cup on the table without continuous nursing observation. Additionally, Resident 2 had seven pills left out of reach on a bedside table, and Resident 3, who was confused, had diclofenac gel on her bedside table without a self-administration assessment. The facility's policy on self-administration of medications was not followed, as there was no documentation of comprehensive assessments or secure storage of medications.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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