Bria Of Godfrey
Inspection history, citations, penalties and survey trends for this long-term care facility in Godfrey, Illinois.
- Location
- 1623 29 West Delmar, Godfrey, Illinois 62035
- CMS Provider Number
- 145656
- Inspections on file
- 43
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Bria Of Godfrey during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments experienced an unwitnessed fall that was not immediately reported to nursing staff. The resident was moved without a nursing assessment, and staff did not follow facility protocol for post-fall evaluation. As a result, the resident endured pain from undiagnosed rib and clavicle fractures for over a day before receiving appropriate medical attention.
The facility did not ensure that staff accused of abuse were immediately removed from resident access and failed to investigate all reported abuse allegations. In one case, a CNA remained in resident areas after an abuse allegation, and in another, a resident's repeated claims of verbal abuse by a nurse were not investigated or documented, contrary to facility policy.
A resident with diabetes and cognitive impairment received a double dose of Lantus insulin after two LPNs each administered the prescribed amount, due to confusion over resident assignments and inability to document in the MAR because of computer issues. The error was discovered after the resident's blood pressure was found to be elevated, leading to hospital evaluation.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, leading to increased risk of resident accidents.
A resident was provided with a makeshift closet area consisting of a PVC pipe and a portable metal rack, without any shelving or a proper wardrobe. The family had to add a curtain to make the space more homelike, as the facility did not meet its policy of providing sufficient individual closet space.
A nurse administered the wrong medication, Clozaril, to a resident who was not prescribed this drug after the resident requested his medication while the nurse was preparing medications for another individual. The resident, who has diabetes, became lethargic and was sent to the hospital, where he was admitted for hypoglycemia and accidental drug overdose. The error was recognized shortly after administration, and staff interviews confirmed that the nurse did not follow proper medication administration protocols.
Two residents did not receive their prescribed medications as ordered by their physicians due to the medications not being available on hand, resulting in multiple missed doses. One resident with multiple chronic conditions missed several daily medications, while another with GERD missed eight doses of calcium carbonate. Facility policy and the DON confirmed that medications are to be administered as ordered.
A resident with complex medical needs was discharged to a hospital without proper arrangements for housing, DME, and medications. The facility assumed the resident would be admitted to the hospital, but when this did not happen, they refused to accept the resident back, leaving him without a place to live and necessary medical support. The discharge process was inadequately managed, with incomplete documentation and lack of coordination, resulting in the resident being temporarily housed by a community social worker.
A long-term care facility failed to manage enteral feeding properly for three residents, leading to severe health complications. One resident was hospitalized with aspiration pneumonia due to incorrect feeding rates and lack of prescribed medication. Another resident received tube feedings while lying flat, and her stoma site was not properly cared for. The third resident's tube placement was not checked before feedings, and Enhanced Barrier Precautions were not followed. These deficiencies indicate a failure to adhere to medical orders and facility policies.
A resident with chronic pain conditions did not receive prescribed Oxycodone due to unavailability, leading to severe pain, incontinence, and aggressive behavior. The facility's staff failed to follow medication administration policies, resulting in missed doses and significant distress for the resident.
The facility failed to conduct suicide risk assessments for four residents upon admission, despite their histories and diagnoses indicating a need for such evaluations. This oversight involved residents with conditions like Major Depressive Disorder, Schizophrenia, and a history of suicidal ideation or self-harm, contrary to the facility's policy requiring such assessments.
The facility failed to administer medications on time for four residents, resulting in significant medication errors. Residents received medications two hours or more after scheduled times, affecting various medications for conditions like depression, dementia, and hypertension. Staffing issues contributed to the delays, and the facility's policy on timely administration was not followed.
The facility failed to implement fall interventions for two high-risk residents. One resident did not receive a required therapy evaluation after multiple falls, while another experienced falls due to improper transfer techniques and lack of prescribed safety measures like a floor mat and lowered bed. Staff were unaware of specific fall interventions, indicating a communication gap.
Two residents in the facility did not receive adequate pressure ulcer care as per physician orders. One resident, who is severely cognitively impaired, was found without pressure-relieving boots, leading to red heels. Another resident with multiple sclerosis had a pressure ulcer without a dressing, and CNAs failed to inform the nurse, leaving the ulcer exposed. The Director of Nursing was unaware of these lapses in care.
A resident with a history of falls and multiple medical conditions experienced several falls and injuries due to inadequate supervision and ineffective fall prevention strategies. Despite being identified as high risk, the facility failed to implement and monitor appropriate interventions, leading to repeated falls and a head laceration. The facility also lacked timely fall risk assessments and documentation of enhanced supervision.
A resident with multiple health conditions, including an above-the-knee amputation and severe malnutrition, was admitted to the facility and identified as high risk for pressure ulcers. The facility failed to provide timely wound care and follow the care plan, resulting in severe pressure wounds and infection, necessitating hospitalization.
The facility failed to perform catheter care for three residents with indwelling catheters, as documented in their care plans and treatment administration records. The residents experienced delays in catheter care documentation and treatment, leading to issues such as contaminated catheters and bladder infections.
The facility failed to complete wound treatments as ordered for a resident with a stage 4 pressure ulcer on the left buttock. The Treatment Administration Record showed multiple instances of undocumented wound care over several months. The DON acknowledged the issue, particularly with agency staff, and the resident confirmed delays in dressing changes.
The facility failed to provide adequate CNA coverage, particularly during the evening and night shifts, as reported by multiple residents and staff members. The DON and Administrator confirmed staffing shortages, exacerbated by high call-offs and staff leaving for higher-paying jobs. A review of Daily Staffing Sheets revealed multiple instances where the facility did not meet its own staffing grid requirements.
The facility failed to provide proper perineal and catheter care, leading to UTIs in two residents. One resident with acute cystitis and Alzheimer's disease received inadequate perineal care, while another resident with an indwelling urinary catheter received improper catheter care. Staff interviews revealed a lack of awareness and concern regarding the high incidence of UTIs.
A resident with chronic pain did not receive Hydrocodone/Acetaminophen as ordered by the physician due to delays in obtaining the medication from the pharmacy and the need for a hard prescription. The resident experienced significant distress, and the medication was eventually administered from the emergency kit.
The facility failed to provide quality and good tasting food to three residents, who reported issues with food palatability, portion sizes, and overall quality. Staff confirmed frequent complaints, and the facility lacked a policy for Food Palatability.
The facility failed to adhere to infection control practices for two residents, leading to deficiencies in infection prevention and control. Improper hand hygiene and perineal care techniques were observed, likely contributing to recurrent UTIs in the affected residents. Staff acknowledged the presence of UTIs but did not express significant concern or awareness of the potential link to improper practices.
Failure to Timely Assess and Report Resident Fall Resulting in Delayed Treatment
Penalty
Summary
A resident with a complex medical history, including Parkinson's disease, chronic respiratory failure, severe malnutrition, and cognitive impairment, experienced a fall in the dining room that was not witnessed by nursing staff. The resident was dependent on staff for mobility and required substantial assistance for activities of daily living. After the fall, the resident was found on the floor by a CNA, but the incident was not immediately reported to nursing staff, and the resident was moved without a nursing assessment. The fall was only brought to the attention of nursing staff the following day, at which point a range of motion and skin assessment was performed, and the resident was noted to be in pain and resistant to having her arm touched. Subsequent evaluation by hospice and hospital staff revealed that the resident had sustained multiple rib fractures and a fractured clavicle, as well as a urinary tract infection. The delay in notifying nursing staff and the lack of immediate assessment resulted in the resident enduring pain for over a day before appropriate medical intervention was initiated. Interviews with facility staff confirmed that the expected protocol was for staff to notify nursing immediately and not to move a resident after a fall until assessed by a nurse, but this protocol was not followed in this instance. Facility policy required that all falls be promptly evaluated for injury, with the physician and emergency contact notified, and an incident report completed. However, in this case, the failure to follow these procedures led to a significant delay in the identification and treatment of the resident's injuries. The deficiency centers on the lack of timely assessment and communication following the resident's fall, contrary to facility policy and standard care expectations.
Failure to Remove Accused Staff and Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure that staff members accused of abuse were immediately removed from resident access and that all abuse allegations were properly investigated. In one instance, a resident with significant physical impairments and cognitive intactness reported a verbal altercation with a certified nursing assistant (CNA). The CNA was not immediately removed from the premises and remained in areas accessible to residents, including the nurse's station, after being told to leave. Statements from staff and the CNA confirm that she was present in the facility and in proximity to residents after the allegation was made, contrary to facility policy requiring immediate suspension and removal of accused staff pending investigation. Additionally, the facility did not investigate all reported abuse allegations. Another resident with a history of traumatic brain injury and behavioral issues made repeated allegations that a nurse made inappropriate comments about his body. The resident's family also reported these concerns. Despite these reports, there was no documentation of any investigation into the allegations, and the administrator confirmed that no investigation was conducted. The administrator attributed this failure to the absence and inaction of the previous Director of Nursing (DON), who did not initiate or document any inquiry into the matter. The facility's own abuse policy requires immediate protection of residents and prompt, thorough investigation of all abuse allegations. However, in both cases, the facility did not follow its policy: the alleged perpetrator was not immediately removed from resident areas, and one resident's abuse allegation was not investigated at all. These failures were confirmed through interviews, record reviews, and the absence of required documentation.
Double Dosing of Insulin Due to Medication Administration Error
Penalty
Summary
A resident with diagnoses including Type 2 Diabetes Mellitus, Alzheimer's Disease, Dementia, and Anxiety Disorder was admitted to the facility and prescribed 27 units of Lantus insulin to be administered subcutaneously at bedtime. On the night in question, two LPNs each administered a full dose of Lantus insulin to the same resident, resulting in a double dose. The first LPN administered the insulin and was unable to immediately document the administration in the Medication Administration Record (MAR) due to computer and internet issues. Subsequently, the second LPN, confused about her assigned residents and not seeing the prior administration on the MAR, also gave the resident the prescribed dose of insulin. Following the double administration, the resident's blood sugar and blood pressure were monitored, with the blood pressure found to be elevated. The on-call physician was notified, and the resident was given glucose gel and snacks as a precaution. The resident was then transferred to a local hospital for evaluation of hypertension, which was reported to be related to the double dose of insulin. Documentation from the hospital confirmed the double dosing incident and the resident's subsequent evaluation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Adequate Closet Space and Shelving
Penalty
Summary
The facility failed to provide adequate closet space with shelving for one resident. According to a family member, the resident's room was located at the end of the hall and did not contain an actual closet or a portable wardrobe. Instead, the facility had installed a PVC pipe from the ceiling, forming a box-like structure intended for hanging clothes, but there were no shelves available. The family had to purchase a curtain and tension rod to make the space more homelike, as the original setup was not considered homelike. Observation of the room confirmed the absence of a built-in wardrobe or closet. The only available storage was a portable metal clothes rack and the PVC pipe structure, with no shelving present. The facility administrator acknowledged that the wardrobe had been removed from the room and that maintenance had installed the PVC pipe, but no shelves were provided. The facility's own policy requires sufficient individual closet space for each resident, which was not met in this case.
Significant Medication Error: Wrong Medication Administered to Resident
Penalty
Summary
A significant medication error occurred when a nurse administered the wrong medication to a resident. The nurse was preparing medications for another resident when the affected resident approached and requested his medication. The nurse mistakenly gave the resident another individual's medication, specifically Clozaril (Clozapine) 150 mg, which was not prescribed for him. The error was recognized by the nurse approximately 15-20 minutes after administration, at which point the resident exhibited lethargy. The resident, who has a history of diabetes and is described as a severe brittle diabetic with rapidly fluctuating blood sugars, was sent to the emergency room for evaluation. Upon arrival at the hospital, the resident was found to be hypoglycemic and was admitted for observation due to accidental drug overdose and altered mental status. The emergency department records indicate that critical care was necessary to manage the resident's hypoglycemia and acute ingestion of the medication. The resident remained hospitalized for several days before returning to the facility. Review of the resident's physician orders confirmed there was no order for Clozaril for this individual, while another resident did have an active order for the medication. Interviews with facility staff confirmed the sequence of events, with the nurse acknowledging the error and the DON stating that the nurse did not follow the rights of medication administration, which include verifying the right medication and right resident prior to administration.
Failure to Administer Physician-Ordered Medications Due to Unavailability
Penalty
Summary
The facility failed to administer medications as ordered by physicians for two of four residents reviewed for pharmacy services. One resident, who had multiple diagnoses including a three-part fracture of the left humerus, COPD, neuropathy, major depressive disorder, CHF, cardiac pacemaker and defibrillator, history of falling, arthropathy, gout, hypertension, low back pain, and chronic atrial fibrillation, did not receive several prescribed medications on two consecutive days. Documentation in the Medication Administration Record (MAR) and progress notes indicated that these medications were not administered because they were not available on hand. Another resident, diagnosed with GERD, reported not receiving her prescribed calcium carbonate tablets after meals for several days, resulting in a total of eight missed doses. The MAR confirmed these omissions, and the resident's care plan specifically included the intervention to administer medications as ordered. The facility's policy requires all medications to be administered safely and appropriately, and the Director of Nurses confirmed that medications are to be given as ordered by the physician.
Incomplete Discharge Process for Resident
Penalty
Summary
The facility failed to ensure a complete discharge process for a resident, identified as R2, who was transferred to a hospital due to behavioral issues. R2, who had a complex medical history including spinal stenosis, diabetes, and bipolar disorder, was discharged to the hospital without proper arrangements for housing, Durable Medical Equipment (DME), and medications. The facility assumed R2 would be admitted to the hospital, but when the hospital did not admit R2, the facility refused to accept him back, leaving R2 without a place to live and without necessary medical equipment and medications. The discharge process was inadequately managed, as evidenced by incomplete documentation and lack of coordination between the facility and external parties. R2's discharge plan assessment and instructions were left blank, and there was confusion regarding the ordering and approval of DME. The facility's Social Service Director and Administrator were not fully aware of the readiness of R2's apartment, and the facility did not hold a bed for R2's potential return. This lack of communication and preparation resulted in R2 being temporarily housed in a Bed and Breakfast by his community social worker until his apartment was ready. The facility's actions were based on the assumption that R2 would be admitted to the hospital for a psychiatric evaluation, but this did not occur. The facility's Administrator and staff did not verify R2's admission status before proceeding with the discharge, leading to a situation where R2 was left without adequate support. The facility's discharge policy was not followed, as evidenced by the lack of a completed discharge instruction form and the failure to ensure R2 had access to his medications and necessary equipment upon discharge.
Inadequate Enteral Feeding Management and Care in LTC Facility
Penalty
Summary
The facility failed to provide appropriate enteral feeding management for three residents, leading to significant health complications. Resident R2, who was admitted with severe cognitive impairment and multiple medical conditions, was returned from the hospital with specific discharge orders for tube feeding. However, the facility did not follow these orders, starting the feeding at a higher rate than recommended, which likely contributed to R2's aspiration pneumonia and subsequent hospitalization. Additionally, the facility failed to provide the prescribed Scopolamine patch for nausea and secretions, and no alternative medication was sought. Resident R1, also severely cognitively impaired, reported that nurses sometimes administered tube feedings while she was lying flat, contrary to her care plan that required the head of the bed to be elevated. During an observation, a nurse provided a tube feeding bolus without checking for residuals or tube placement, and the stoma site was not properly cleaned or assessed for infection, despite signs of tenderness and redness. The dressing on the stoma site was not changed as required, indicating a lack of adherence to care protocols. Resident R3, with a history of severe malnutrition and cerebral palsy, did not receive proper care for her gastrostomy tube. The facility staff failed to check the tube placement before administering feedings and did not maintain a dressing on the stoma site as expected. Additionally, staff did not follow Enhanced Barrier Precautions during care, which is crucial for preventing the transmission of infections. These deficiencies highlight a pattern of inadequate care and failure to follow medical orders and facility policies, putting residents at risk for serious health issues.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to provide physician-prescribed narcotic pain medication for a resident, resulting in severe pain and distress. The resident, who had a history of spinal stenosis, chronic pain syndrome, and other related conditions, was admitted with a care plan that included administering pain medication and assessing its effectiveness. However, the facility did not have the prescribed Oxycodone available for the resident on multiple occasions, leading to missed doses and significant pain. During the period when the medication was unavailable, the resident experienced severe pain, became incontinent of bowel and bladder, and exhibited aggressive behaviors. The resident was documented as being in a fetal position, experiencing loose stools, and expressing extreme distress due to the lack of pain management. Staff interviews confirmed that the resident was usually continent and mobile but was significantly affected by the absence of the medication. The Director of Nursing and other staff members were unaware of the missed doses until the resident's behavior escalated, prompting a call to the police. The facility's medication administration policy required documentation and notification of the healthcare provider if medication was not given as ordered, but these steps were not followed. The delay in obtaining the medication from the pharmacy and the lack of immediate access to the emergency medication kit contributed to the resident's prolonged suffering.
Failure to Conduct Suicide Risk Assessments
Penalty
Summary
The facility failed to assess four residents for risks of self-harm upon their admission, which is a necessary component of behavioral health care and services. Resident 2 was admitted with diagnoses including Major Depressive Disorder and Vascular Dementia, and had a history of threatening suicide when upset, as reported by family members. Despite these indicators, there was no documentation of a suicide risk assessment upon admission. Similarly, Resident 3, with a history of Suicidal Ideation and diagnoses such as Schizophrenia and Major Depressive Disorder, also lacked a documented suicide risk assessment upon admission. Resident 11, admitted with multiple diagnoses including Major Depressive Disorder and a history of Suicidal Ideations, did not have a suicide risk assessment documented in her records. Resident 12, who had a diagnosis of Non-Suicidal Self-Harm and Major Depressive Disorder, was also not assessed for suicide risk upon admission. The facility's policy requires a suicide assessment for residents with a history or diagnosis of suicidal ideation, but this was not followed for these residents, as confirmed by the facility administrator.
Significant Medication Errors Due to Delayed Administration
Penalty
Summary
The facility failed to administer medications as prescribed and according to its policy and procedures for four residents, resulting in significant medication errors. Residents received their medications two hours or more after the scheduled times. This issue was identified through interviews and record reviews, highlighting a pattern of delayed medication administration. Resident 2, who has a history of major depressive disorder, vascular dementia, and other conditions, received multiple medications late, including Aricept, Seroquel, Depakote, Synthroid, Xarelto, Metoprolol, Paroxetine, Losartan, and Hydroxyzine. The delays ranged from 3 to 19 doses being administered more than two hours late. The resident's niece confirmed that medications were not given on time, and the facility's administrator acknowledged the issue, citing staffing challenges as a contributing factor. Similarly, Resident 3, with diagnoses including schizophrenia, PTSD, and hypertension, experienced delays in receiving medications such as Lidoderm Patch, Acetaminophen, Aspirin, Metoprolol, Bupropion, Clozapine, Fluoxetine, Lisinopril, Amlodipine, Vraylar, Olanzapine, and Donepezil. The delays affected a significant number of doses, with some medications consistently administered late. Resident 5 and Resident 13 also faced similar issues, with medications like Norco, Morphine, Lyrica, Gabapentin, Lasix, Duloxetine, Lopressor, Mirtazapine, Prozac, Hydroxyzine, Metoprolol, Metformin, Trulicity, and Lisinopril being administered late. The facility's policy requires timely medication administration, and the failure to adhere to this policy was not communicated to the nurse practitioner, potentially impacting medication management decisions.
Failure to Implement Fall Interventions for High-Risk Residents
Penalty
Summary
The facility failed to implement progressive fall interventions for two residents identified as high risk for falls. The first resident, admitted with conditions such as bipolar disorder and unsteadiness, had multiple falls documented over several months. Despite a fall intervention requiring a therapy evaluation after a fall in February, the evaluation was never completed. This oversight indicates a lack of follow-through on planned interventions to mitigate fall risks for this resident. The second resident, with severe cognitive impairment and dependent for transfers, experienced falls due to improper transfer techniques and self-transferring. The root cause analysis identified that a mechanical lift should have been used for transfers, but this was not consistently implemented. Additionally, the resident's care plan included interventions such as keeping the bed in the lowest position and using a floor mat, but these were not in place during an observation. Staff members were unaware of the specific fall interventions, highlighting a communication gap and failure to adhere to the care plan designed to prevent falls.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for two residents, R3 and R35, as observed during the survey. R3, who is severely cognitively impaired and requires substantial assistance, was found without the physician-ordered pressure-relieving boots on multiple occasions, resulting in red heels. Despite having a care plan intervention to protect her heels, the boots were not utilized as required, and the Director of Nursing acknowledged the oversight. R35, diagnosed with multiple sclerosis and pressure ulcers, was admitted with skin complications. Despite having a care plan and physician orders for wound treatment, R35's pressure ulcer on the left ischium was found without a dressing during incontinent care. The CNAs did not inform the nurse about the missing dressing, and the Director of Nursing was unaware if the treatment was applied after the resident was changed. The wound nurse later applied the necessary treatment, but the deficiency in care was evident as the pressure ulcer was exposed without protection.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to implement appropriate fall interventions and supervision for a resident, resulting in multiple falls and injuries. The resident, who was admitted with a history of falls and several medical conditions including hemiplegia, diabetes, and a recent hip fracture, was identified as being at high risk for falls. Despite this, the facility did not ensure adequate supervision or implement effective fall prevention strategies, leading to the resident experiencing multiple falls, including one where she sustained a head laceration. The resident's care plan and fall risk assessments documented her high risk for falls and outlined interventions such as keeping the call light within reach and providing a clutter-free environment. However, these interventions were not effectively implemented or monitored. The resident reported that staff were slow to respond to her call light, and she attempted to transfer herself to the bathroom, resulting in falls. The facility also failed to conduct timely fall risk assessments and root cause analyses following each fall, as required by their policy. Additionally, the facility did not maintain adequate documentation of the resident's enhanced supervision, which was supposed to include 15-minute checks. The lack of documentation and failure to update the care plan with new interventions after each fall further contributed to the resident's repeated falls and injuries. The facility's inaction and inadequate supervision directly led to the resident's multiple falls and injuries, highlighting a significant deficiency in their fall prevention and management practices.
Failure to Assess and Treat Pressure Wounds
Penalty
Summary
The facility failed to assess and treat pressure wounds for a resident (R2) who was admitted with multiple health conditions, including severe protein calorie malnutrition, type 2 diabetes mellitus, and an above-the-knee amputation. Upon admission, R2 was identified as high risk for pressure ulcers and required assistance with turning and repositioning. Despite this, there was no documentation of wound care from the time of admission until several days later, and the resident's care plan was not followed. The resident's treatment administration record (TAR) showed gaps in wound care documentation, and there was no record of indwelling catheter care. When R2 was transferred to the emergency room, the resident was found to have severe pressure wounds, including stage 3/4 ulcers, and an infection at the surgical site. The ER staff noted that the resident's catheter appeared filthy and had not been properly cared for. The facility's policy on skin management and pressure injury treatment was not adhered to, as evidenced by the lack of timely wound care and documentation. The failure to follow the care plan and provide necessary treatments led to the resident's condition worsening, requiring hospitalization and further medical intervention.
Failure to Perform Catheter Care for Residents
Penalty
Summary
The facility failed to perform catheter care for three residents who required the use of indwelling catheters. Resident 2 (R2) was severely cognitively impaired and had an indwelling catheter due to obstructive uropathy and urinary retention. R2's care plan did not include instructions for cleaning the catheter, and the treatment administration records (TAR) for March, April, and May did not document any catheter care until late May. R2 was noted to have a contaminated catheter by a local hospital, which led to a catheter change on May 18, 2024. Resident 3 (R3) was moderately cognitively impaired and required an indwelling catheter due to neurogenic bladder and obstructive uropathy. R3's TAR for March, April, and May also lacked documentation of catheter care until May 22, 2024. R3 was placed on isolation for a multidrug-resistant organism in the urine and had multiple instances of bladder infections requiring antibiotic treatment. Resident 4 (R4) had a diagnosis of obstructive and reflex neuropathy and was moderately cognitively impaired. R4's care plan did not address catheter cleaning, and the TAR for March, April, and May did not document catheter care until May 22, 2024. Multiple CNAs confirmed that catheter care was not performed until late May, despite the facility's policy requiring daily and as-needed catheter care.
Failure to Complete Wound Treatments as Ordered
Penalty
Summary
The facility failed to complete wound treatments as ordered by the physician for a resident with multiple diagnoses, including Multiple Sclerosis, Paraplegia, and a stage 4 pressure ulcer on the left buttock. The resident's Treatment Administration Record (TAR) showed multiple instances where the wound care was not documented as completed over several months. Specifically, the TAR for February, March, and April 2024 showed that the wound care was not documented 4, 17, and 5 times, respectively. The Director of Nurses (DON) acknowledged that the treatments might not have been done or were not signed off, particularly by agency staff, and attempts were made to contact them to ensure treatments were completed as ordered. The resident confirmed that there were instances where the dressing was not changed for up to three days, although the wound was not worsening, it was also not improving. The resident's care plan included an intervention to provide treatment as ordered for the left buttock wound, but the facility failed to adhere to this plan. The facility's policy on Skin Management: Pressure Injury Treatment/General Wound Treatment required documentation of routine and PRN treatments in the treatment administration record of the Electronic Health Record (EHR) and significant observations in the Nursing Progress Note. The failure to consistently document and possibly perform the wound care treatments as ordered led to the deficiency noted in the report.
Inadequate CNA Coverage During Evening and Night Shifts
Penalty
Summary
The facility failed to provide adequate CNA coverage for residents, particularly during the evening and night shifts. Multiple residents and staff members reported that the facility often had only one nurse and one CNA working during these times. The Director of Nurses (DON) confirmed that the staffing levels were lower than required, especially in the evenings and nights, and that they were relying on agency staff and recruitment efforts to fill the gaps. The Administrator also acknowledged the staffing issues and mentioned that they had experienced a high number of call-offs recently, which exacerbated the problem. The Social Services Director noted that many staff members had left for higher-paying jobs at other facilities, further contributing to the staffing shortages. A review of the Daily Staffing Sheets from 4/1/24 to 4/25/24 revealed multiple instances where the facility did not meet its own staffing grid requirements. For example, on 4/14/24, the day shift had only 1 LPN, 1 RN, and 2 CNAs, while the evening shift had 1 LPN, 1 RN, 1 nurse in training, and 2 CNAs. Similar deficiencies were noted on other dates as well. The facility's staffing policy, dated 6/2015, mandates that appropriate numbers of staff be available to meet the needs of the residents, a standard that was not met according to the documented staffing levels and the Midnight Census Report, which showed 45 residents residing in the facility on 4/25/24.
Failure to Provide Proper Perineal and Catheter Care
Penalty
Summary
The facility failed to provide proper perineal care and adhere to infection control practices, leading to urinary tract infections (UTIs) in two residents. One resident, diagnosed with acute cystitis and Alzheimer's disease, was observed receiving inadequate perineal care. The CNA did not perform hand hygiene or change gloves during the procedure, and the resident was left soiled with urine and feces. This resident was later admitted to the hospital with a UTI and readmitted to the facility with the same diagnosis. Another resident, with a diagnosis of obstructive and reflux uropathy and an indwelling urinary catheter, also received improper catheter and perineal care. The CNA did not maintain a clean/dirty field and failed to change gloves or perform hand hygiene during the procedure. This resident had multiple UTIs, as documented in their progress notes, and was treated with various antibiotics. Interviews with facility staff revealed a lack of awareness and concern regarding the high incidence of UTIs. The Director of Nursing denied any concerns, while an LPN acknowledged the frequent occurrence of UTIs but was unsure of the cause. The facility's policies on perineal and incontinence care were not followed, contributing to the deficiencies observed.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as ordered by the physician for a resident diagnosed with chronic pain. The resident's physician had prescribed Hydrocodone/Acetaminophen 10/325mg to be given every 4 hours. However, the Medication Administration Record (MAR) showed that the medication was not administered as ordered. The resident, who was cognitively intact with a BIMS score of 15, reported not receiving any medications for a week upon admission and experienced delays in receiving pain medication due to issues with the pharmacy and the need for a hard prescription from the Nurse Practitioner or Medical Doctor. The resident's progress notes documented multiple instances where the pharmacy was contacted regarding the medication, and the resident expressed significant distress due to the delay. On one occasion, the resident was yelling and screaming in pain, and the nurse had to obtain the medication from the emergency kit to administer it. The Director of Nurses confirmed that nurses have access to the emergency medication kit and can obtain medications from there if needed. The facility's Medication Administration policy emphasizes the importance of administering medications safely and appropriately, but this was not adhered to in this case.
Failure to Provide Quality and Palatable Food
Penalty
Summary
The facility failed to provide quality and good tasting food to three residents, as evidenced by multiple complaints about the food's palatability, portion sizes, and overall quality. Resident R2 reported not receiving a full meal and described the food as horrible, particularly during the evening meal. R2 had previously filed a grievance regarding the unsatisfactory food, which was addressed by educating R2 on available menu items and substitutions. Resident R4 also complained about the food quality, stating it tasted bad and the portions were sometimes insufficient, leading to hunger at night. Resident R3 echoed similar sentiments, describing the food quality and taste as horrible. All three residents were cognitively intact, as indicated by their BIMS scores of 15, 13, and 14, respectively. The Resident Council Note documented issues with the quality and variety of food, including the lack of meat for breakfast and repetitive meals. Staff members, including an RN and an LPN, confirmed that residents frequently complained about the food's taste, quality, and portion sizes. The Administrator acknowledged that the menu options were not the greatest but mentioned a new menu with more hearty meals was forthcoming. The Dietary Manager claimed no complaints had been brought to her attention and stated that they followed the menu and production guide for portion sizes. The Social Services Director noted that food presentation and taste had been an ongoing issue for the past year. The facility was unable to provide a policy for Food Palatability when requested.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control practices for two residents, leading to deficiencies in infection prevention and control. Resident 1 (R1) had multiple diagnoses, including acute cystitis and Alzheimer's disease, and was dependent on assistance for toileting. During an observation of perineal care, a CNA did not perform hand hygiene or change gloves while providing care, and the resident was left soiled with urine and feces. This improper technique likely contributed to R1's recurrent urinary tract infections (UTIs), as documented in the resident's progress notes and hospital records. Resident 5 (R5) had a diagnosis of obstructive and reflux uropathy and required an indwelling urinary catheter. During an observation of catheter and perineal care, a CNA failed to maintain a clean/dirty field and did not change gloves or perform hand hygiene until the care was completed. R5 had a history of UTIs, as indicated by multiple progress notes and urine culture results showing the presence of Citrobacter freundii and vancomycin-resistant Enterococcus faecalis. The improper infection control practices observed during care likely contributed to R5's recurrent UTIs. The facility's hand hygiene and perineal care policies, dated June 2015, emphasize the importance of proper hand hygiene and perineal care to prevent infections. However, the observations and interviews with staff revealed a lack of adherence to these policies. The Director of Nursing (DON) and other staff members acknowledged the presence of UTIs but did not express significant concern or awareness of the potential link to improper infection control practices.
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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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