Bella Terra Bloomingdale
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomingdale, Illinois.
- Location
- 165 South Bloomingdale Road, Bloomingdale, Illinois 60108
- CMS Provider Number
- 145638
- Inspections on file
- 32
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Bella Terra Bloomingdale during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including venous insufficiency and CHF, had a right lower extremity duplex ordered, but the contracted radiology provider did not perform the exam within the 24-hour timeframe required by contract and did not communicate the delay to the facility. The imaging was completed several days after the order, and the results were not read or transmitted until days after the exam, despite the provider’s usual 6–8 hour turnaround. Facility leadership confirmed they did not receive results until days later and only contacted the radiology company after the family asked about the test, and there was no documentation of communication between the facility and the provider regarding the delays.
A nursing home area was not kept free from accident hazards, and staff did not provide adequate supervision to prevent accidents. This resulted in a deficiency related to the facility's failure to ensure a safe environment and proper oversight for residents.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed environmental risks and insufficient oversight, resulting in unsafe conditions for residents.
Several residents did not receive their prescribed medications at the scheduled times due to a gap in nursing coverage, resulting in medications such as Velphoro, Coreg, Gabapentin, and Budesonide-Formoterol Fumarate inhaler being administered hours late. Residents with complex medical needs, including those on dialysis and with chronic conditions, were affected, and facility policies requiring timely medication administration and documentation were not followed.
Four residents with diabetes did not receive their scheduled insulin doses on time due to a gap in nursing coverage, resulting in insulin being administered several hours late. The facility's failure to follow physician orders and its own medication administration policies led to significant medication errors, as confirmed by EMR review and resident interviews.
Due to a lack of administrative oversight and failure to revise nursing assignments when an agency RN arrived late, multiple residents did not receive their scheduled medications, including insulin and cardiac medications, at the prescribed times. Staff interviews and medical records confirmed that medications were administered several hours late, and no direction was given to other staff to cover the absent nurse's assignment, resulting in delayed nursing care for all affected residents.
During a COVID-19 outbreak, a facility failed to follow its respiratory testing policy by not testing symptomatic residents for both COVID-19 and influenza. Staff also neglected proper infection control practices, such as wearing required PPE and disinfecting glucometers correctly. These lapses affected multiple residents, including those with confirmed COVID-19 cases and those requiring regular blood glucose monitoring.
The facility failed to follow the posted menu, affecting residents on mechanical soft and puree diets. Residents were served different meals than indicated, such as beef instead of pork and ham instead of sausage patties, without prior approval from the dietician. The dietary manager made substitutions due to perceived poor quality, but the registered dietician was not informed, leading to confusion and non-compliance with facility policies.
A resident's bed remained unrepaired despite being reported as broken, with the footboard's plastic cover detached and exposing an electric connector. The facility's policy requires staff to report such issues, but no maintenance work order was found, indicating a failure to maintain a safe environment.
The facility failed to provide adequate grooming and hygiene care for residents requiring assistance with ADLs. A resident with cognitive impairment had untrimmed, dirty fingernails, while another was found with a urine-soaked brief, indicating a lack of timely incontinence care. Additionally, a female resident was observed with facial hair over several days, despite needing assistance with grooming. The facility lacked a specific policy for facial hair grooming, and staff noted that agency staff might overlook such details.
The facility failed to ensure accurate blood glucose testing for residents with diabetes, as nurses used alcohol pads improperly, affecting readings. Additionally, a resident's urinary concerns were not promptly addressed, with delayed sample collection and inadequate communication with the physician. These actions violated the facility's diabetes management and urinary catheter care policies.
The facility failed to implement fall prevention measures for two residents at high risk for falls. One resident, with multiple diagnoses including impaired cognition, lacked a wing mattress and properly positioned alarm pad, leading to recent falls. Another resident with severe cognitive impairment had a call light on the floor and missing floor padding, contrary to care plan requirements. Both residents had documented falls, highlighting a failure to adhere to prescribed interventions.
The facility failed to properly position urinary catheter tubing and drainage bags for three residents, leading to potential infection risks. One resident's catheter tubing was over his pants, and the drainage bag was placed on his bed. Another resident's tubing was looped under his leg, and a third resident's tubing was unsecured, with the drainage bag containing sediment. Facility policy requires securement and proper positioning of catheter equipment, which was not followed.
A facility failed to report a resident fall caused by improper transfer methods, including not using a sit-to-stand machine as required. Additionally, staff did not consistently use gait belts during transfers, and resident transfer statuses were not accurately documented, leading to unsafe practices.
The facility failed to provide showers as scheduled for five residents who required assistance with bathing. Documentation showed significant gaps between showers, contrary to the policy of providing showers twice weekly. The residents had various medical conditions necessitating assistance with ADLs, and the facility did not adhere to its hygiene care procedures.
The facility failed to follow its urinary catheter care policy, resulting in inadequate documentation and assessment of symptoms for three residents with indwelling catheters who developed UTIs. A resident was sent to the hospital with a UTI, but the nurse did not document urine appearance or output. Another resident had a UTI diagnosed without documented symptoms, and antibiotics were prescribed without assessment. A third resident had a change in antibiotic treatment without documented symptoms or lab results. The DON confirmed the expectation for staff to monitor and document urinary output, which was not met.
A resident with dysphagia requiring 1:1 feeding assistance was left unattended with a meal tray, despite needing help from qualified staff. The Activity Director present was not qualified to assist, and a CNA left the tray after the resident refused lunch. The DON confirmed the need for staff assistance, as per the resident's medical records.
A resident was observed receiving thickened water despite an agreement to allow thin liquids and ice chips between meals to prevent dehydration. The speech therapist had recommended this change after evaluating the resident, but the facility failed to implement the updated dietary orders.
The facility failed to ensure a resident's legal representative was fully informed about the use of psychotropic medications. The resident was administered several psychotropic medications without proper consent documentation, and the legal representative expressed concerns about the lack of information and potential side effects. Facility staff confirmed that consent forms were incomplete, failing to provide necessary details.
Failure to Ensure Timely Diagnostic Imaging and Results
Penalty
Summary
The deficiency involves the facility’s failure to obtain and/or ensure timely diagnostic imaging and results for a resident with multiple complex medical conditions. The resident was admitted with diagnoses including hydronephrosis, hypertension, type 2 diabetes mellitus, diabetic foot ulcer, venous insufficiency, and congestive heart failure. An order was placed on February 6, 2026, for a right duplex venous scan related to venous insufficiency, and the order indicated the imaging was sent that same day. The radiology company reported that the exam was not actually performed until February 9, 2026, three days after the order, despite a contract requirement that services be provided within 24 business hours or a time be scheduled with notification to the facility if that timeframe could not be met. The radiology company further stated that results are usually available within six to eight hours after imaging, but in this case the exam was not read by a radiologist and the results were not sent to the facility until February 13, 2026. The DON confirmed the facility did not receive the diagnostic imaging results until February 13, 2026, and that she only contacted the radiology company after the resident’s family inquired about the results during a care plan meeting that same day. The radiology company liaison and territory manager acknowledged the delays in both performing the duplex and in resulting the exam, and indicated there was no communication with the facility about these delays, contrary to the contractual obligation to promptly notify the facility if the 24-hour service time could not be met. The facility did not have documentation showing any communication with the radiology company regarding the delayed exam or delayed receipt of results.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified in which a nursing home area was not maintained free from accident hazards, and adequate supervision was not provided to prevent accidents. The report notes that the facility failed to ensure the environment was safe and that appropriate oversight was in place to minimize the risk of accidents for residents. This lack of supervision and failure to address potential hazards directly contributed to the deficiency cited by surveyors.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Failure to Administer Medications as Ordered and Scheduled
Penalty
Summary
The facility failed to administer medications as ordered by physicians and as scheduled in the electronic medical record (EMR) for five residents. On a specific date, a nurse was late for her shift, resulting in a gap between the departure of the day shift nurse and the arrival of the evening shift nurse. During this period, residents did not receive their scheduled medications on time. One resident, who requires Velphoro to be taken with meals due to dialysis, did not receive the medication with dinner, and both Velphoro and Coreg were administered more than four hours after the scheduled time. The resident expressed frustration, noting that management was aware of the nurse's tardiness but did not arrange alternative coverage to ensure timely medication administration. Other residents were similarly affected by the delay. One resident had to approach the nurse to request a blood sugar check and pain medication, receiving Gabapentin almost two hours late. Another resident with moderate cognitive impairment received Gabapentin over four hours late. Additional residents with complex medical histories, including COPD, diabetes, and heart disease, also experienced delays in receiving scheduled medications such as Gabapentin and Budesonide-Formoterol Fumarate inhaler, with administration occurring up to four hours after the scheduled time. The facility's policies require that medications be administered according to physician orders and documented immediately after administration. The pharmacist confirmed that certain medications, such as Velphoro, must be given with meals for effectiveness, and significant delays in administering medications like Coreg could result in symptomatic changes. The documentation and interviews confirm that the facility did not adhere to its own policies or physician orders regarding medication administration times for multiple residents.
Failure to Administer Insulin as Ordered Results in Significant Medication Errors
Penalty
Summary
The facility failed to administer insulin as ordered by physicians for four residents with diabetes, resulting in significant medication errors. On May 17, 2025, there was a gap in nursing coverage when the day shift nurse left at approximately 3:00 PM and the evening shift nurse did not arrive until 5:45 PM. During this period, no other staff were assigned to administer medications, leading to delays in scheduled insulin administration. Residents reported not receiving their medications on time, and electronic medical records confirmed that insulin doses scheduled for the evening meal were administered several hours late. For example, one resident with multiple chronic conditions, including diabetes and heart failure, received their scheduled 5:00 PM insulin dose at 9:14 PM, more than four hours after dinner. Another resident, also with diabetes and other comorbidities, received their 5:00 PM insulin at 6:50 PM and their 4:00 PM sliding scale insulin at 6:50 PM, both significantly delayed. A third resident with moderate cognitive impairment received their 5:00 PM insulin at 9:09 PM, and a fourth resident received their 5:00 PM insulin at 8:42 PM. In all cases, the insulin was ordered to be given with meals or at specific times, but was not administered as scheduled. The facility's own policies require medications and treatments to be administered according to physician orders and federal and state regulations. The pharmacist confirmed that the types of insulin involved are intended to be given with meals or at specific times to maintain stable blood glucose levels, and that significant delays can cause blood sugar fluctuations. The failure to follow physician orders and facility policy resulted in significant medication errors for multiple residents.
Failure to Revise Nursing Assignments Resulting in Delayed Medication Administration
Penalty
Summary
The administration failed to provide adequate oversight and leadership to ensure that nursing care assignments were revised in response to a change in staffing, resulting in residents not receiving nursing care and medications as ordered by their physicians. On a specific day, an agency RN who was scheduled to work the evening shift arrived late, and no arrangements were made to cover her assignment or ensure that her residents received timely care. The staffing coordinator confirmed that the nurse was assigned to care for a group of residents but was not present for the start of her shift, and no other staff were directed to absorb her responsibilities during her absence. Multiple residents reported and records confirmed that scheduled medications, including critical medications for conditions such as diabetes, hypertension, and pain management, were administered several hours late. For example, one resident did not receive his prescribed Velphoro, carvedilol, and insulin at the scheduled time with his meal, which he stated was necessary for the medications to be effective. The electronic medical records showed that these medications were administered more than four hours after the scheduled time. Other residents also experienced delays in receiving their medications, with documentation showing administration times ranging from nearly two to over four hours late. Interviews with staff and residents corroborated that there was a lack of communication and direction from management regarding coverage for the absent nurse. The administrator acknowledged awareness of the nurse's anticipated late arrival but did not provide a reason for the failure to revise assignments or instruct available staff to cover the affected residents. As a result, all residents assigned to the absent nurse experienced delays in receiving necessary nursing care and medications as ordered.
Infection Control and Testing Failures During COVID-19 Outbreak
Penalty
Summary
The facility failed to adhere to its respiratory testing policy during a COVID-19 outbreak, as evidenced by the improper testing of residents for both COVID-19 and influenza. Despite the facility's policy and guidance from the local health department, symptomatic residents were only tested for COVID-19, not influenza, which was necessary given the co-circulation of both viruses. This oversight affected multiple residents, including those who tested positive for COVID-19, and led to a delay in appropriate testing and management of the outbreak. In addition to testing failures, the facility did not consistently follow infection control practices for residents on transmission-based and enhanced-barrier precautions. Staff members were observed not wearing the required personal protective equipment (PPE), such as N95 masks and face shields, when entering rooms of residents with confirmed COVID-19 cases. Furthermore, staff failed to don gowns when providing care to residents under enhanced-barrier precautions, increasing the risk of spreading infections. The facility also did not properly disinfect glucometers between uses. Staff members were observed wrapping glucometers in bleach wipes without first wiping down the surfaces, contrary to the facility's policy and CDC guidelines. This improper disinfection practice was noted across multiple instances, involving several residents with diabetes who required regular blood glucose monitoring. These deficiencies highlight significant lapses in the facility's infection prevention and control program.
Failure to Follow Posted Menus and Ensure Nutritional Needs
Penalty
Summary
The facility failed to adhere to the posted menu for residents, impacting all 18 residents on non-vegetarian mechanical soft and puree regular diets, and one resident on a vegetarian pureed diet. On the specified date, the menu indicated that roasted pork loin was to be served for lunch, but residents on mechanical soft diets were served beef instead. The dietary server was unsure why beef was prepared instead of pork, despite the pork loin being suitable for mechanical soft diets. Additionally, the dietary department was not provided with an updated list of residents receiving mechanical soft diets, which affected meal preparation. Further discrepancies were observed during breakfast service, where the menu listed sausage patties, but residents were served mechanical soft ham instead. The dietary server was uncertain about the substitution, suggesting it might have been due to a shortage of sausage patties. An unidentified puree item served during breakfast was also not labeled, leading to confusion about its contents. The dietary manager admitted to making substitutions without prior approval from the dietician, citing poor quality and appearance of the original items as reasons for the changes. The registered dietician confirmed that menu substitutions should be approved in advance to ensure nutritional equivalence. However, the dietician was not informed of the changes and was unsure about the items served. The facility's policy mandates that menus be followed as written unless changes are necessary due to preferences, unavailability, or special meals, and that any changes should be approved by the dietician. The failure to follow these protocols resulted in residents not receiving the meals indicated on their meal tickets, highlighting a breakdown in communication and adherence to dietary guidelines.
Failure to Repair Resident's Bed
Penalty
Summary
The facility failed to repair a resident's bed, which was identified as broken by the resident herself. The resident reported that the footboard's plastic cover was detached and broken, and an unidentified male staff member assessed the bed but did not provide a timeline for repair. A Certified Nurse Assistant (CNA) later assessed the issue and stated she would complete a maintenance work order request. However, the resident continued to report that the bed was not fixed, and the plastic cover eventually fell off completely, exposing an electric connector. The facility's administrator reviewed the maintenance work orders and found no record of a request for the resident's broken bed. The facility's policy requires staff to report malfunctioning equipment to the maintenance department, but this procedure was not followed in this case. The lack of a maintenance work order and the continued disrepair of the bed indicate a failure to maintain a safe and comfortable environment for the resident.
Deficiencies in Grooming and Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate grooming and hygiene care for residents who require assistance with Activities of Daily Living (ADLs). One resident, a male with severe cognitive impairment, was observed with long, dirty fingernails and a broken nail, despite the facility's policy that nursing staff should regularly check and trim residents' nails. Another resident, a male with mild cognitive impairment, was found with a urine-soaked incontinent brief and a strong odor of urine, indicating a failure to provide timely incontinence care as per the facility's policy of checking for incontinence every two hours. Additionally, a female resident was observed with noticeable facial hair over several days, despite the expectation that CNAs should address grooming needs during shower times. The resident's care plan indicated a need for assistance with ADLs, including grooming, but there was no documentation of refusal to be groomed. The facility lacked a specific policy for facial hair grooming, and staff acknowledged that agency staff might overlook such details.
Deficiencies in Blood Glucose Testing and Urinary Output Monitoring
Penalty
Summary
The facility failed to ensure accurate blood glucose testing for four residents with diabetes. Observations revealed that agency nurses used alcohol pads to wipe away the first drop of blood without allowing the alcohol to dry, which can affect glucose readings. This practice was observed in multiple instances, leading to potentially inaccurate blood glucose readings for residents with orders to monitor their blood sugar levels closely due to their diabetes diagnoses. Additionally, the facility did not adequately address a resident's concerns regarding urinary output. The resident reported pain and discomfort during urination, which was not promptly addressed by the staff. The resident's urinary output was significantly decreased, and the urine was cloudy, foul-smelling, and contained blood. Despite these symptoms, there was a delay in collecting urine and nephrostomy drainage samples for analysis, and the resident's physician was not immediately informed of the situation. The facility's policies on diabetes management and urinary catheter care were not followed, contributing to these deficiencies. The diabetes management policy required allowing alcohol to dry before testing blood glucose, and the urinary catheter care policy required monitoring and reporting unusual urine appearances and resident complaints. These lapses in following established procedures led to the deficiencies identified in the report.
Failure to Implement Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to implement care plan interventions to prevent falls for two residents with recent histories of falls. Resident R100, who was admitted with multiple diagnoses including nontraumatic intracerebral hemorrhage and impaired cognition, was identified as being at high risk for falls. Despite this, the care plan interventions such as a bed/chair alarm and a wing mattress were not properly implemented. On observation, R100 was found in bed without the wing mattress, and the sensory fall alarm pad was not positioned correctly. R100's wife expressed concern for his safety due to recent falls, and the Director of Nursing acknowledged the expectation for these interventions to be in place. Resident R14, who has severe cognitive impairment, was also identified as being at high risk for falls. However, during observation, the call light was found on the floor, and the floor padding was not in place as required by the care plan. Additionally, the resident's name tag did not have the yellow star indicating a high fall risk. The Director of Nursing confirmed that these interventions should have been implemented according to the facility's fall occurrence policy. Both residents had documented falls prior to these observations, indicating a failure to adhere to the prescribed fall prevention measures.
Improper Catheter Care and Positioning
Penalty
Summary
The facility failed to ensure proper positioning of urinary catheter tubing and drainage bags to prevent infection for three residents. One resident's catheter tubing was improperly positioned over his pants, and the drainage bag was placed on top of his bed, above the level of his bladder. The securement device for the tubing was ripped and detached, leaving the tubing unsecured. Another resident's catheter tubing was looped underneath his leg and was not secured because the securement device was wrapped around the tubing instead of being attached to his leg. The third resident also had unsecured catheter tubing, as the securement device was not attached to her leg, and her drainage bag contained urine with sediment. The facility's policy on urinary catheter care requires that catheter tubing be secured with a leg strap and that drainage bags be positioned below the bladder to prevent backflow. The Director of Nursing confirmed that catheter tubing should not be positioned over a resident's pants and that drainage bags should be placed below the bladder. The care plans for the residents involved indicated the need for catheter care every shift and proper positioning of the catheter bag and tubing, which was not adhered to in these instances.
Improper Transfer Practices and Inadequate Reporting of Falls
Penalty
Summary
The facility failed to ensure proper reporting and handling of a resident fall incident, which was caused by an improper transfer. A resident with a history of lumbar spinal fusion surgery and mobility issues was improperly transferred by a CNA, who did not use the recommended sit-to-stand machine with a 2-person assist. The CNA did not report the fall to the licensed staff, and the resident was assisted off the floor without a proper assessment. The resident later experienced increased pain and was transferred to the hospital for further evaluation. Additionally, the facility did not consistently use gait belts during resident transfers, as observed with multiple residents. One resident was assisted off the toilet without a gait belt, despite having a care plan indicating the need for such a device due to high fall risk. Another resident self-transferred to the toilet without supervision, and the CNA assisting did not use a gait belt, contrary to the resident's care profile requirements. The facility also failed to ensure that resident transfer statuses were accurately communicated and documented. Several residents had discrepancies between their care profiles and the actual transfer methods used by staff. For instance, two residents were transferred using a sit-to-stand machine, although their care profiles did not reflect this requirement. The lack of accurate documentation and communication regarding transfer statuses contributed to unsafe transfer practices.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers in accordance with its schedule and policy for residents who required assistance with bathing. This deficiency was identified for five residents who were reviewed for showers and baths. The facility's documentation showed that these residents did not receive showers as scheduled, with significant gaps between the showers provided. For instance, one resident did not receive a shower from September 16 to September 26, and another did not receive any shower or complete bed bath during their entire stay from September 21 to October 8. These lapses exceeded the facility's policy of providing showers at least once weekly. The residents involved had various medical conditions, including chronic heart failure, kidney disease, diabetes, dementia, and other health issues, which necessitated assistance with activities of daily living, including bathing. The facility's policy required that residents receive showers twice per week, and any refusals should be documented. However, the documentation provided did not align with this policy, indicating a failure to adhere to the established schedule and procedures for resident hygiene care.
Inadequate Urinary Catheter Care and Documentation
Penalty
Summary
The facility failed to adhere to its policy for urinary catheter care, resulting in inadequate documentation and assessment of symptoms for residents with indwelling urinary catheters who developed urinary tract infections (UTIs). Three residents, identified as R1, R2, and R8, were affected by this deficiency. The facility's policy required staff to monitor and document urinary output, including color, clarity, and any unusual appearance, as well as to observe and report signs of UTIs. However, these requirements were not consistently met. Resident R2 was admitted with multiple diagnoses, including neuromuscular dysfunction of the bladder and dementia, and had an indwelling urinary catheter. R2 was sent to the hospital with symptoms of lethargy and altered mental status, where a UTI was diagnosed. The nurse, V14, did not document the appearance of R2's urine or the urinary output in the electronic medical record (EMR), despite the facility's policy. Similarly, Resident R8, who was severely cognitively impaired, had a UTI diagnosed based on lab results, but there was no documentation of symptoms or urine characteristics in the progress notes. The physician prescribed antibiotics without a documented assessment of symptoms or response to treatment. Resident R1, with a suprapubic indwelling urinary catheter, had a change in antibiotic treatment for a UTI without documented symptoms or lab results to justify the change. The progress notes lacked documentation of R1's response to the treatment. The Director of Nursing, V2, confirmed the expectation for staff to monitor and document urinary output and characteristics, which was not fulfilled in these cases. The facility's failure to follow its urinary catheter care policy led to inadequate monitoring and documentation, contributing to the deficiency.
Failure to Provide Required Feeding Assistance for Resident with Dysphagia
Penalty
Summary
The facility failed to provide adequate feeding assistance for a resident diagnosed with dysphagia, who required one-to-one feeding assistance. During an observation, the resident was seen at lunch with a mechanical soft tray and thickened liquids in front of him, attempting to drink the liquids without assistance. The Activity Director present at the table stated she was not qualified to feed residents. A Certified Nursing Assistant (CNA) mentioned that the resident had refused lunch and left the tray in front of him. The Director of Nursing confirmed that residents requiring one-to-one feeding assistance should be helped by a CNA, nurse, or speech therapist, and a tray should not be left unattended in front of such residents. The resident's medical records indicated a diagnosis of dysphagia and specified the need for one-to-one assistance with meals.
Failure to Follow Updated Dietary Orders for Resident
Penalty
Summary
The facility failed to follow dietary orders for a resident, identified as R1, who was on a special diet. On October 2, 2024, R1 was observed sitting near the nursing station with thickened water, which was consistent with his dietary orders. However, the speech therapist, V11, had evaluated R1 on September 24, 2024, and noted that although R1's hospital video swallow did not show aspiration, R1 was coughing on honey thick liquids during the evaluation. A care conference with R1's family on September 27, 2024, resulted in an agreement to allow thin liquids and ice chips between meals to promote hydration, as R1 was at risk for dehydration. Despite this agreement, the facility did not adhere to the updated dietary orders. On October 2, 2024, the Licensed Practical Nurse, V4, provided R1 with thickened water, contrary to the agreed-upon plan of allowing thin liquids and ice chips between meals. The Director of Nursing, V2, acknowledged that speech therapy recommendations should be followed, yet the facility failed to implement the updated dietary plan. The Order Summary Report dated October 2, 2024, confirmed the dietary orders for a regular diet with mechanical soft texture, nectar thick liquid consistency, and allowance for thin water and ice chips between meals, effective from September 27, 2024.
Failure to Inform Legal Representative About Psychotropic Medications
Penalty
Summary
The facility failed to ensure the legal representative of a cognitively impaired resident was fully informed regarding the use of psychotropic medications. The resident, who has a history of traumatic brain injury, major depressive disorder, and other significant health issues, was administered several psychotropic medications without proper consent documentation. The medications included Lorazepam, Aripiprazole, Escitalopram, and Trileptal. The consent forms for these medications were either incomplete or missing, failing to provide necessary information such as drug classification, targeted behaviors, side effects, and whether the legal representative agreed to the medication use. The resident's father, who is the designated Power of Attorney (POA), was not fully informed about the medications being administered. He expressed concerns about the use of these medications, particularly the mood stabilizer/antiepileptic medication Trileptal, which he believed could have detrimental side effects. The father also indicated that he was not notified about the administration of these medications and showed copies of incomplete consent forms provided by the facility. Interviews with facility staff, including the psychotropic nurse and the attending physician, confirmed that the consent forms should have included detailed information to ensure the POA was fully informed. The facility's policy on psychotropic medications, dated 5/30/2016, mandates adherence to federal regulations and obtaining consent for each psychotropic medication. However, the facility failed to comply with these requirements, leading to the deficiency identified in the report.
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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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