Belhaven Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 11401 South Oakley Avenue, Chicago, Illinois 60643
- CMS Provider Number
- 145549
- Inspections on file
- 65
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Belhaven Nursing & Rehab Center during CMS and state inspections, most recent first.
The facility failed to follow its own policies and practice of offering daily menu alternatives by not providing consistent food substitutions on weekends. Cognitively intact residents reported that activity staff offer meal choices and alternatives only on weekdays, and that on weekends they are told they must eat the posted menu item, with some residents stating they go hungry or must obtain outside food if they dislike the meal. Staff interviews corroborated that menu substitutions are routinely offered Monday through Friday but not on weekends, despite management statements and written policies indicating that alternatives and an "Always Available Menu" should be offered every day at every meal.
The facility failed to maintain sanitary food service practices by transporting meal trays on open carts with only the main plate wrapped, while drinks, desserts, cereal, condiments, and utensils remained uncovered, and by allowing staff to handle and portion food without consistent use of hair restraints and beard guards. A resident reported that his food, juice, dessert, and silverware were not covered and that he had previously found hairs on his sandwich. Surveyors observed CNAs and dietary staff preparing and delivering trays with uncovered items on open, unattended carts in hallways, and noted dietary staff in the kitchen and on units without required beard protectors. The dietary manager, regional food service manager, and a CNA with prior dietary experience all acknowledged that carts and all tray items should be covered and that hair restraints are expected at all times when handling food, consistent with the facility’s infection control and hair restraint policies.
A resident with paraplegia and multiple medical conditions, who required substantial assistance with ADLs and was care planned to use the call light for help, experienced repeated delays in staff response to his call light. On separate occasions, the call light system showed his room light active for extended periods while the hallway light remained on, and the resident reported waiting over an hour for assistance with bathing after a CNA left him with a bucket of water and did not return. An LPN at the nurses’ station acknowledged the call light had been on for over an hour, and both the CNA and LPN stated call lights should be answered promptly, consistent with facility policy and the DON’s expectation of response within 15 minutes.
A cognitively intact wheelchair user with multiple chronic conditions and a history of suspected abuse was moving toward the smoking area with an unlit cigarette in his mouth so he could propel his wheelchair. An LPN allegedly approached, snatched the cigarette from his mouth, broke it, and, according to the resident and the Administrator, threw it at him, then yelled at him and threatened to call the police, which two CNAs described as intimidating and emotionally abusive. One CNA reported the incident to the DON that evening, but the LPN was allowed to finish the shift and continue working, despite facility policy and leadership expectations that any staff member alleged to have committed abuse be immediately separated from the resident, removed from the building, and reported to the Administrator and DON.
The facility failed to submit a final investigation report of alleged staff-to-resident abuse to the state agency within the required five business days. A resident with multiple chronic conditions, who uses a wheelchair and has a history that increases susceptibility to abuse, reported that an LPN snatched an unlit cigarette from his mouth, broke it, threw it at him, and threatened to call the police. Two CNAs corroborated that the cigarette was unlit and that the LPN’s actions and threats were verbally and mentally intimidating. The Administrator, serving as abuse coordinator, received the allegation, sent the initial report to the state, but did not submit the final written investigation report until several days past the facility policy and regulatory five-business-day deadline.
A resident with Lennox-Gastaut syndrome and a history of seizures, hemiplegia, and other comorbidities reported missing doses of prescribed anti-seizure medications (Keppra, phenobarbital, and pregabalin/Lyrica) due to medications not being available, and described having a seizure episode after missed doses. A CNA and an LPN confirmed the resident had a recent seizure in the dining room. Review of the MARs showed multiple missing initials for scheduled doses of the resident’s anti-seizure medications across two months, indicating doses were not administered or documented as required, despite physician orders, a care plan directing administration of seizure medications, and facility policies requiring timely MAR documentation and adherence to physician orders.
A resident with severe cognitive impairment, osteoporosis, prior femur fracture, and a history of falls was dependent on staff for bed-to-chair transfers and had a care plan identifying fall risk and self-care deficits, but without a timely, specific focus on mechanical lift transfers despite staff reporting such dependence for over a year. A CNA with limited tenure attempted to transfer the resident alone using what was later recognized as a weight machine rather than the proper mechanical lift, during which the resident began to slide as the legs lifted off the bed. The DON and ADON, responding to the CNA’s call for help, found the resident in a sling off the bed with an insecure lower body position and assisted in lowering the resident to the floor. Facility policy required two caregivers for mechanical lift transfers and mandated notifying the resident’s responsible party of incidents and falls, yet the transfer was performed by a single CNA, the event was documented as an "other incident" rather than a fall, and the resident’s representative was not promptly informed.
Two residents with contrasting conditions—one with hemiplegia and one with schizophrenia and other psychiatric diagnoses—were placed as roommates despite the latter’s history of verbal aggression, intact mobility, poor hygiene, and intimidating behavior. During a dispute over room temperature and a complaint about odor, the mobile resident made physical contact with the other resident’s leg, which the impaired resident, who had left-sided weakness, later described as being hit and reported pain in the left arm, leading to an X-ray. The impaired resident then struck back with a reacher, causing a minor skin injury to the aggressor’s nose. The DON and Administrator/Abuse Coordinator determined that the contact by the aggressive resident met the facility’s definition of physical abuse, and a police report classified the event as simple battery.
The facility failed to follow its abuse reporting policy when two residents, one with hemiplegia and one with psychiatric diagnoses and intact cognition, were involved in a physical altercation in their shared room. An initial abuse report was submitted alleging that one resident struck the other, who retaliated with a reacher while in a wheelchair, and documentation showed the aggressive resident required hospital evaluation for agitation and aggression. Although facility policy required that a detailed final investigation report be forwarded to the state agency within five working days, the administrator/abuse coordinator acknowledged that the final report, which concluded that physical abuse occurred and referenced a police report for simple battery, was not submitted within the required timeframe because it was forgotten.
The facility failed to update and post required daily nurse staffing information, resulting in the staffing notice at the reception desk displaying the prior day’s date and data. The receptionist, who arrives early and is responsible for changing the posting each day, confirmed that the posting should show the number of residents, CNAs, and nurses present but could not explain why it was not updated. Facility records showed that the daily nurse staffing information was not posted for one day, affecting all 199 residents and failing to meet federal requirements for current, clearly displayed staffing data.
Surveyors found unsanitary kitchen conditions, including buildup of brown substances, food particles, sticky liquids, and greasy walls with fruit flies, as well as employee food and drinks stored in the walk-in cooler with resident food. Cleaning and sanitizing practices were inconsistent with facility policy, with dirty solution in a red bucket under a prep table and confusion between detergent and sanitizer use. The only kitchen handwashing sink lacked paper towels. On a unit steam table, water in several compartments was only lukewarm, and one hot food item was held below 135°F, despite policy requiring hot foods to be maintained at or above this temperature. Several cognitively intact residents with multiple chronic conditions reported that hot meals were frequently cold or room temperature and that they could not request reheating.
Surveyors found that the facility failed to properly dispose of dietary garbage, affecting all residents. Two of four dumpsters behind the kitchen had open side sliding doors with dietary food waste visible and trash scattered on the surrounding ground, including numerous small packets of coffee cream or butter, sanitizing gloves, and large clear bags bulging from an open dumpster door. The Regional Director of Dietary was unsure of trash pick-up schedules and acknowledged that dumpster lids and doors should be closed, while the DON stated that staff were expected to regularly monitor the garbage area and pick up fallen trash. The Administrator acknowledged that the dumpster grounds should be clean and free of debris. These conditions did not comply with the facility’s written Cleaning Standard and policy "812 Food Procurement, Store/Prepare/Serve," which require removal of food and debris and proper cleaning and sanitizing.
Surveyors found that the facility failed to fully implement its infection prevention and control program. A resident with a draining foot wound had an active order for Enhanced Barrier Precautions, but no EBP sign or PPE supplies were posted at the room, and the resident was not listed on the facility’s EBP tracking document, which the IP attributed to oversight. Another resident on contact isolation for MDRO in the urine had appropriate signage and PPE at the door, yet a CNA entered without gown or gloves, handled the resident’s tray and belongings, assisted with positioning, and exited without performing hand hygiene, despite staff and leadership stating PPE and hand hygiene are required for any tasks in contact isolation rooms. The maintenance director, designated as part of the water management team, reported not being familiar with Legionella testing or whether the water system was tested, contrary to the written Water Management Program. Infection surveillance logs were incomplete: a resident receiving Doxycycline and Ertapenem was not recorded, another resident on isolation for a rash lacked full documentation, and the IP acknowledged logging antibiotics only at month’s end and not maintaining an employee infection log, even though an employee reported being off work for varicella contracted from a resident.
The facility failed to maintain an adequate antibiotic stewardship program and accurate antibiotic surveillance when a resident who received a 14-day course of Doxycycline in November was not recorded on the monthly infection and ABT tracking log. When the surveyor requested the antibiotic stewardship program, the Administrator did not provide it. The IP nurse later acknowledged that omitting the resident from the log was an oversight and could not recall whether the resident had been on antibiotics or had an active infection. The DON and facility policies state that the IP is responsible for championing the antibiotic stewardship program, completing surveillance in a timely manner, maintaining records, and communicating infection status to leadership.
Surveyors found that the facility failed to consistently offer, administer, and document influenza and pneumococcal vaccines for multiple eligible residents. Record review showed missing vaccine orders, absent documentation of vaccine education, consents, or declinations, and incomplete immunization logs. An LPN responsible for infection control acknowledged only one vaccine clinic occurred, admitted forgetting to reschedule another, and stated she did not document RSV, COVID, or flu vaccine consents or refusals. Several residents with complex medical histories had no record of being offered or receiving required vaccines, and one resident reported wanting vaccination but was never given consent forms.
The facility failed to ensure that residents and staff were educated about and offered the COVID-19 vaccine and that vaccination status was properly documented. The Infection Control Nurse admitted she had not offered the COVID-19 vaccine to residents for the current year, had no records of resident consent or declination, and did not use declination forms for staff, instead relying on verbal responses. A CNA reported providing immunization records and signing a declination form for an influenza vaccine, but the HR director stated there was no documentation in the CNA’s file and no vaccination information received from the Infection Control Nurse for staff. The DON stated she expected the Infection Control Nurse to provide vaccine education, obtain signed consents or declinations, and maintain surveillance logs, as required by the Infection Control Nurse’s job description.
Surveyors found that the facility failed to prevent flying insects, identified as fruit flies, from being present above and around food and in food preparation areas, affecting nearly all residents receiving meals from the kitchen. Insects were observed flying around uncovered pasta, over cooking ground meat, near sticky, greasy walls by a large kettle, and around a steam table where food temperatures were taken. The Regional Director of Dietary was unsure of the kitchen’s pest control schedule or policy, while the DON and the administrator both stated that insects should not be present in the kitchen and that the kitchen should be pest free. The facility did not follow its written “Sanitation and Food Safety: Pest Control” policy, which required the pest control company to respond to reports of active pest infestations, and the report states that this situation had the potential to cause foodborne illnesses.
A resident with multiple complex medical conditions repeatedly reported feeling cold air entering through cracks in their room window. Despite raising the issue during resident council meetings and informing staff, maintenance was not notified, and no work orders were submitted. The problem was only confirmed during a surveyor's assessment, revealing a failure to provide a comfortable environment as required by facility policy.
A resident with severe cognitive impairment and multiple urologic and renal diagnoses was observed in bed with a urinary catheter drainage bag hanging and draining to gravity without a privacy bag, leaving the urine visible. A CNA confirmed that the drainage bag should have been placed in a privacy bag to maintain dignity. The resident’s medical record included orders to monitor urine color and a care plan for chronic kidney disease, and facility policies stated that residents’ rights to dignity and a home-like environment would be protected, yet the drainage bag was not covered, resulting in a dignity-related deficiency.
A resident with acute right heart failure, pulmonary edema, reduced mobility, lack of coordination, and moderate cognitive impairment was observed with a call light attached low on the bed rail and not within reach. The resident reported the call light was usually on the floor and demonstrated inability to reach it due to nonfunctioning of one hand. An LPN acknowledged that call lights should be within reach but initially believed the resident could access it, and the DON confirmed that call lights are required to be accessible. This placement did not follow facility policy and CNA responsibilities for ensuring residents can use the call system to request assistance.
A resident with multiple serious diagnoses and cognitive impairment had a care plan and POLST indicating full code/CPR status, but no corresponding code status order was entered on the physician order sheet in the EMR. The DON reported that admitting nurses are expected to implement code status orders from verified hospital transfer and admission orders so that staff know and can honor the resident’s wishes. Facility policies on advance directives and resident rights require determining and documenting code status upon admission, yet this resident’s code status was not converted into an active physician order.
A resident with intact cognition and multiple medical conditions was observed with a privacy curtain that had large holes and a pinkish stain, and the resident reported requesting a replacement for months without resolution. Housekeeping staff and the Housekeeping Director stated that they are responsible for removing, cleaning, and replacing stained or torn curtains and for documenting needed replacements, but the director reported not being aware of this resident’s need for a new curtain. In addition, two residents were observed in the dining room sitting in wheelchairs with debris and old dried particles on the chair surfaces and brake levers. CNAs and the DON confirmed that CNAs are responsible for wheelchair cleaning according to a written schedule and that nurses are expected to ensure the cleaning is completed.
A resident with multiple medical and psychiatric diagnoses, including schizophrenia, anxiety disorder, type 2 DM, and HTN, had a PASRR determination for Short Term Approval without Specialized Services that included a specified end date. The facility did not submit a new PASRR request to the state agency before this short-term approval expired. During interview, the Social Service Director acknowledged awareness of the short-term PASRR status and stated that a new PASRR request should have been submitted, contrary to the facility’s written PASRR policy.
A resident with hemiplegia and multiple comorbidities had physician orders and a care plan directing daily use of a right AFO splint for several hours to maintain range of motion and prevent further decline. Surveyors twice observed the resident up in a wheelchair without the AFO in place, while the device sat on a nearby shelf and the resident reported it had not been applied and that he wanted it on. A posted sign instructed CNAs to apply the AFO when getting the resident up, but a CNA stated he thought restorative staff applied it, later admitted he became busy and forgot, and an LPN confirmed the AFO should have been on when the resident was in the wheelchair. Facility policies and job descriptions assigned responsibility for implementing restorative splint programs and following the care plan, yet the ordered AFO application was not carried out as required.
A resident with COPD, chronic respiratory failure, chronic bronchitis, and dependence on supplemental O2 was observed receiving 2 L/min oxygen via nasal cannula with a humidifier bottle that was dated but tubing that was not labeled. The physician order and facility policy required weekly changes and labeling of oxygen tubing and humidifier bottles, but an LPN reported these items were changed every 14–30 days and that tubing was not dated, assuming it was changed with the bottle. The DON stated that night nurses were responsible for changing and labeling both components weekly for infection control, and the written policy required at least weekly changes and labeling with date, time, and staff initials, which was not done for this resident’s nasal cannula tubing.
Surveyors found that controlled substance accountability records were inaccurately signed as correct for a resident’s lorazepam and morphine sulfate solutions even though the medications were not present on the unit’s medication cart. An LPN reported the drugs had been missing during consecutive shift counts and had contacted hospice, but the medications were later located in a different floor’s medication room refrigerator. This conflicted with facility policy requiring oncoming and off-going nurses to visually verify and reconcile all controlled substances at each shift change before signing the count.
A resident with multiple medical conditions and documented memory problems was observed without a privacy curtain extending around the bed after the curtain had been removed for washing and not replaced. The Environmental Services Director reported that only male housekeepers were permitted to replace privacy curtains and that the designated staff member had an emergency, resulting in the curtain remaining down. Facility policies state that residents have rights to privacy, dignity, and rooms that are safe, comfortable, and attractively maintained.
Several residents did not receive meals according to their documented dislikes and preferences, with staff and direct observation confirming that disliked foods were repeatedly served despite being noted on meal tickets. Staff reported ongoing issues with the kitchen providing incorrect meals, and residents' requests for substitutions were not consistently honored, contrary to facility policy.
The facility did not provide meals and snacks at scheduled times, resulting in residents waiting for extended periods before receiving food. Staff and residents reported ongoing delays, particularly with lunch service, due to kitchen staffing shortages after a change in management. Facility leadership and the Dietary Director were aware of the issue, which affected all residents receiving oral meals.
Three residents did not receive their prescribed therapeutic diets as ordered by their physicians. One resident did not receive double portions as ordered, another did not receive double portion protein, and a third was given thin liquids instead of nectar thick liquids. Staff interviews and record reviews confirmed these failures to follow dietary orders.
A resident with a history of hypertension and other chronic conditions did not have daily vital signs monitored and documented as ordered by a provider. Although a nurse reported checking the resident's blood pressure, the readings were not entered into the electronic medical record, and documentation was missing for extended periods. This failure to follow physician orders and maintain proper records resulted in a deficiency related to quality of care.
A malfunctioning call light system on the second floor prevented staff from identifying which resident was calling for assistance, as reported by an RN and a CNA. The system's constant beeping and failure of room lights to activate required staff to check rooms individually. Housekeeping and maintenance staff were unaware of the issue, and 64 residents were affected according to the facility census.
Several residents experienced uncomfortably cold room temperatures due to non-functioning heating units, with some rooms having exposed wires after staff moved beds. Residents reported the issues to staff, but the Maintenance Director was unaware of the problems until the survey. Affected residents included those with significant medical needs, and room temperatures were found to be below the facility's required range.
Nursing staff failed to document and administer medications as ordered for three residents with complex medical needs, as shown by missing entries on the MARs for multiple medications and times. The DON confirmed that missing documentation means the medication was not given, and facility policy requires all administered doses to be recorded at the time of administration.
A resident with multiple sacral wounds did not receive timely wound care upon admission due to a lack of hospital paperwork and a delay in obtaining physician orders. The admitting nurse did not complete any treatments, and the wound care coordinator was unavailable. The resident expressed dissatisfaction and requested hospital transfer. Facility policy requires timely wound care to promote healing and prevent infection.
A resident with a history of hemiplegia and diabetes developed a worsening pressure ulcer due to the facility's failure to provide consistent care and documentation. The resident's care plan included turning and repositioning every 1-2 hours and specific wound care treatments, but these were not consistently documented or followed. The wound deteriorated, leading to infection and hospitalization. The facility's policies and job descriptions emphasize proper documentation and adherence to treatment protocols, which were not followed, contributing to the resident's condition worsening.
The facility failed to respond promptly to call lights for two dependent residents requiring assistance with self-care activities. Despite facility policies and job descriptions mandating prompt responses, staff did not adhere to these guidelines, leaving residents waiting for assistance. This deficiency was observed when a resident's call light was on for over 10 minutes while staff were at the nurse's station, and another resident's call light was ignored despite their need for cleaning.
A facility failed to administer medications within the scheduled time frame for a resident with conditions including paraplegia and hypertension. The resident reported consistent delays in medication administration across all shifts, confirmed by observations and record reviews. Medications were given outside the one-hour window before or after the scheduled time, with instances of significant delays. The facility's policy requires timely administration, but this was not adhered to, affecting the resident's care.
A resident with moderate cognitive impairment and mobility issues was affected by a malfunctioning call light system, which failed to register on the nurse's station board. Despite the CNA's acknowledgment of the issue, the Maintenance Director initially dismissed it. The facility's policy mandates daily checks and immediate reporting of defects, which were not followed.
A resident with a history of aggression assaulted another resident in the dining room. Despite the presence of an aide who intervened immediately, the facility failed to prevent the incident. The aggressive resident has severe cognitive impairment and a documented history of physical aggression, while the victim has mild cognitive impairment. The facility's abuse policy was not effectively implemented to protect the residents.
The facility failed to provide adequate supervision and medication administration, with residents left unattended and medications not given as ordered. Staff were unaware of their responsibilities, and medication carts were left unlocked. Unprofessional conduct was observed, with a nurse on a video call during medication prep and another yelling at a surveyor.
The facility failed to prevent physical abuse among residents, resulting in two incidents in the dining room. In one case, a resident was pushed from a wheelchair, and in another, a resident was hit in the face during an altercation. Both incidents occurred without adequate staff supervision, contrary to the facility's abuse prevention policy.
A lack of supervision in the dining room led to two separate physical altercations between residents, resulting in one resident being pushed from a wheelchair and another being hit in the face. Staff acknowledged the absence of supervision, which is contrary to facility policies requiring visual monitoring during mealtimes.
The facility failed to accurately log dish machine temperatures and ensure proper functionality, affecting 162 residents. A dietary aide used a temperature strip to test the dishwasher, which did not reach the required 160°F for sanitation. The aide admitted the issue persisted for over a week without informing the dietary manager. The temperature log showed falsification, with strips colored in 25 times, and documented failure to reach the required temperature. Facility policy mandates reporting deviations to the food service manager.
The facility failed to ensure proper infection control measures, including the availability of PPE for residents on enhanced barrier precautions and appropriate signage. Staff did not wear PPE when required, and soiled linens were improperly handled. Additionally, the facility had not conducted necessary Legionella water testing, compromising the water management program.
The facility failed to follow its policies for pneumococcal vaccinations, affecting several residents. Records showed no documentation of vaccine offering or education, and no physician orders for the vaccine were found. The IP admitted reliance on an annual mobile clinic visit without an alternative plan, while the ADON confirmed the expectation to offer vaccines upon admission. The facility's policy to obtain standing orders and provide vaccine information was not adhered to.
The facility failed to ensure proper documentation of controlled substance counts during shift changes, affecting residents on two units. Observations revealed missing signatures on accountability records, indicating that required counts were not consistently performed. This deficiency impacted residents prescribed controlled medications for conditions like seizures and pain management. Staff interviews confirmed the lapses, and the facility's guidelines emphasize the importance of accurate narcotic records.
A facility failed to obtain psychotropic medication consents for four residents before administering antipsychotic drugs, despite having a policy requiring consents at the start of medication usage. The residents, diagnosed with severe cognitive impairments, received medications like Quetiapine, Risperdal, and Trazadone without prior consent. The DON confirmed the absence of consents, and the ADON highlighted the necessity of consents due to potential sedative effects and classification as chemical restraints.
The facility failed to label multidose medications with open and discard dates, affecting four residents. Insulin pens and a vial were found without proper labeling, and a discharged resident's medication was not removed from the cart. The DON confirmed that facility policy requires labeling and removal of medications for discharged residents.
The facility failed to maintain heating unit vents in the third-floor dining room and hallway in a sanitary condition. Observations showed the vents were missing covers and filled with garbage. The Memory Care Director was informed, and the Maintenance Assistant began addressing the issue, noting a vent had stopped working due to resident interference.
Failure to Offer Menu Alternatives on Weekends
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide menu alternatives and substitutions on weekends, despite policies stating that residents may choose foods they wish to have and that an alternative menu is available daily. Multiple cognitively intact residents reported that from Monday through Friday, activity staff visit units to review the day’s lunch and dinner options and offer a list of alternative items, which are then communicated to the kitchen. However, these residents stated that this process does not occur on weekends and that they are only served the posted menu items on those days. Several residents described that on weekends they are unable to obtain substitutions if they do not like the main entrée. One resident stated that CNAs tell him the kitchen does not do substitutions on weekends, so he must eat what is served. Another resident reported he can only get substitutions during the week and wishes weekend options were available for variety. A different resident stated that while he can order ahead and receive substitutions Monday through Friday, on weekends staff tell him there is no other food to give him if he dislikes the meal, resulting in him going hungry. Another resident reported that on weekends he has to eat whatever is served because no substitutions are available, and another said that when he does not like the weekend meal, he calls his family for money to buy snacks or order outside food so he has something to eat. Staff interviews confirmed that the practice of offering and documenting menu alternatives occurs only on weekdays. A dietary aide stated that substitutes are available Monday through Friday but not on weekends, and that any weekend changes depend on what food happens to be available. Activity aides reported that they solicit residents’ meal choices and offer alternatives only during the week, not on weekends, and that on weekends residents receive only the posted menu entrée. In contrast, the regional food service manager and dietary manager both stated that menu alternatives are supposed to be available and offered every day at every meal, consistent with facility policies and an “Always Available Menu” listing items such as cheeseburgers, hamburgers, grilled cheese, peanut butter and jelly, deli sandwiches, and chef salad. The discrepancy between stated policy and actual weekend practice led to residents not being offered menu alternatives on weekends.
Uncovered Food Items and Lack of Hair Restraints During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to maintain sanitary conditions during food delivery and meal service, including not fully covering food and utensils during transport and not ensuring food service staff consistently wore hair restraints. A resident reported that his food was not always covered and that this bothered him because he did not want anyone talking while carrying his tray, as he was concerned spit could get on his food. He also stated that his juice, dessert, and silverware were never covered and reported finding two black hairs on top of the bread of his grilled cheese sandwich on an unspecified date. The facility’s own infection control and hair restraint policies require staff to wear hair restraints and beard guards and to follow regulations to assure a safe and sanitary dining services department. Surveyors observed multiple instances during meal distribution where food and utensils were not adequately covered. During lunch distribution on one unit, two dietary aides portioned food from a portable steam table, and one aide was not wearing a hair restraint or beard protector. CNAs preparing trays for residents who ate in their rooms placed uncovered drink cups and uncovered utensils on trays in open carts, and both CNAs stated that drink cups and silverware were never covered during transport, only the plates of food were wrapped. Additional observations on different floors showed open carts in hallways with trays where the main plate was covered in plastic wrap, but desserts, salsa containers, drink cups, bowls of cereal, and silverware remained uncovered. Carts were left open and unattended while CNAs delivered trays and set up residents in their rooms. Further observations in the main kitchen showed a dietary aide prepping lunch trays with a hairnet but without a beard protector, and another dietary aide in the food preparation area also without a beard protector. The dietary manager confirmed that these staff should have been wearing beard protectors and stated that staff in the kitchen and upstairs portioning food are expected to always wear hair restraints because of the potential for hair to fall into food and contaminate it. The dietary manager and regional food service manager both stated that food delivery carts are open and should be covered with large plastic covers during transport, especially when traveling long distances, left unattended, or placed where residents could touch the trays, because desserts, cereal, bowls, drinking cups, and silverware are not otherwise covered. A CNA with prior dietary and housekeeping experience also stated that carts and all tray items should be covered for infection control reasons, noting that the kitchen was only covering the plate of food and not the other tray items.
Failure to Respond Promptly to Resident Call Light
Penalty
Summary
The facility failed to respond to a resident’s call light in a timely manner, despite policies and job descriptions requiring prompt response. On multiple observations, the call light system monitor at the 2nd floor nursing station showed that the resident’s room call light had been activated for extended periods, with the hallway light outside the room remaining on. On one day, the call light for this resident’s room remained active from at least 12:53 PM until 1:11 PM, and the resident reported that it took staff a long time to check on him. On another day, the monitor showed the resident’s call light had been on for 62 minutes while an LPN sat at the nursing station; the LPN acknowledged that the system tracks minutes since activation and stated that someone likely went in but forgot to turn off the light, although the hallway light remained on. The resident involved had diagnoses including paraplegia, colostomy care, joint contractures, intestinal obstruction, UTI, and urogenital implants, and his MDS indicated intact cognition with substantial/moderate assistance needed for toileting, bathing, lower body dressing, personal hygiene, and transfers. His care plan identified him as at risk for falls related to generalized weakness and paraplegia, with interventions including keeping the call light within reach and encouraging its use for assistance. The resident reported that a CNA brought him a bucket of water at about 10:50 AM so he could bathe himself, but he could not wash his feet independently and activated his call light for help; more than an hour later, no staff had entered his room, and the CNA confirmed she had not returned since 10:50 AM and had been busy passing meal trays. Both the CNA and LPN stated that call lights should be answered right away or as soon as possible, and the DON stated that call lights should be responded to within 15 minutes, noting that staff do not know why a resident triggered the call light unless they check on them. Facility policy and the CNA job description both require call lights to be answered promptly.
Failure to Protect Resident From Emotional Abuse and to Immediately Remove Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from emotional/mental abuse and to immediately remove the alleged staff perpetrator from resident contact after an abuse allegation. A cognitively intact resident with multiple chronic medical conditions, including coronary artery disease, CHF, COPD, CKD, schizoaffective disorder (bipolar type), major depressive disorder, and nicotine dependence, used a wheelchair for mobility and depended on staff for transfers. The resident had a care plan noting a history of suspected abuse, neglect, exploitation, past trauma, and other factors increasing susceptibility to abuse/neglect, with an expectation that the resident would be treated with respect and dignity and live free from mistreatment. On the evening in question, the resident was propelling himself in his wheelchair toward the designated smoking area with an unlit cigarette in his mouth so that both hands were free to move the wheelchair. Two CNAs reported that the LPN at the nurses’ station got up, approached the resident, and snatched the unlit cigarette out of the resident’s mouth, broke it in half, and, per the resident and the Administrator, threw it at the resident. The CNAs stated the LPN did this without first speaking to the resident and described the LPN as rude. The resident and both CNAs reported that the LPN told the resident he was not supposed to have the cigarette in his mouth, and the CNAs further reported that the LPN yelled at the resident and threatened to call the police on him as a way to scare or intimidate him. The resident stated he was not trying to smoke in the building and that he was not scared by the threat, but he was upset and intended to report the LPN. One CNA stated she immediately texted the DON to report what she believed was emotional/mental abuse based on her training, and the other CNA stated she knew this report was made that night. Both CNAs later wrote statements dated two days after the incident. The DON stated that staff are expected to report abuse immediately, that staff-to-resident abuse requires immediate separation of the staff from the resident and removal of the staff from the building, and that this is necessary to ensure resident safety and prevent continuation of abuse. The Administrator, who is the abuse coordinator, similarly stated that staff must report suspected abuse immediately, that it is not their role to determine whether abuse occurred, and that any staff member involved in alleged abuse must be removed from the building and placed on administrative leave pending investigation. The Administrator stated that the first time he became aware of the incident was when the resident reported it to him two days later, at which time he learned that the LPN had snatched the cigarette from the resident’s mouth and threatened to call the police, actions he acknowledged could be intimidating, humiliating, and a form of abuse. Facility records showed the LPN continued to work after the incident and was not removed from the building the night of the alleged abuse, contrary to the facility’s abuse prevention policy, which requires immediate separation of the alleged perpetrator and notification of the Administrator and DON when abuse is suspected.
Late Submission of Final Abuse Investigation Report to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to submit a final investigation report of alleged staff-to-resident abuse to the Illinois Department of Public Health (IDPH) within the required five business days. The facility’s own Abuse Prevention Program policy, dated 01/2019, states that the final investigation report will be completed within five working days of the reported incident and that the Administrator is responsible for forwarding a final written report of the results of the investigation and any corrective action taken to IDPH within that same timeframe. The Administrator (V1), who serves as the facility’s abuse coordinator, confirmed that once abuse is reported, an initial report must be submitted to IDPH within two hours and the final report within five business days. The incident under investigation involved R6, a cognitively intact resident with multiple medical diagnoses including atherosclerotic heart disease, chronic diastolic heart failure, COPD, hypertension, hyperlipidemia, polyneuropathy, chronic kidney disease, schizoaffective disorder bipolar type, rheumatoid arthritis, gout, nicotine dependence, major depressive disorder, and anemia. R6 uses a wheelchair and is dependent on staff for transfers and has a care plan noting a history of suspected abuse, neglect, exploitation, past trauma, and other factors increasing susceptibility to abuse/neglect, with an expectation to be treated with respect and dignity and to reside free from mistreatment. R6 reported that while wheeling himself down the hallway toward the designated smoking area with an unlit cigarette in his mouth, an LPN (V21) snatched the cigarette from his mouth, broke it, threw it at him, and told him he should not have it in his mouth, and further threatened to call the police on him. Two CNAs (V22 and V23) corroborated R6’s account, stating that R6’s cigarette was unlit and in his mouth only so he could use both hands to propel his wheelchair, and that V21 abruptly got up from the nurses’ station, snatched the cigarette from R6’s mouth, broke it, and then verbally threatened him by saying she would call the police, which they characterized as intimidating and verbally/mentally abusive. R6 reported the incident to the Administrator on 12/09/25, stating it had occurred on 12/07/25. The facility submitted the initial report to IDPH on 12/09/25 at 5:23 PM. However, the final report was not submitted until 12/19/25 at 3:40 PM, which the Administrator acknowledged was late, noting that it should have been submitted by 12/16/25. This delay in forwarding the final written investigation report to IDPH beyond the five-business-day requirement constitutes the cited deficiency.
Failure to Consistently Administer and Document Anti-Seizure Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to prescribed anti-seizure medications. The resident, admitted with multiple diagnoses including spastic hemiplegic cerebral palsy, cerebral infarction with left-sided hemiplegia, Lennox-Gastaut syndrome, other seizures, atherosclerotic heart disease, and type 2 diabetes mellitus, was cognitively intact and ambulatory with a walker. During an interview, the resident reported that doses of her anti-seizure medications (phenobarbital, Keppra, and pregabalin/Lyrica) were missed because the medications were not available or the facility was “out of it,” and that she experienced seizure episodes when she did not receive these medications. She stated she had a seizure episode a couple of weeks prior that she associated with missed doses of Keppra, phenobarbital, and Lyrica. Staff interviews corroborated that the resident had a recent seizure episode. A CNA who regularly worked on the unit and was assigned to the resident reported observing a seizure 2–3 weeks earlier in the dining room, describing shaking while the resident was in her wheelchair and noting that it was a quick seizure and did not result in hospitalization. An LPN assigned to the resident stated he follows physician orders and the “5 rights” of medication administration and that he signs or initials the MAR after giving medications, acknowledging that if the MAR is not signed or initialed, it could mean the medication was not given. The DON similarly stated that nurses are expected to sign or initial the MAR after administering medications and that if the MAR is not signed, it could possibly mean the medication was not given, adding that standard nursing practice is that if it is not documented, it was not given. Record review showed multiple missing signatures/initials on the MAR for the resident’s anti-seizure medications, indicating doses were not administered as ordered. The physician orders included pregabalin 200 mg PO twice daily at 9 AM and 5 PM, phenobarbital 100 mg PO twice daily at 9 AM and 5 PM, and Keppra 1000 mg PO twice daily at 6 AM and 6 PM. The March MAR showed no signatures/initials for Keppra on three dates and for phenobarbital and pregabalin on one date, while the February MAR showed no signatures/initials for Keppra on two dates and for phenobarbital and pregabalin on one date. A nursing progress note documented a seizure on a prior date with jerking movements of all extremities lasting one minute. The resident’s care plan identified risk for seizure activity related to Lennox-Gastaut syndrome and directed staff to administer medications as ordered. Facility policies required medications to be administered as prescribed, documented on the MAR at the time of administration, and signed out as soon as given, with refusals and reasons documented, which was not consistently done in this case.
Failure to Safely Perform and Care Plan Mechanical Lift Transfer and Notify Representative After Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent a fall, to accurately and timely care plan for mechanical lift transfers, to ensure two staff were present during a mechanical lift transfer, and to notify the resident’s representative of a fall. The resident had diagnoses including osteoporosis, Alzheimer’s disease, dementia, dysphagia, a displaced fracture of the left femur, and a history of falling, and was documented as severely cognitively impaired and dependent on staff for bed-to-chair transfers. The care plan identified the resident as at risk for falls and self-care deficits, with interventions to follow the facility fall protocol and anticipate and meet needs, and noted that assistance with transfers might occasionally increase due to fluctuating needs. However, the care plan did not include a specific focus on mechanical lift transfers until several days after the incident, despite multiple staff interviews indicating the resident had required mechanical lift assistance for more than a year. On the date of the incident, a CNA with a little over a month of employment at the facility attempted to transfer the resident from bed to chair using a mechanical device without assistance from a second staff member. During the transfer, when the resident’s legs lifted off the bed, the resident began to slide. The CNA realized the device being used was a weight machine rather than the appropriate mechanical lift for resident transfers. The CNA reported that the resident “kind of slid down slow,” and the CNA paused the transfer and called for help. The DON and ADON, who were rounding on the unit, heard the call for help and entered the room, observing the resident in a sling off the bed and the CNA attempting the transfer alone. Both the DON and ADON stated the resident’s lower body did not look secure or comfortable, and they, along with the CNA, lowered the resident to the floor. The facility’s own policies required two caregivers for mechanical lift transfers and directed that the resident’s responsible party be notified of incidents, accidents, and falls. The CNA had signed the Resident Handling Policy and completed a mechanical lift competency validation that specified use of a second caregiver. Despite this, the transfer was performed by a single CNA, and the incident was documented by the DON as an “other incident” rather than a fall. The DON stated the facility was calling the event an “assisted transfer” to the floor and not a fall, and both the DON and ADON acknowledged they did not inform the resident’s responsible party at the time of the incident. The responsible party was not notified about staff placing the resident on the floor until several days later, and the facility’s conclusion was that the event was not a fall, despite regulatory guidance defining a fall as unintentionally coming to rest on the floor or a lower level, including episodes where a resident would have fallen if not assisted to the floor.
Failure to Protect Roommates From Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse as required by its abuse prevention policy, resulting in two residents experiencing physical abuse. One resident with hemiplegia and hemiparesis following cerebrovascular disease shared a room with another resident diagnosed with schizophrenia, schizoaffective disorder, and major depressive disorder, who was admitted with a history of primarily verbal aggression. During a disagreement in their shared room, the cognitively intact resident with psychiatric diagnoses attempted to adjust the heat on the roommate’s side of the room. The roommate complained that the other resident smelled, after which the aggressive resident made physical contact with the roommate’s leg. The resident with hemiplegia, who had left-sided weakness and could not effectively block the contact, reported being hit first on the leg and later stated it was the arm, and complained of left arm pain, prompting an X-ray. The incident report and interviews documented that the resident with psychiatric diagnoses made physical contact with the roommate, and the facility’s Administrator/Abuse Coordinator and DON concluded that this contact met the facility’s definition of physical abuse. The roommate reacted by striking the aggressive resident with a reacher, causing a minor skin alteration to the aggressor’s nose. A police report characterized the event as simple battery, and social services documented that the aggressive resident required psychiatric evaluation due to aggression toward the roommate and difficulty with redirection. Despite known behavioral issues, lack of physical limitations, poor hygiene, and an intimidating demeanor, the aggressive resident had been placed and maintained as a roommate to a physically impaired resident who could not adequately protect herself from being hit on her weak side, resulting in the abusive contact and associated pain complaint.
Failure to Timely Submit Final Abuse Investigation Report
Penalty
Summary
The facility failed to follow its abuse reporting policy for two residents involved in a physical altercation. One resident with hemiplegia and hemiparesis and another resident with schizophrenia, schizoaffective disorder, and major depressive disorder, who had intact cognition with a BIMS score of 15, were roommates at the time of the incident. An initial abuse reportable incident was submitted alleging that the cognitively intact resident made physical contact with the other resident, who then retaliated by striking with a reacher while seated in a wheelchair. Social service notes documented that the aggressive resident was sent to the hospital for psychiatric evaluation due to aggression toward the roommate and difficulty with redirection, and census records showed that this resident later returned to the facility on the same floor but a different room. The facility’s Abuse Prevention Program required that abuse allegations involving one resident upon another be reported to the state agency and that a final written investigation report, including specified investigative details, be forwarded within five working days of the incident. The administrator/abuse coordinator acknowledged that the final report, which concluded that the aggressive resident did hit the roommate and that the act met the definition of physical abuse, was not submitted within the required timeframe. The final report, including reference to a police report documenting simple battery, was sent more than two weeks after the incident because the administrator forgot to send it and did not follow the policy requiring submission of the initial and final reports within five working days.
Failure to Update and Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to update and post required daily nurse staffing information as mandated by 42 CFR §483.35(g). On 12/14/25 at 8:55 a.m., a surveyor entered the facility and observed that the daily staffing posting displayed in a clear standing frame holder at the receptionist desk was dated 12/13/25, indicating it had not been updated for the current day. The posting is intended to show the facility name, current date, total number and actual hours worked by RNs, LPNs/LVNs, and CNAs directly responsible for resident care per shift, as well as the resident census. The failure to update this information affected all 199 residents residing in the facility. On 12/15/25 at 11:20 a.m., the receptionist stated that receptionists arrive at 6:30 a.m. and are responsible for changing the daily staff posting every day, and confirmed that the posting is supposed to show how many residents, CNAs, and nurses are present in the building each day. The receptionist reported not knowing why the daily staff posting was not updated on 12/14/25. Facility documentation titled "Daily Nursing Staff For Direct Resident Care" dated 12/13/25 showed that the daily staff was not posted for 12/14/25. These observations and interviews demonstrated that the facility did not ensure that the nurse staffing information was up-to-date and current as required, and that the required daily posting was missing for that date.
Unsanitary Kitchen Conditions and Inadequate Hot Food Temperatures
Penalty
Summary
The deficiency involves failure to maintain sanitary kitchen conditions and proper food handling practices, as well as failure to consistently maintain safe hot food temperatures. During an initial kitchen tour, surveyors observed that the only kitchen handwashing sink had no paper towels available. The kitchen floor contained buildup of dry brown substances, dark food particles, sticky liquids, and residue from a pasta pot leak, with compacted dark brown particles along the perimeter behind a large pot. Similar dark brown substances were seen throughout kitchen preparation areas and on the walls. Personal employee food and beverages were stored on a serving tray in the walk-in cooler where resident food was stored, despite the traveling chef manager stating that employee items should not be in that area. Surveyors also identified improper use and handling of cleaning and sanitizing solutions. A red bucket under the cook’s preparation table contained a dirty-looking liquid and a dish towel; when asked to test the solution, the dietary cook immediately removed the bucket and discarded the contents in the three-compartment sink, ignoring the request. The traveling chef manager later stated that the discarded solution was dishwashing solution used to wipe food preparation areas, contrary to the dietary manager’s explanation that green buckets are for soap/detergent and red buckets are for sanitizing solution. The facility’s policy stated that cleaning involves removing food and debris from equipment and work surfaces, that floors and walls should be cleaned and then sanitized, and that sanitizing solution should be clean. On a subsequent observation, greasy, sticky brown substances were noted on walls near the stove and mixing area, with fruit flies flying within 12 inches of the sticky walls. The regional dietary director acknowledged that the kitchen and floors should be deep cleaned and was unsure of the cleaning or deep cleaning frequency. The facility also failed to consistently maintain hot food at or above the required temperature of 135°F during meal service. On one observation of the second-floor steam table, the first compartment held semi-hot water and the remaining compartments had lukewarm water while holding beef goulash, green beans, and bread. When temperatures were checked, the green beans measured 131.3°F, below the facility’s stated standard of 135°F or higher, while other items were 135°F or above. Several cognitively intact residents with multiple medical diagnoses, including multiple sclerosis, diabetes mellitus, COPD, heart disease, and mental health conditions, reported that hot meals were often cold or room temperature; one resident stated he had given his lunch tray away because the food was cold, and others stated that for the most part hot meals were room temperature or cold and that they could not ask for the food to be warmed. The regional dietary director stated that steam tables are plugged in and filled 30 minutes before meal service, take 10–15 minutes to warm up, and that hot foods should be held at 135°F or higher to keep food out of the danger zone because it is dangerous for residents.
Improper Disposal and Management of Dietary Trash in Dumpster Area
Penalty
Summary
Surveyors observed that the facility failed to properly dispose of dietary garbage and refuse for all 199 residents, as evidenced by conditions in the outdoor dumpster area behind the kitchen. On observation, four dumpsters were present, and two of the dumpsters closest to the building had open side sliding doors with dietary food trash visible inside and scattered on the surrounding ground. The trash on the ground included numerous small packets that appeared to contain coffee cream or butter, sanitizing gloves, and two large clear bags bulging out of the open sliding door of one dumpster. The Regional Director of Dietary stated he was not certain of the trash pick-up dates and times and acknowledged that dumpster lids and sliding doors should be closed. The DON stated that the garbage area was expected to be monitored regularly for fallen trash and that dietary staff were expected to pick up trash on the ground, and further stated that the facility must be compliant in all areas of nutrition. The Administrator stated it was unfortunate that the dumpster ground area contained trash and confirmed that the dumpster grounds should be clean, with no debris or scattered trash, and that trash should always be picked up and discarded. The facility did not adhere to its undated policy "812 Food Procurement, Store/Prepare/Serve" and Cleaning Standard, which describes cleaning as the use of water, chemicals, and physical effort to remove all food and debris from equipment and work surfaces, and specifies that floors and walls should be cleaned and then sanitized and that sanitizing solution should be clean. No specific individual residents were described in the report beyond the reference to 199 residents living in the facility who were affected by this failure to properly dispose of dietary trash.
Infection Control Failures in EBP, Contact Isolation, Water Management, and Surveillance
Penalty
Summary
Surveyors identified multiple failures in the facility’s infection prevention and control program related to Enhanced Barrier Precautions (EBP), contact isolation practices, water management for Legionella, and infection/antibiotic surveillance. One resident with a right heel wound and diabetes had an active physician order for EBP related to wounds, requiring staff to use gown and gloves during high-contact care every shift. On observation, this resident was in a wheelchair with a right foot dressing showing visible strike-through drainage, but there was no EBP sign on the door and no PPE bin or supplies outside the room as required by facility policy. The infection preventionist (IP) stated that residents with wounds should have an EBP sign and PPE bin, acknowledged she receives the wound report and is responsible for ensuring EBP signage and supplies, and admitted it was an oversight that the sign and PPE were not in place. The facility’s EBP tracking document did not show that this resident had been placed on EBP, despite the active order. Surveyors also observed failures to follow contact isolation protocols for another resident on contact precautions for multidrug-resistant organisms (MDRO) in the urine. This resident had diagnoses including paraplegia, resistance to multiple antibiotics, history of UTI, and MDRO infections, and was care planned and ordered to remain on contact isolation with PPE (gown and gloves) to be used by staff. The room had a contact precautions sign and PPE hanging on the door. However, a CNA was observed entering the contact isolation room without gown or gloves, picking up the resident’s breakfast tray, tidying belongings, touching the bedside table and items, having the privacy curtain in contact with their body, assisting with positioning, and then exiting the room carrying the tray without performing hand hygiene before or after leaving the room. The CNA later stated they should have worn gown and gloves and performed hand hygiene. Multiple staff, including LPNs, CNAs, the DON, the ADON, and the IP, all stated that staff are expected to don PPE and perform hand hygiene before and after entering contact isolation rooms and when performing any tasks or touching items in such rooms, confirming that the observed actions were inconsistent with facility expectations and practice standards. Additional deficiencies were found in the facility’s water management and infection surveillance systems. The maintenance director, identified as part of the water management program team along with the administrator, stated he was not familiar with Legionnaires disease water testing, did not know if the water had been tested for Legionella, and was unsure whether the water company’s recent testing included Legionella. The administrator stated he was not aware of Legionella testing logs and described expectations that the maintenance director communicate any issues with required testing. The facility’s Water Management Program policy requires identification of building water systems needing Legionella control measures and assigns responsibility for developing, implementing, and reviewing the program to the safety committee/maintenance supervisor and consultants. In infection surveillance, the IP stated she tracks infections and antibiotics using McGeer criteria but admitted she does not log all antibiotic information until the end of the month and acknowledged this practice may not be effective. Review of monthly infection logs showed missing entries: one resident receiving Doxycycline and Ertapenem in November was not listed on the infection log, and another resident on isolation for a rash had no onset date and no documentation of the ordered cream, both described by the IP as oversights. The IP also stated she does not maintain a log for employee infections, despite a social services director reporting she was off work for weeks after contracting varicella from exposure to a resident and not submitting any infection-related paperwork to the IP. The DON and the IP job description both describe expectations for timely, complete surveillance, antibiotic stewardship, and maintenance of infection records, which were not met in these instances.
Failure to Maintain Antibiotic Stewardship and Accurate Antibiotic Surveillance
Penalty
Summary
The facility failed to maintain an adequate antibiotic stewardship program and to accurately track antibiotic use for one resident, with potential impact on all residents. A resident admitted with multiple diagnoses, including chronic pain, abnormal liver function, anemia, benign prostatic hyperplasia with lower urinary tract symptoms, stage 4 pressure ulcers of the right buttock and right hip, and neurogenic bowel, received Doxycycline for 14 days in November 2025. Review of the resident’s medical record and the facility’s November 2025 monthly infection log and antibiotic tracking surveillance showed that this antibiotic therapy was not recorded on the November log. When the surveyor requested the facility’s antibiotic stewardship program from the Administrator, it was not provided. Further review of the facility’s antibiotic surveillance log by the surveyor showed that the Infection Preventionist (IP) nurse did not include this resident on the November 2025 Monthly Infection Log. The IP nurse stated she was unsure why the resident was not recorded and described it as an oversight, and she could not recall whether the resident had been on antibiotics or had a current infection. The DON stated that the purpose of the antibiotic stewardship program and maintaining up-to-date data is to ensure residents receive appropriate antibiotics and that ineffective antibiotics can result in prolonged or worsening infection. Facility documents, including the IP job description and the Guidelines for Infection Prevention and Control, specify that the IP is responsible for championing the antibiotic stewardship program, ensuring surveillance is completed timely, maintaining records appropriately, and spearheading the infection control program, with regular communication to the DON and Administrator regarding infection status.
Failure to Provide and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of influenza and pneumococcal vaccination practices, including failure to vaccinate eligible residents, failure to obtain and/or process consents, and failure to document vaccine offers, education, consents, or declinations in the electronic medical record. Record review for six sampled residents showed no documentation of pneumococcal and/or influenza vaccine offering or education from admission through mid-December, and physician orders contained no standing or individual orders for these vaccines. Immunization logs did not reflect tracking for influenza or pneumococcal vaccines. The Infection Control Nurse (V11) stated that all immunizations should be recorded under the immunization tab when offered or administered, but acknowledged that this was not consistently done. V11 reported that only one vaccine clinic was actually held during the year, on 10/30, and that a second clinic planned for early November was not rescheduled because she forgot to follow up with the vendor. She also stated that RSV vaccine was offered but she did not document whether residents consented or declined, and she could not recall which resident had inquired about it. V11 admitted she had not been recording declinations or consents for residents, describing this as an oversight and acknowledging that this placed residents and staff at risk. The facility’s undated pneumococcal vaccination policy stated that standing orders for pneumococcal vaccine were to be obtained on admission and that residents or representatives were to receive information on risks and benefits upon admission, and the Infection Control job description included ensuring maintenance of the resident health program for influenza and pneumococcal vaccines. For the six residents cited, records showed specific failures in vaccine offering and documentation. One resident with dementia, schizoaffective disorder, anxiety, anoxic brain damage, thyroid dysfunction, and hypertension had no record of being offered or receiving influenza vaccine and did not receive any vaccines at the 10/30 clinic. Another resident with spinal stenosis, breast cancer, major depressive disorder, diabetes, hyperlipidemia, hypertension, anxiety, and COPD had no documentation of influenza or pneumococcal vaccination or declination; V11 believed a declination form had been signed but could not locate it and had not entered it into the medical record. A resident with encephalopathy, epilepsy, hypertension, seizures, hypokalemia, and a history of COVID-19 had a signed influenza consent dated early October but no documentation of vaccine administration in the chart; V11 initially produced a consent with another resident’s name, later confirming via clinic list that the vaccine had been given but not documented, and also stated she failed to document whether COVID and RSV vaccines were accepted or declined. Additional residents with hemiplegia, diabetes, hyperlipidemia, CKD, schizoaffective disorder, cerebral palsy, asthma, thyroid disorder, major depressive disorder, adult failure to thrive, anxiety, hyperlipidemia, multiple sclerosis, ataxic gait, protein-calorie malnutrition, suicidal ideation, and schizoaffective disorder were not offered influenza and/or pneumococcal vaccines, had no consents or declinations on file, and in one case the resident reported wanting vaccination but not being offered consent forms; V11 attributed one resident’s lack of vaccine offer to the social services staff not being present at admission.
Failure to Offer, Educate, and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The deficiency involves the facility’s failure to educate residents and staff on COVID-19 vaccination, to offer the COVID-19 vaccine to eligible residents and staff, and to document each individual’s vaccination status. Surveyors determined that the facility had not offered the COVID-19 vaccine to residents for 2025 and had no records showing that residents consented to or declined the vaccine. The Infection Control Nurse (V11) acknowledged that she had not offered the COVID-19 vaccine to residents for 2025, had no documentation of resident consent or declination, and described this as an oversight. She further stated that she does not document staff declinations on forms, instead relying on verbal responses and a “mental note.” The facility identified that this failure had the potential to affect all 199 residents. Regarding staff, a CNA (V14) reported that he had been offered the influenza vaccine and declined it because he had already received it at his clinic, and he stated he had given the Human Resource Director a copy of his immunization records and signed a declination form. However, the Human Resource Director (V23) stated she had not received any documentation from the Infection Control Nurse about staff vaccinations for 2025, and there was no information in V14’s file reflecting that he had been educated about or offered immunizations. V23 also reported that V14 did not provide her with any immunization records for his file. The DON (V2) stated that her expectation was that the Infection Control Nurse would timely complete resident immunizations, ask residents about immunizations on admission and during influenza season, educate staff on vaccines, obtain signed consents or declinations from residents and staff, and maintain surveillance logs for tracking and analysis. The Infection Control Nurse’s job description included providing educational offerings and ensuring resident and staff vaccination programs are completed timely, which was not carried out as expected in this instance.
Failure to Control Flying Insects in Kitchen Food Preparation Areas
Penalty
Summary
Surveyors observed that the facility failed to prevent flying insects from being present above and around food and in food preparation areas, affecting 196 residents who received food from the kitchen. During an initial kitchen tour, two insects were seen flying around an uncovered kettle bowl of pasta and over the stove where ground meat was cooking, in the aisle between three stoves and the food preparation area. On a subsequent observation, multiple flying insects were seen within 12 inches of sticky walls, in the back area near a large 20‑pound kettle, and near greasy, sticky brown substances on the walls; the Regional Director of Dietary identified these insects as fruit flies. Later, two fruit flies were observed flying around the steam table where food temperatures were being taken. The Regional Director of Dietary stated uncertainty about the kitchen’s pest control schedule or policy, while the DON stated that flying insects in the kitchen should be non‑existent and that it was not acceptable not to know if or where pests might be laying eggs on food. The Administrator stated that the facility and kitchen should be pest free. The facility did not follow its “Sanitation and Food Safety: Pest Control” policy, dated 8/8/2023, which documented that the pest control company would respond to any reports of active pest infestations. All of these observations and statements were based on surveyor observations, staff interviews, and record review, and the report notes that the presence of insects around food and food preparation areas had the potential to cause foodborne illnesses for residents receiving food from the facility’s kitchen.
Failure to Address Resident's Environmental Concern Regarding Window Cracks
Penalty
Summary
The facility failed to provide a comfortable environment for one resident with multiple medical conditions, including paraplegia, osteomyelitis, pneumonia, a sacral pressure ulcer, major depressive disorder, chronic kidney disease, peripheral vascular disease, and anxiety. The resident, who was cognitively intact, reported feeling cold air coming from cracks in the window of his room on multiple occasions. These concerns were documented in resident council minutes, where the resident requested maintenance to check his room. Despite these repeated requests, the Maintenance Director stated he was not informed of the issue and had not received any work orders for the room. Upon assessment, both the surveyor and the Maintenance Director confirmed the presence of multiple cracks in the window and cold air entering the room, which the Maintenance Director classified as an emergency situation. A wound care technician reported that the resident had communicated feeling cold due to the window, and that maintenance had been informed. The facility's policies and job descriptions require prompt response to maintenance and life safety needs, and the Administrator confirmed that maintenance requests should be addressed as soon as possible or within 24 hours. However, the Administrator was unaware of the resident's repeated complaints about the window. Facility policies also emphasize the importance of providing a safe, clean, and comfortable environment and ensuring residents' rights and dignity, including timely response to concerns raised through the resident council.
Failure to Maintain Resident Dignity by Not Using Privacy Bag for Catheter Drainage
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s dignity by not placing the resident’s urinary catheter drainage bag in a privacy bag as required by facility practice. During observation, the resident was noted lying in bed with clean linens, a clean gown, and an air mattress with appropriate layers. The urinary catheter was in place and the drainage bag was hanging and draining to gravity with 330 milliliters of urine visible, but it was not enclosed in a privacy bag. A CNA confirmed at the time of observation that the drainage bag was not in a privacy bag and stated that the drainage bag should be placed in a privacy bag to maintain the resident’s dignity. The resident had multiple medical diagnoses including malignant neoplasm of the prostate, chronic kidney disease, obstructive and reflux uropathy, hypertension, and the presence of urogenital implants. The MDS documented a BIMS score of 6, indicating severely impaired cognition. The physician’s orders included monitoring and recording the color of urine within the urinary catheter, and the care plan addressed chronic kidney disease and risk for renal complications. Facility policy and statements indicated that all residents’ rights would be honored, including the right to dignity and a home-like environment, and that residents have the right to a dignified existence and communication, which the facility would protect and promote. Despite these policies and care planning, the resident’s urinary drainage bag was left uncovered, resulting in the cited dignity-related deficiency.
Failure to Maintain Accessible Call Light for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff job descriptions. The resident involved had diagnoses including acute right heart failure, acute pulmonary edema, lack of coordination, shortness of breath, and reduced mobility, and had a Brief Interview of Mental Status score of 11, indicating moderate cognitive impairment. During observation, the surveyor noted the resident’s call light device was attached to the bottom of the quarter hand rails and not within the resident’s reach. When interviewed, the resident stated that the call light was normally on the floor and confirmed that they could not reach it, explaining that their right hand did not work and they could not reach the call light with the other hand. The LPN present initially stated that the call light should be within reach and that the resident could reach it, but the resident then demonstrated that they could not. The DON later confirmed that call light devices should be within reach of residents. Facility policy on call lights requires that call lights be placed in an accessible location for residents, and the CNA job description specifies that CNAs respond to and answer resident call lights promptly, underscoring that the call light placement for this resident did not comply with established expectations.
Failure to Enter Resident Code Status Order in EMR
Penalty
Summary
The facility failed to ensure that a resident’s code status physician order was entered into the electronic medical record (EMR), despite documentation elsewhere that the resident had elected a specific code status. The resident had multiple significant diagnoses, including peripheral vascular disease, type 2 diabetes mellitus, primary osteoarthritis, pneumonia, acute kidney failure, chronic diastolic heart failure, unspecified dementia, anemia, lack of coordination, need for assistance with personal care, unsteadiness on feet, weakness, dysphagia, impulsiveness, left bundle-branch block, and transient cerebral ischemic attack. The resident’s care plan documented that the resident had elected to be full code, and a Practitioner Order for Life-Sustaining Treatment (POLST) form indicated an “attempt to resuscitation/CPR” status. However, review of the physician order sheet showed no active code status orders for this resident. During interview, the DON explained that the admitting nurse is responsible for implementing the resident’s code status order from verified hospital transfer orders at the time of admission, and that residents should have a code status order implemented from their admission orders. The DON further stated that if a resident does not have a code status order on the physician order sheet, staff may not know the resident’s wishes and there can be a delay in care. The facility’s Advanced Directives Policy and Procedure and its Resident Rights document both state that residents have the right to accept or refuse treatment and to formulate an advance directive, and that the facility will determine on admission whether a resident has an advance directive or wishes to formulate one. Despite these policies and the existing POLST and care plan documentation, the resident’s code status was not reflected as a physician order in the EMR.
Failure to Maintain Clean Privacy Curtains and Wheelchairs
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment by not ensuring that a resident’s privacy curtain was clean and intact and by not keeping two residents’ wheelchairs clean. One resident, who had diagnoses including Vitamin D deficiency, presence of urogenital implants, and osteomyelitis and was cognitively intact with a BIMS score of 15, was observed with a privacy curtain that had two large holes in the netted area and a large pinkish stain at the bottom. This resident reported having requested a new curtain since admission in June 2024 and stated that the curtain had been stained for months. Housekeeping staff later acknowledged responsibility for removing, cleaning, and replacing stained or torn curtains and stated that they notify their supervisor when curtains are removed for cleaning. The Housekeeping Director stated that stained curtains should be washed and replaced and torn curtains should be replaced with new ones from her office, and that staff are required to complete a Deep Cleaning Duties form to identify rooms needing new curtains. She reported not being aware that this resident needed new curtains prior to the survey week. The facility also failed to ensure that wheelchairs used by two residents were kept clean. One resident was observed sitting in a wheelchair in the dining room with debris and old dried particles on the sides of the chair and next to the brake levers on both sides. Another resident was observed in the dining room in a wheelchair with old dry particles on the chair, front and back, and on the leg rest. A CNA who served as a union representative stated that CNAs should be aware of their job duties and acknowledged that one wheelchair “could be cleaner,” adding that night shift is responsible for cleaning wheelchairs. Another CNA stated that it is the CNA’s duty to clean wheelchairs and that if a wheelchair is dirty, they would wipe it down with soap and disinfectant. The DON stated that CNAs are responsible for cleaning wheelchairs, nurses are responsible for checking that the task is completed, and that there is a wheelchair cleaning schedule assigning cleaning to the 11p–7a shift on specified days, with nurses expected to ensure the schedule is followed.
Failure to Obtain Timely PASRR Rescreening Before Short-Term Approval Expired
Penalty
Summary
The facility failed to refer one resident for a required PASRR rescreening before the expiration of the resident’s Short Term Approval without Specialized Services determination. The resident’s PASRR, dated 05/23/25, documented a determination of Short Term Approval without Specialized Services and specified an end date for that short-term approval. The resident had multiple medical and psychiatric diagnoses, including type 2 diabetes mellitus without complications, lack of coordination, cognitive communication deficit, schizophrenia, anxiety disorder, and essential hypertension. During an interview, the Social Service Director acknowledged that the resident had a short-term PASRR approval and stated that she should have submitted a new PASRR request for the resident before the approval period ended. The facility’s policy titled “Pre-admission Screening and Resident Review,” dated 12/2023, states that the facility will comply with federal, state, and the appointed screening agency standards addressing the PASRR assessment and screening process. Despite this policy, the required rescreening referral to the state PASRR agency was not made prior to the expiration of the resident’s short-term approval, resulting in noncompliance with the PASRR requirements for that resident.
Failure to Implement Ordered AFO Splint Restorative Program
Penalty
Summary
The deficiency involves the facility’s failure to implement a restorative rehabilitation program for an ankle-foot orthosis (AFO) splint as outlined in the resident’s care plan and physician orders. One cognitively intact resident with hemiplegia and multiple comorbidities, including diabetes mellitus, chronic kidney disease, reduced mobility, and limitation of activities due to disability, had a physician’s order dated 6/9/2025 for a right AFO with insert to be placed on in the morning and removed in the evening, to be worn 4–6 hours daily. The resident’s care plan, also dated 6/9/2025, specified that staff were to apply the right AFO splint after morning care for 4–6 hours daily, 6–7 days per week, to help maintain and improve range of motion and prevent further deterioration, and to observe the splint site for skin irritation. On multiple observations, the resident was up in a wheelchair without the ordered AFO in place. On 12/14/2025 at 11:00 a.m., the resident was observed sitting in a wheelchair next to the bed with no leg rests on the wheelchair, the right lower extremity/foot resting on the floor in an inward position, and the AFO splint on a shelf directly in front of the resident. The resident stated that staff sometimes placed the splint but had not done so that day and that he wanted the AFO applied. At 11:25 a.m., a CNA entered the room, read a posted sign instructing CNAs to put the AFO on when getting the resident up and to place it on the shelf when laying him down, and stated that the restorative aide places the AFO and that he did not know what the sign meant. The CNA acknowledged that the AFO should be placed to prevent the resident’s feet from becoming worse and confirmed he was not the staff member who got the resident up. Later the same day at 1:12 p.m., the resident was again observed, this time in the dining room prepared to eat lunch, with the right leg on the floor and the AFO still not in place. When interviewed at 1:15 p.m., the CNA stated he became busy and it slipped his mind, and that without the AFO the resident could drag his foot and leg, which could cause him to stumble and fall out of the chair; he also stated he had not had time to put the AFO on yet. An LPN, after reading the same posted sign, stated that the AFO should be on when the resident is up in the wheelchair, that CNAs or restorative aides should place it, and that the CNA should have put it on. The facility’s policy and job descriptions indicated that the restorative nurse is responsible for development and monitoring of the splint program, that CNAs must provide care per the resident’s care plan, and that LPNs must ensure personnel provide care in accordance with the care plan, but the ordered and care-planned AFO application was not carried out as required for this resident.
Failure to Label and Timely Change Oxygen Tubing and Humidifier Equipment
Penalty
Summary
The deficiency involves the facility’s failure to properly label oxygen nasal cannula tubing and humidifier bottles in accordance with physician orders and facility policy for a resident receiving continuous oxygen therapy. The resident had multiple respiratory and related diagnoses, including COPD with acute exacerbation, acute and chronic respiratory failure, chronic bronchitis, dependence on supplemental oxygen, and hypertensive chronic kidney disease. The physician order directed that the oxygen tubing and bottle be changed weekly on the night shift every Sunday. The resident’s care plan identified oxygen therapy needs related to ineffective gas exchange and respiratory risk from asthma and COPD, and the resident was cognitively intact with a BIMS score of 15. During observation, the resident’s oxygen was running at 2 L/min with a humidifier bottle labeled with a date and the nasal cannula tubing not dated. Staff interview with an LPN revealed that humidifier bottles and tubing were being changed every 14 to 30 days, and that tubing was not dated because it was assumed to be changed when the humidifier bottle was changed. The LPN acknowledged the tubing was not dated and stated the purpose of changing tubing was to prevent respiratory infection. In contrast, the DON stated that both the humidifier bottle and tubing should be labeled and that night nurses were responsible for changing and labeling them every 7 days on Sunday, for contamination prevention and infection control. The facility’s oxygen administration policy required tubing, humidifier bottles, and filters to be changed, cleaned, and maintained at least weekly and PRN, and to be labeled with date, time, and staff initials, which was not followed for this resident’s nasal cannula tubing.
Inaccurate Controlled Substance Accountability for Hospice Medications
Penalty
Summary
The facility failed to ensure accurate narcotic accountability for controlled medications for one resident, with potential impact on all residents on the third-floor unit. During a narcotics count on the third-floor medication cart, the surveyor and an LPN observed that the shift change narcotics accountability record had been signed for the day shift, indicating an accurate count. However, the individual controlled substance records for a resident’s lorazepam 2 mg/mL oral solution and morphine sulfate 20 mg/mL solution were present in the narcotics accountability book, while the actual medications were not found on the third-floor medication cart. The LPN reported that these medications had not been present when she counted narcotics at the start of her shifts on two consecutive days and stated she had called hospice about the missing medications and needed to follow up. When this discrepancy was reported to the ADON/RN, it was determined that the resident’s lorazepam and morphine sulfate solutions were stored in the first-floor medication room refrigerator rather than on the third-floor cart where they were recorded. The resident’s physician orders and individual controlled substance records confirmed active orders for these medications. Despite the facility’s policies requiring that controlled substances be reconciled upon receipt, administration, disposition, and at the end of each shift, and that oncoming and off-going nurses visually inspect drug packages and verify counts before signing, the narcotics accountability record had been signed as accurate even though the medications were not visible on the cart at the time of the count.
Failure to Maintain Resident Bed Privacy Curtain
Penalty
Summary
The deficiency involves the facility’s failure to provide a privacy curtain that extended around a resident’s bed to ensure visual privacy. The resident had multiple medical diagnoses, including heart failure, unspecified dementia, atrial fibrillation, dysphagia, gastro-esophageal reflux disease without esophagitis, hyperlipidemia, restless legs syndrome, sepsis, and a history of falls. A Brief Interview for Mental Status (BIMS) indicated the resident had memory problems. During an observation on 12/14/25 at 10:25 a.m., the surveyor noted that the resident’s room did not have a privacy curtain that extended around the bed, and the resident was unable to state how long the curtain had been missing. In an interview on 12/15/25 at 9:45 a.m., the Environmental Services Director stated that privacy curtains are intended to give residents privacy and reported that the resident’s privacy curtain had been taken down on 12/13/25 to be washed. The Environmental Services Director further explained that only male housekeepers were allowed to replace privacy curtains and that the specific male housekeeper she wanted to perform this task had an emergency, resulting in the curtain not being replaced. She acknowledged that if a resident does not have a privacy curtain, the resident’s dignity can be at risk. Facility documents on Residents’ Rights state that residents have the right to a dignified existence, free privacy during personal care and medical treatment, and to be treated with dignity and respect. The housekeeper job description includes ensuring residents’ rooms are safe, comfortable, and maintained in an attractive manner.
Failure to Honor Resident Meal Preferences and Substitutions
Penalty
Summary
The facility failed to ensure that residents received meals in accordance with their documented preferences and dislikes, as well as requested substitutions. One resident repeatedly informed staff that he disliked ham, turkey, dressing, and oatmeal, and requested these dislikes be noted on his meal ticket. Despite this, his meal ticket only documented 'No Pork' and did not reflect his specific dislikes. The resident continued to receive oatmeal on his tray, and staff confirmed that the kitchen, operated by a new company, frequently provided incorrect meals, including items specifically listed as dislikes on residents' meal tickets. Staff interviews revealed that although residents' preferences were communicated to dietary staff, corrections were not consistently made, and disliked foods continued to be served. Another resident, who had a documented dislike of peanut butter and jelly sandwiches, received such a sandwich on her tray. When she requested a cheeseburger substitute, staff verified her dislike was noted on the meal ticket and contacted dietary for the substitution. The facility's policy states that residents should be able to choose foods from available items and that alternatives are available daily, with the activity department assisting in selections. Despite these policies, the facility did not consistently honor residents' meal preferences and substitutions, as evidenced by direct observations and staff and resident interviews.
Failure to Provide Timely Meal Service to Residents
Penalty
Summary
The facility failed to provide meals and snacks to residents at appropriate and scheduled times, as required by federal regulations. Observations revealed that residents were left waiting in dining rooms for extended periods before receiving their meals, with some residents not receiving food trays at the scheduled meal times. Staff interviews confirmed that meal service, particularly lunch, was consistently delayed due to food being sent late from the kitchen. Multiple staff members, including CNAs and restorative aides, attributed the delays to kitchen staffing shortages following a change in the company managing kitchen duties. Residents reported that their concerns about late meals had been voiced to staff and during resident council meetings, but the issue persisted. The Dietary Director, who had recently started, acknowledged the ongoing problem of delayed meal service and stated that efforts were being made to address the staffing issues in the kitchen. The Assistant Director of Nursing and other facility leadership were aware of the residents' complaints and confirmed that the kitchen, operated by an independent vendor, was not meeting the scheduled meal times. Review of facility policy indicated that meals were to be served according to a planned schedule, but observations and interviews demonstrated that this was not being followed, affecting all 199 residents who received oral meals from the facility's kitchen.
Failure to Provide Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to ensure that therapeutic diets were provided as ordered by the attending physician for three residents. One resident, who had an order for a double portion regular diet with thin liquids, reported not receiving the required double portion of food on multiple occasions, as confirmed by both his statements and direct observation of his meal tray. Another resident, with an order for a general diet with mechanical soft texture, thin liquids, and double portion protein, was observed receiving only a single portion of protein on his tray. Both residents' medical records confirmed the dietary orders, and staff interviews acknowledged the importance of following these orders. Additionally, a third resident with orders for a no added salt, pureed texture, nectar thick liquids, and a magic cup supplement was observed receiving thin liquid juice instead of the prescribed nectar thick consistency. The staff member who provided the tray was unsure of the liquid's consistency and later replaced it with thickened juice after the deficiency was noted. The DON confirmed that not following diet orders, such as providing thin liquids instead of thickened liquids, can compromise resident safety and is an example of not adhering to physician orders.
Failure to Follow Physician Order for Daily Vital Sign Monitoring
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order to monitor and document a resident's vital signs daily. The resident, who has a history of hypertension, COPD, and asthma, reported experiencing frequent migraines and sensations of elevated blood pressure. Although a nurse practitioner had recently ordered daily vital sign monitoring, the resident stated that staff were not checking his blood pressure daily, and the nurse confirmed that while she had monitored the vital signs, she did not document them in the electronic medical record. Instead, the nurse wrote the readings on a piece of paper, which was later discarded. A review of the resident's records revealed significant gaps in documentation, with only one blood pressure reading logged for June and none for April and May, despite an active order for daily monitoring. The resident's care plan included monitoring for hypertension and symptoms associated with high blood pressure, but the lack of consistent documentation and adherence to the physician's order resulted in a failure to provide appropriate care as directed. Facility policy requires all physician orders to be implemented and followed, but this was not done in this case.
Failure to Maintain Functional Call Light System on Second Floor
Penalty
Summary
The facility failed to ensure that the resident call light system was functioning properly on the second floor, affecting 64 residents. During the investigation, a constant beeping sound was observed near the nurse's station, and staff members, including an RN and a CNA, reported that the malfunctioning system made it impossible to determine which resident was calling for help. The CNA further explained that the lights outside patient rooms did not always illuminate when a call was made, requiring staff to physically check each room to identify who needed assistance. Housekeeping staff were unaware of the issue and unable to disarm the alarm, while the Maintenance Director stated he was not informed of the malfunction. Facility policy requires a working call system to allow prompt staff response to resident calls and to ensure the system is in proper working order. Despite this, the malfunction persisted, with staff indicating that unresolved call alarms could result in resident calls being ignored. The facility census confirmed that 64 residents resided on the affected floor at the time of the deficiency.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment by not ensuring proper room temperatures for four out of seven residents reviewed for heating. Multiple residents reported that the heat in their rooms had not been working for two weeks, with one resident specifically pointing out exposed wires from the heating unit after staff moved beds. Residents expressed discomfort due to cold room temperatures, and one resident stated they had informed several nurses about the issue. Observations confirmed that some rooms had temperatures as low as 65°F, below the facility's stated acceptable range of 72°F to 82°F. The Maintenance Director was unaware of the heating issues and the exposed wires until informed by the surveyor during the inspection. Residents affected included individuals with significant medical conditions, such as paraplegia, hypertension, opioid abuse, anxiety disorder, and colostomy. One resident, who was cognitively intact, reported fluctuating room temperatures and had previously requested adjustments. The facility's policy requires a safe, clean, and comfortable environment, but the failure to promptly address heating malfunctions and exposed wiring resulted in residents experiencing discomfort and unsafe conditions in their rooms.
Failure to Document and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for three residents, as evidenced by missing entries of nurses' signatures, initials, or codes on the medication administration records (MARs) for multiple medications, dates, and times. The Director of Nursing (DON) confirmed that the absence of documentation on the MAR indicates that the medication was not administered, and stated that it is the expectation for nurses to document on a progress note if a medication is unable to be given for any reason. The facility's policy also requires that the person administering medications records the administration on the MAR at the time the medication is given and reviews the MAR at the end of each medication pass to ensure all doses are documented. The affected residents had complex medical histories and required multiple medications. One resident had diagnoses including metabolic encephalopathy, severe malnutrition, diabetes, dementia, and other serious conditions, and was noted to have severely impaired cognitive skills. Another resident, with intact cognition, had diagnoses such as paraplegia, pressure ulcers, anemia, and osteomyelitis. The third resident, also with intact cognition, had conditions including seizures, diabetes, hypertension, anemia, and a stage 4 pressure ulcer. For each of these residents, specific medications and administration times were identified where documentation was missing, indicating a failure to administer or record the administration of prescribed medications. Review of facility policies and job descriptions confirmed that both registered nurses and licensed practical nurses are required to perform routine charting duties in accordance with established documentation policies. The facility's drug administration guidelines specify that only licensed personnel may administer medications and must record the administration on the MAR at the time the medication is given. The policy further states that all administered doses must be documented before the end of the medication pass, and any withheld, refused, or rescheduled doses must be properly noted on the MAR.
Failure to Provide Timely Wound Care for Resident
Penalty
Summary
The facility failed to provide necessary treatment and services to promote the healing of existing wounds for a resident, leading to a potential worsening of the resident's condition. The resident, who was admitted with multiple sacral wounds and a history of Fournier's gangrene and necrotizing fasciitis, did not receive timely wound care. Upon admission, the resident's wounds were not immediately treated due to a lack of paperwork from the hospital and a delay in obtaining physician orders. The admitting nurse, who was responsible for assessing the resident and obtaining orders, did not complete any treatments, and the wound care coordinator was unavailable to assess the resident's wounds. The Director of Nursing confirmed that standing orders to clean the wounds with normal saline and apply dry dressings were not documented or executed. The resident expressed dissatisfaction with the care received and requested to be transferred to a hospital for medical attention. The facility's policy requires that residents with pressure ulcers receive necessary treatment and services to promote healing and prevent infection, which was not adhered to in this case.
Failure in Pressure Ulcer Care Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident with a pressure ulcer, resulting in the worsening of the wound and subsequent hospitalization for infection. The resident, who had a history of hemiplegia, type 2 diabetes, and a sacral pressure ulcer, was supposed to be turned and repositioned every 1-2 hours as per physician orders. However, documentation for these interventions was missing on multiple dates, indicating that the care may not have been provided consistently. Additionally, the resident's wound care treatment was not documented on specific dates, and the wound showed significant deterioration over time. The wound increased in size and developed a strong odor, with cultures revealing infection. The resident's wound care was compromised by the lack of proper supplies, as a Licensed Practical Nurse (LPN) admitted to improvising with available dressings due to the treatment cart being located on a different floor. This lack of adherence to the prescribed wound care regimen contributed to the resident's condition worsening. The facility's policies and job descriptions emphasize the importance of documentation and adherence to treatment protocols, yet these were not followed. The Director of Nursing acknowledged that undocumented care is considered not done, highlighting a systemic issue in the facility's care delivery. The resident's condition was further complicated by the development of a new wound, suspected to be caused by friction from heel protectors, indicating a failure in preventive measures as well.
Failure to Respond to Call Lights Promptly
Penalty
Summary
The facility failed to respond promptly to call lights for two dependent residents, R5 and R6, who require assistance for self-care activities such as toileting hygiene and bathing. R5, who is cognitively intact with a BIMS score of 15, and R6, who has moderate cognitive impairment with a BIMS score of 12, both rely on wheelchairs for mobility and are dependent on staff for self-care. On separate occasions, both residents activated their call lights for assistance, but the facility staff did not respond within the expected timeframe. R6's call light was on for over 10 minutes while staff were observed sitting at the nurse's station, and R6 expressed a need for pain relief. Similarly, R5's call light was on for an extended period, and R5 expressed a need to be cleaned. The facility's policy and job descriptions require staff to respond promptly to call lights, regardless of room assignments. However, during the survey, staff at the nurse's station did not adhere to this policy. When questioned, a CNA acknowledged that all call lights should be answered, even if the assigned CNA is unavailable. The Director of Nurses confirmed that call lights should be answered within 10-15 minutes by any staff member. Despite these guidelines, the facility's failure to respond promptly to the call lights of R5 and R6 indicates a deficiency in meeting the residents' needs and preferences for assistance.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to adhere to its policy for scheduled medication administration time frames, affecting a resident who was reviewed for medication administration. The resident, who is cognitively intact and requires substantial maximal assistance for mobility and self-care, reported that their medications were consistently administered late across all shifts. Observations and record reviews confirmed that medications were given outside the one-hour window before or after the scheduled time, with specific instances noted where medications were administered significantly later than scheduled. For example, on one occasion, medications scheduled for 9:00 am were given at 12:46 pm. The resident's medical history includes conditions such as paraplegia, hypertension, and anxiety, with a care plan indicating a risk for elevated blood pressures related to hypertension. Despite the facility's policy requiring medications to be administered within a specific time frame and the expectation for staff to follow these guidelines, the resident's medications were not administered as ordered. The Director of Nursing acknowledged the expectation for timely medication administration and the need for staff to contact a doctor for orders if medications are administered late. However, no new orders for schedule changes were noted in the resident's records.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility failed to provide a functioning call device for a resident requiring assistance, which was identified during a survey. The resident, who has a history of osteoarthritis, congestive heart failure, spinal stenosis, hypertension, and glaucoma, was noted to have moderate cognitive impairment and requires a wheelchair for mobility. The resident is dependent on staff for self-care activities such as toileting hygiene and bathing. During the survey, it was observed that the resident's call light was on in their room, but it did not register on the call light board at the nurse's station, indicating a malfunction. A Certified Nursing Assistant (CNA) confirmed that the call light should be visible on the call light board at all times when activated. The Maintenance Director was notified of the issue but initially dismissed it, stating the call light was working after turning it off and on again. However, the Director of Nursing later confirmed that the call light system should light up and make a noise at the nurse's station, and any malfunction should be reported immediately. The facility's policies require daily checks of call lights and logging of any defects, which were not adhered to in this instance.
Failure to Prevent Resident-to-Resident Assault
Penalty
Summary
The facility failed to protect a resident (R2) from physical assault by another resident (R1), who has a documented history of physical aggression. R1, diagnosed with Dementia with Behavioral Disturbance, Schizophrenia, and Bipolar Disorder, has a severe cognitive impairment and is non-verbal. R2, who has Depression and Delusional Disorders, has mild cognitive impairment. On the day of the incident, R1 entered the dining room and physically assaulted R2, who was sitting at a table. The aide present immediately intervened and separated the residents. R2 was assessed and reported no injuries or pain, and both families and physicians were notified. R1's care plan, dated prior to the incident, documented multiple instances of physical aggression towards other residents and staff. Despite this history, R1 was able to approach and assault R2. The facility's abuse policy affirms the residents' right to be free from abuse and outlines the definition of physical abuse as the infliction of injury other than by accidental means. The incident report and progress notes confirm that R1's behavior was consistent with past aggressive actions, yet the facility failed to prevent the assault on R2.
Deficiencies in Supervision, Medication Administration, and Staff Conduct
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for residents, as evidenced by the observation of several residents in wheelchairs inside the dining room without any staff present to monitor them. This lack of supervision was acknowledged by the Assistant Director of Nursing, who stated that there should have been someone monitoring the residents. Additionally, a Certified Nursing Assistant was unaware of her responsibility to monitor the dining room, as she was not informed of the schedule. The facility also failed to ensure medications were administered as ordered by the residents' physician. One resident did not receive their Benztropine medication because it was not available in the medication cart, and the nurse did not have access to the automated medication dispenser. Another resident had not received their Escitalopram medication for five days, despite the medication administration record indicating it had been administered. The Director of Nursing was not informed of the medication unavailability until the surveyor's inquiry. Furthermore, the facility did not maintain professional standards in medication administration and staff conduct. A nurse was observed on a video call while preparing medications, acknowledging the potential for HIPAA violations and medication errors. Another medication cart was found unlocked and unattended, posing a risk of unauthorized access to medications. Additionally, a nurse exhibited unprofessional behavior by yelling at the surveyor during an interview, raising concerns about potential similar behavior towards residents.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its abuse prevention policy, resulting in two separate incidents of physical abuse among residents. In the first incident, a resident pushed another resident from a wheelchair in the dining room, causing the latter to fall. This altercation was witnessed by a CNA who was present in the dining room at the time. The resident who was pushed expressed distress and was sent to the hospital for evaluation. The resident who pushed was also sent to the hospital and later stated that they could not remember the incident. The facility's LPN confirmed that there was a commotion and observed the resident on the floor, indicating a lack of adequate supervision in the dining room. In the second incident, two residents engaged in a verbal altercation over a jacket, which escalated to one resident hitting the other in the face, resulting in a swollen lip and a hospital visit for the injured resident. The LPN noted that there was no staff present in the dining room during this incident, highlighting a failure to provide necessary supervision to prevent such altercations. The facility's Director of Nursing, who was new to the position, acknowledged the expectation for staff to supervise residents in common areas to prevent incidents of abuse. The facility's abuse policy emphasizes zero tolerance for abuse, yet the incidents indicate a lapse in policy enforcement and supervision.
Lack of Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide appropriate supervision to four residents in the dining room, leading to two separate incidents of physical altercations. In the first incident, two residents engaged in a verbal altercation, which escalated when one resident pushed the other from a wheelchair, causing a fall. In the second incident, another resident hit a fellow resident in the face during a verbal dispute, resulting in a swollen lip and the injured resident being sent to the hospital. Interviews with the involved residents revealed that the altercations were related to personal disputes, and the staff confirmed that no supervision was present during these incidents. The facility's staff, including a CNA and the Director of Nursing, acknowledged that there should have been visual supervision in the dining room to prevent such incidents. The facility's policies on abuse prevention and standard supervision emphasize the need for proactive intervention and visual monitoring of residents during mealtimes. However, the lack of staff presence in the dining room at the time of the incidents indicates a failure to adhere to these policies, resulting in the physical altercations and subsequent injuries.
Dishwasher Temperature Logging and Functionality Issues
Penalty
Summary
The facility failed to accurately log dish machine temperatures and ensure the dish machine was functioning properly, potentially affecting 162 residents who receive meals from the facility kitchen. During a kitchen tour, a surveyor observed a dietary aide using a temperature strip to test the dishwasher's temperature. The strip indicated that the dishwasher was not reaching the required temperature of 160 degrees Fahrenheit for proper sanitation, as the white box on the strip did not turn black. The dietary aide admitted that the dishwasher had not reached the proper temperature for over a week and had failed to inform the dietary manager. The dietary manager stated that staff are expected to check the dishwasher after each meal to ensure it is functioning correctly and to report any issues immediately. The facility's dishwasher temperature log for October 2024 showed that the temperature strip was colored in with a black marker 25 times, indicating falsification of records. The log also documented that the required temperature was not reached on a specific date. The facility's policy requires the final sanitizing rinse to meet specific temperature guidelines, and any deviations should be reported to the food service manager.
Infection Control Deficiencies in PPE Availability and Water Management
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Residents on enhanced barrier precautions (EBP) did not have appropriate signage or readily available personal protective equipment (PPE) outside their rooms. Specifically, a resident with a gastrostomy tube did not have an EBP sign or PPE bin by their room, and other residents on EBP also lacked accessible PPE. The Infection Preventionist acknowledged that storing PPE in the clean utility room did not make it readily available for staff, which could delay the use of necessary protective measures. Additionally, staff failed to don appropriate PPE when providing care to residents on EBP. A Certified Nursing Assistant was observed performing personal care for two residents without wearing a PPE gown, despite EBP signs being posted on the doors. The Director of Nursing and other staff members confirmed that PPE should be worn when caring for residents on EBP to prevent potential infections. The facility also neglected proper handling of soiled linens and water management. Unbagged soiled linens were found coming out of the laundry chute and on the laundry room floor, contrary to the facility's policy requiring linens to be bagged and tied. Furthermore, the facility had not conducted required Legionella water testing since March 2022, failing to adhere to its water management program designed to reduce the risk of waterborne pathogens.
Failure to Administer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to adhere to its policies and procedures for the immunization of residents against pneumococcal disease, as evidenced by the lack of vaccination for eligible residents. The deficiency was identified through interviews and record reviews, which revealed that nine residents had no documentation of pneumococcal vaccine offering or education in their records. Additionally, there were no physician orders for the pneumococcal vaccination for these residents, and their immunization records did not list a current pneumococcal vaccination. The Infection Preventionist (IP) acknowledged that the facility relies on a mobile vaccination clinic that visits only once a year, and no alternative plan was developed to vaccinate residents as needed. The Assistant Director of Nursing (ADON) stated that the facility's expectation is to offer pneumococcal vaccines to new residents upon admission if they are eligible and have not already received it. However, the facility's policy, which includes obtaining standing orders for the vaccine and providing information on its risks and benefits, was not followed, leading to the deficiency.
Failure to Document Controlled Substance Counts During Shift Changes
Penalty
Summary
The facility failed to ensure that controlled medications were properly counted and documented during shift changes, affecting residents on two different units. Observations and interviews revealed that the Shift Change Accountability Records for Controlled Substances on both 1-West and 2-East units had missing signatures, indicating that the required counts were not consistently performed or documented. This deficiency was noted during a survey conducted on October 28 and 29, 2024, where it was observed that the accountability forms for controlled substances had missing signatures, and the counts were not completed as required. The deficiency affected a total of 12 residents across the two units who were prescribed controlled medications for various conditions, including seizures, bipolar disorder, epilepsy, depression, and pain management. Specific residents were identified with active orders for medications such as Clonazepam, Lacosamide, Tramadol, Zolpidem, Clobazam, and Norco, which are classified as controlled substances. The lack of proper documentation and accountability for these medications raises concerns about the facility's adherence to federal and state regulations regarding the handling of controlled substances. Interviews with staff, including a Licensed Practice Nurse and a Registered Nurse, confirmed the missing signatures on the accountability records. The Director of Nursing acknowledged that nurses are expected to sign off on the shift change accountability sheet after counting the controlled substances. The facility's guidelines and job descriptions emphasize the importance of accurate narcotic records and the requirement for two licensed nurses to conduct and document a physical inventory of controlled substances at each shift change. However, the observed lapses in documentation indicate a failure to comply with these established procedures.
Failure to Obtain Psychotropic Medication Consents
Penalty
Summary
The facility failed to ensure that four residents had psychotropic consents signed prior to administering antipsychotic medication. This deficiency was identified during an investigation on 10/30/2024, where it was noted that residents R55, R104, R116, and R118 were administered psychotropic medications without the necessary consents. The Director of Nursing (DON) confirmed that there were no additional psychotropic medication consents for these residents, despite the expectation that consents should be obtained before administering such medications. Resident R55, diagnosed with Alzheimer's disease and severe cognitive impairment, was administered Quetiapine and Paroxetine multiple times in September and October 2024 without prior consent, which was only obtained on 10/10/2024. Similarly, Resident R104, with unspecified dementia and schizophrenia, received Hydroxyzine Pamoate, Risperdal, and Trazadone without consent until 10/30/2024. Resident R116, also with Alzheimer's disease and severe cognitive impairment, was given Quetiapine and Risperidone without consent, with only Risperidone consent obtained on 10/10/2024. Resident R118, with severe cognitive impairment, was administered Risperidone without any informed consent. The facility's policy on psychotropic drug usage mandates that informed consents be initiated upon the start of medication usage and upon any dosage increase. However, this policy was not adhered to, as evidenced by the lack of consents for the aforementioned residents. The Assistant Director of Nursing (ADON) emphasized the importance of obtaining consents due to the potential sedative effects and the classification of some psychotropic medications as chemical restraints. The facility's list of residents on psychotropic medication included 89 individuals, indicating a broader potential impact of this deficiency.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that multidose medications were properly labeled with open and discard dates, affecting four residents. During an inspection of the medication cart, it was observed that insulin pens for three residents and a vial for another resident were opened but lacked the necessary labeling. This oversight was confirmed by an LPN who acknowledged the absence of open and discard dates on the insulin pens and vial. The Director of Nursing later confirmed that the facility's policy requires nurses to label insulin with open and discard dates, as insulin is effective for only 28 days after opening. Additionally, the facility did not remove a multidose medication belonging to a discharged resident from the medication cart. The LPN verified that the resident was no longer at the facility, yet their insulin remained in the cart. The Director of Nursing stated that medications of discharged residents should be returned to the pharmacy, indicating a lapse in following the facility's procedures for medication management. The CMS Medication Storage and Labeling pathway, which the facility claims to follow, mandates that opened multidose vials be dated and discarded within 28 days.
Facility Fails to Maintain Heating Vents in Sanitary Condition
Penalty
Summary
The facility failed to maintain the wall heating unit vents in the dining room and hallway on the third floor in good repair and sanitary condition. Observations revealed that the vents were missing covers and were filled with garbage items such as paper, straws, plastic cups, hairbrush, and medication cups. This issue was identified during a survey conducted on the third floor, which houses 50 residents. The Memory Care Director acknowledged the problem and indicated that maintenance would be notified. The Maintenance Assistant later confirmed that he had been informed about the issue and was in the process of cleaning the vents and obtaining the necessary covers. He also mentioned that the heating vent in the hallway had stopped working after a resident urinated in it, and he planned to repair or replace it. The facility's maintenance staff job description includes responsibilities for performing inspections, documentation, and maintenance of facility equipment, which were not adequately fulfilled in this instance.
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A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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