Country Health
Inspection history, citations, penalties and survey trends for this long-term care facility in Gifford, Illinois.
- Location
- 2304 C R 3000 N, Gifford, Illinois 61847
- CMS Provider Number
- 145708
- Inspections on file
- 37
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Country Health during CMS and state inspections, most recent first.
Two residents with dementia and behavioral symptoms were involved in repeated altercations, including an incident where one resident sustained a skin tear to the wrist during mutual striking in a hallway. Despite a history of aggression, intrusive behaviors, and prior physical contact, the facility’s care plans contained only general behavior monitoring and psychotropic use, without individualized interventions such as increased supervision or environmental changes to prevent further resident-to-resident contact. After the injury, staff did not complete an abuse-specific or comprehensive post-incident skin/body assessment, and care plans were not revised to address the ongoing risk of altercations, while staff interviews reflected reliance on hospital transfers and normalization of aggressive behaviors rather than implementation of targeted preventive measures.
The facility failed to provide coordinated behavioral health services and individualized interventions for two residents with dementia, mood, and anxiety disorders who exhibited escalating behaviors such as agitation, hallucinations, aggression, and emotional instability. One resident’s care plan focused mainly on monitoring and psychotropic medications without a structured behavioral treatment plan, and the POA was not adequately educated about or given individualized clinical justification for psychotropic GDR. The other resident’s care plan contained only general measures like monitoring and redirection, with no evidence of psychiatric follow-up or structured behavioral programming, despite ongoing behavioral symptoms and vulnerability around aggressive peers. The facility did not have on-site behavioral health services and relied on hospital transfers when behaviors escalated, and these failures contributed to a resident-to-resident altercation causing a skin tear.
A resident with multiple comorbidities, including cancer, CHF, CAD, DM2, and neuromuscular bladder dysfunction, was admitted with an indwelling urinary catheter and several skin issues, but the facility did not obtain any MD orders for catheter placement, maintenance, or indication, and did not include catheter care in the care plan. The resident reported catheter-related pain during repositioning that CNAs did not investigate until an RN wound nurse later found an open wound under the catheter tubing. Although the resident had a mastectomy wound and moisture-associated skin damage to the buttocks and labia, and later developed a suspected in-house acquired pressure injury on the thigh, the care plan was not updated to reflect current wound status or needed skin and wound interventions.
A resident did not receive the prescribed increased dose of Hydrocodone-Acetaminophen for about a week after a medication order change. Staff continued to administer the discontinued lower dose due to not removing the old medication card, resulting in a significant medication error. The DON confirmed the error, and records showed the resident received the incorrect dose during this period.
A resident with multiple high-risk conditions and on medications increasing fall risk was found after a fall with no fall mats in place and the bed not in the lowest position. Staff confirmed that required fall prevention interventions were not implemented, leading to the resident sustaining a nasal fracture and laceration requiring sutures.
Two residents with documented exit-seeking and wandering behaviors were not promptly identified in their care plans as being at risk for elopement, nor was the use of departure alert systems included until after physician orders were placed. Despite assessments and behavioral notes indicating risk, care plans were only updated after orders were obtained, contrary to facility policy requiring individualized planning based on cognitive assessments and activity logs.
A resident with a history of falls and mobility limitations was not provided with the required one staff assist during ambulation. Instead, a CNA positioned themselves in front of the resident and allowed the resident to walk independently, resulting in a fall and multiple injuries. Staff interviews confirmed that proper procedures for one staff assist with a gait belt and walker were not followed.
A resident with severe cognitive impairment and multiple medical conditions was left unsupervised in the assisted dining room, leading to a hot tea spill that caused burns and blisters. The facility failed to have nursing staff present, as required, to supervise residents needing assistance with eating.
The facility failed to prevent and treat pressure ulcers for two residents, resulting in one developing an unstageable deep tissue injury and another developing seven stage two wounds. Despite being at risk, daily skin assessments were not documented, and necessary interventions like specialty mattresses and timely treatment orders were not implemented. Observations revealed untreated wounds and inadequate care, contributing to the worsening of the residents' conditions.
A resident with dysphagia experienced a choking incident after an LPN left the room before ensuring the medication was swallowed. Another resident with a history of falls and hallucinations had multiple falls, including one resulting in a broken back, without thorough investigation or documentation. The facility failed to adhere to its medication administration and fall management policies.
The facility failed to implement a performance improvement program project over the past year, affecting all 85 residents. Despite having a policy for a systematic approach to quality improvement, no project was in place involving frontline staff or measures to monitor effectiveness. The administrator acknowledged this deficiency.
The facility failed to properly handle and launder linens exposed to scabies, risking contamination for all residents. Additionally, staff did not follow Enhanced Barrier Precautions for two residents, neglecting to wear gowns during high-contact care activities, despite facility protocols requiring such measures.
The facility failed to administer medications timely and according to physician's orders for four residents, resulting in a 32% medication error rate. Errors included late administration, failure to prime insulin pens, and lack of physician notification. The facility's policy requires notifying the physician of medication errors, but this was not documented.
The facility failed to maintain a clean and homelike environment for two residents, as a chair in their room was found with significant stains. The Housekeeping Supervisor was unaware of the issue, and the chair was removed for cleaning only after the deficiency was identified.
A resident with dementia and muscle weakness was observed with a lap cushion in a wheelchair, functioning as a restraint. The facility lacked a physician's order and consent for its use, and staff were unaware of the resident's inability to remove it. Documentation of restraint reduction attempts was also missing.
A resident with moderate cognitive impairment and hearing loss did not have a care plan addressing their hearing aid use until a specific date. The resident's hearing aids were missing, affecting communication, and staff were not consistently applying the remaining hearing aid. The DON confirmed the absence of a care plan prior to the noted date, leading to the deficiency.
A facility failed to manage and document the care of a resident with a g-tube. The resident received Osmolite 1.5 Cal at 60 ml per hour, but the facility did not check and record gastric residual volume to verify g-tube placement before administering medications. Instead, an RN used the air rush technique, contrary to facility policy. The total volume of feeding and water flushes was not recorded, and there were no orders to routinely check gastric residuals or parameters to hold feeding based on residual volumes. The facility's policies require checking tube placement and documenting these checks, which was not done.
The facility failed to label, store, and change oxygen and nebulizer tubing for three residents, leading to deficiencies in respiratory care. One resident's oxygen tubing was undated and uncovered, with no routine change documented. Another resident's nebulizer equipment was undated and uncovered, with no record of scheduled changes. A third resident's oxygen tubing was outdated, and the resident was unsure of change frequency. Facility policies requiring weekly changes and proper storage were not followed.
The facility failed to implement effective infection control measures for COVID-19, including not stocking isolation carts with N95 masks, missing isolation signage, and improper PPE disposal by staff. A resident with COVID-19 and multiple health conditions did not receive documented symptom monitoring as required. Staff were unaware of proper PPE procedures, increasing exposure risks.
A resident with severe cognitive impairment physically abused another resident in their room. The incident occurred when the aggressor, who has a history of aggressive behaviors, entered the victim's room and struck them in the chest after being asked to leave. The event was witnessed by another resident and reported by a CNA to an LPN, revealing a failure in the facility's policy to protect residents from abuse.
Failure to Prevent and Assess Repeated Resident-to-Resident Altercations Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not assessing, care planning, and implementing effective interventions in response to repeated resident-to-resident altercations. One resident (R4) had diagnoses including frontotemporal neurocognitive disorder, dementia with agitation, mood disorder, and anxiety disorder, and a care plan that identified behaviors such as agitation, hallucinations, exit-seeking, and entering other residents’ rooms. Despite documented incidents in which this resident hit another resident in the dining room, raised a fork toward staff in a stabbing motion, and made verbal threats toward staff, the care plan only included general interventions such as monitoring behaviors and administering psychotropic medications and lacked specific, individualized interventions to prevent resident-to-resident altercations. The record showed ongoing intrusive and aggressive behaviors, including moving rapidly through hallways in a wheelchair and reaching toward others, without evidence of increased supervision, environmental modifications, or individualized behavioral strategies. Another resident (R6) had diagnoses including dementia, severe protein-calorie malnutrition, adult failure to thrive, anxiety disorder, major depressive disorder, repeated falls, and multiple chronic medical conditions, with a care plan identifying agitation, yelling, resistiveness to care, and potential for making false allegations. Documentation showed that R4 and R6 were involved in repeated altercations over several weeks, including an incident in which both residents were actively striking one another and R6 sustained a skin tear to the right wrist. The facility did not complete an abuse-specific assessment or a comprehensive post-incident skin/body assessment to determine the extent of injury, and there was no evidence that care plans were revised to address the risk of continued resident-to-resident altercations or that individualized interventions were implemented. Staff interviews indicated that aggressive behaviors were attributed to resident diagnoses and that the facility did not provide behavioral services, relying instead on hospital transfers when behaviors escalated, while the facility’s abuse policy required appropriate interventions to be implemented, care plans updated with changes in condition, and information communicated to direct care staff.
Failure to Provide Coordinated Behavioral Health Services and Individualized Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate behavioral health services and individualized interventions for residents with diagnosed mental disorders and behavioral symptoms, specifically two residents with dementia and associated mood and anxiety disorders. One resident had a care plan that listed behaviors such as agitation, hallucinations, exit-seeking, and intrusive behaviors toward others, with interventions limited to monitoring and administering psychotropic medications. The care plan did not include an effective, individualized behavioral health treatment plan or structured behavioral health services, despite a documented pattern of escalating behaviors including hitting another resident in the dining room, aggressive behavior toward staff, verbal threats, and rapid movement through hallways while reaching toward others. During a gradual dose reduction of psychotropic medications, the resident’s POA reported not understanding why medications were being reduced and stated the facility only explained it as required by state law, with no evidence of individualized clinical justification or adequate education regarding the relationship between medication changes and behavioral symptoms. The second resident had dementia, anxiety disorder, major depressive disorder, and multiple chronic medical conditions, with documented behaviors including agitation, yelling, resistiveness to care, and emotional instability. The care plan contained only general interventions such as monitoring behaviors, identifying triggers, and redirection, and record review did not show evidence of effective behavioral health services such as psychiatric follow-up, structured behavioral intervention planning, or individualized behavioral supports. There was no evidence that this resident received behavioral health services to address risk factors related to repeated exposure to aggressive residents or to reduce vulnerability in shared environments. The facility’s Clinical Director of Operations confirmed that the facility does not provide on-site behavioral health services and relies on hospital transfers when behaviors escalate, with no evidence of ongoing behavioral health specialist involvement, behavioral programming, or structured interdisciplinary behavioral care planning. These failures contributed to a resident-to-resident physical altercation in which both residents struck one another and one resident sustained a skin tear to the wrist, constituting actual harm.
Failure to Obtain Catheter Orders and Update Care Plan for Skin Integrity
Penalty
Summary
The facility failed to provide physician-ordered direction and care planning for an indwelling urinary catheter and did not maintain an accurate, updated care plan for a resident with multiple skin integrity issues. The resident was admitted with an indwelling urinary catheter documented as patent on the admission assessment, but the electronic health record contained no physician order for catheter placement, maintenance, or indication for continued use. Nursing staff, including an RN and an LPN, confirmed that the resident had a catheter since admission but were unable to identify when it was placed and verified there were no corresponding physician orders or care plan interventions addressing catheter care or monitoring. The cognitively intact resident reported having the catheter on admission and stated that during repositioning, the plastic part of the catheter caused pain, and although this was reported to multiple CNAs, no one examined the catheter tubing until the wound nurse assessed it. The resident also had complex medical conditions, including malignant neoplasms of the colon and breast, chronic diastolic heart failure, hypertension, type 2 diabetes mellitus, coronary artery disease, acute kidney failure, neuromuscular bladder dysfunction, generalized weakness, and muscle wasting, and was receiving hospice/palliative care. On admission, the resident had a surgical wound at the right breast mastectomy site and moisture-associated skin damage to the buttocks and labia, along with other skin concerns. Although the care plan identified risk for impaired skin integrity related to diabetes and muscle wasting, it was not updated to reflect the current wound status or a suspected in-house acquired pressure injury on the left thigh. The wound nurse stated they were not informed of the left thigh wound until several days after admission, identified it as a potential in-house acquired pressure injury, and confirmed that the care plan had not been updated to include the resident’s current skin conditions or necessary wound management interventions.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident did not receive pain medication as prescribed following a change in their medication order. After a nurse practitioner increased the resident's Hydrocodone-Acetaminophen dose from 5 mg to 7.5 mg, staff continued to administer the original 5 mg dose for approximately one week. This error was due to staff not removing the discontinued 5-325 mg medication card and instead placing the new 7.5-325 mg card behind it, resulting in the continued administration of the lower dose despite the updated physician's order. The resident reported that they were informed by the DON that the incorrect dose had been given for a week. Medication administration records and controlled drug receipt records confirmed that the resident received the lower dose during this period. The facility's policy requires medications to be administered accurately according to physician orders, but this was not followed, leading to a significant medication error involving the administration of the wrong dose of pain medication.
Failure to Implement Fall Prevention Interventions Resulting in Resident Injury
Penalty
Summary
The facility failed to implement necessary fall prevention interventions for a resident identified as high risk for falls, resulting in a significant injury. The resident had multiple diagnoses including osteoarthritis, heart disease, lumbar disc displacement, anxiety, vertigo, repeated falls, glaucoma, type II diabetes, difficulty in walking, and psychotic disturbance with hallucinations. The resident was prescribed several medications known to increase fall risk, such as Haldol, Dilaudid, and Fentanyl. Despite being assessed as high risk for falls and having a recent history of falls, the resident was found alone in their room after a fall, with no fall mats in place and the bed not in the lowest position. The nightstand was positioned between the wall and the bed, and the resident was found partially under the bed, which was covered in blood along with the nightstand. Staff interviews confirmed that the fall prevention interventions, specifically the use of fall mats and maintaining the bed in the lowest position, were not in place at the time of the incident. The resident sustained an acute nasal fracture and a laceration requiring five sutures as a result of the fall. Observations after the incident further confirmed that the bed was not kept in the lowest position, and the Director of Nursing verified that if the bed had been lowered, the resident would not have been able to get under the bed. The lack of these interventions directly contributed to the resident's fall and subsequent injuries.
Failure to Timely Update Care Plans for Elopement Risk and Departure Alert Systems
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan addressing elopement risk and the use of a departure alert system for two residents identified as exit seeking. Both residents had documented histories of wandering and were assessed as being at risk for exit seeking/wandering, as evidenced by multiple behavioral notes and formal assessments. Despite these findings, their care plans did not reflect their elopement risk or the use of departure alert systems until a much later date, even after incidents such as one resident being found wandering near a door with the alarm sounding. Physician orders for the use of departure alert systems were not placed until after these risks and behaviors had been documented, and the care plans were only updated following the placement of these orders. Staff interviews confirmed that the care plans were not updated to include elopement risk and interventions until the physician's orders were in place, despite facility policy indicating that cognitive assessments and activity logs should inform individualized service plans. This delay resulted in a lack of timely, comprehensive care planning for residents at risk of elopement.
Failure to Provide Required Staff Assistance During Resident Ambulation
Penalty
Summary
A deficiency occurred when a resident, who was at risk for falls due to limited physical mobility, chronic pain syndrome, and osteoarthritis, was not provided with the required one staff assistance during ambulation. The resident's care plan specified the need for one staff assist with a gait belt and walker for transfers. On the day of the incident, a Certified Nursing Assistant (CNA) assisted the resident off the toilet, cleaned the resident, and provided the walker. The CNA then positioned themselves in front of the resident, near the bathroom door, rather than at the resident's side or behind, and allowed the resident to ambulate independently. As the resident attempted to walk toward the CNA, the resident fell backwards, resulting in multiple injuries including a hematoma, bruises, and skin tears. Interviews with facility staff confirmed that the CNA did not follow the proper procedure for assisting a resident who requires one staff assist with a gait belt and walker. The CNA was not in a position to provide support or assist in lowering the resident to the floor if needed, as required by the resident's care plan and standard practice. The incident was witnessed and documented by staff, and the resident was assessed for injuries following the fall.
Lack of Supervision Leads to Resident Injury from Hot Beverage Spill
Penalty
Summary
The facility failed to adequately supervise a resident, identified as R504, after providing a hot beverage, resulting in the resident spilling hot tea on themselves. This incident led to the resident sustaining redness and six blistered areas on their bilateral upper extremities, requiring treatment for three days. The resident, who has severe cognitive impairment and requires supervision or assistance with eating, was in the assisted dining room at the time of the incident, which is designated for residents needing supervision. R504's medical history includes diagnoses such as Congestive Heart Failure, Reflux Disease, Alzheimer's Disease, Dementia, and other conditions that contribute to their need for supervision. The resident's care plan indicates they are at risk for altered nutrition and require queuing in the dining room. On the day of the incident, the resident attempted to remove the lid from their hot tea, resulting in the spill and subsequent burns. Interviews with facility staff revealed that there were no nursing staff present in the dining room at the time of the incident, which is contrary to the facility's requirement for supervision in the assisted dining room. The Director of Nursing confirmed that supervision should include at least one nursing staff member present when residents are in the dining room with food or beverages. The lack of supervision directly contributed to the resident's injury.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide targeted interventions to prevent skin breakdown and did not assess, evaluate, or document resident skin conditions regularly. This resulted in one resident developing a new, unstageable, deep tissue injury and another resident developing seven new stage two pressure wounds. The facility's Wound and Ulcer Policy required daily skin assessments for residents at moderate or high risk, but these were not documented for the affected residents. One resident, identified as R20, was found to have an unstageable deep tissue injury on her left heel, which was not previously documented or treated. Despite being at moderate risk for skin breakdown, R20's medical records did not show daily skin checks. Observations revealed that R20 was not provided with a specialty mattress, and her complaints of foot pain were not addressed. The wound nurse confirmed that the injury had likely been present for several weeks without treatment. Another resident, R58, was identified as having multiple new wounds on her buttocks and thighs, which were not documented or treated according to the facility's protocols. R58 was at high risk for skin breakdown, yet her medical records lacked daily wound assessments. Observations showed that R58 was sitting in a wet brief without dressings on her wounds, and the necessary notifications and treatment orders were not obtained. The facility's failure to implement appropriate interventions and conduct regular skin checks contributed to the development and worsening of these pressure wounds.
Inadequate Monitoring and Documentation in LTC Facility
Penalty
Summary
The facility failed to adequately monitor a resident with dysphagia after administering oral medication, leading to a choking incident. The resident, who was cognitively intact and had a history of muscle weakness and dysphagia, was given a chewable tablet for gas relief by an LPN. The LPN left the room before ensuring the resident had thoroughly chewed and swallowed the medication. Shortly after, the resident began to choke, and staff had to perform the Heimlich maneuver to clear the airway. Additionally, the facility did not thoroughly investigate and document falls for another resident who had experienced multiple falls, including one that resulted in a broken back. The resident, who required significant assistance for mobility and was occasionally incontinent, had a history of hallucinations and falls. The facility's documentation was incomplete, lacking details about the circumstances of the falls, staff interviews, and post-fall assessments. The facility's policies on medication administration and fall management were not followed, contributing to these deficiencies. The medication administration policy required staff to ensure residents took their medication properly, which was not adhered to in the case of the resident with dysphagia. Similarly, the fall management policy required comprehensive documentation and investigation of falls, which was not completed for the resident with multiple falls.
Lack of Performance Improvement Program in Facility
Penalty
Summary
The facility failed to develop, implement, measure, act on, or analyze a performance improvement program project over the past twelve months. This deficiency potentially affects all 85 residents residing in the facility. The facility's Quality Assessment Performance Improvement Policy, dated December 8, 2023, outlines a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality, involving all caregivers in problem-solving. However, the facility did not have a performance improvement project in place for the last four quarters, which included the involvement of frontline staff or measures to monitor effectiveness. The administrator acknowledged the absence of such a project and indicated that performance improvement projects would be integrated into the quality process in the future.
Infection Control and Barrier Precaution Failures
Penalty
Summary
The facility failed to properly store, handle, and launder linens potentially exposed to scabies, affecting all 85 residents. The facility's infection control policy for scabies requires contaminated items to be bagged and washed separately at high temperatures. However, the Housekeeping/Laundry Supervisor was unaware of this protocol, leading to the mixing of potentially contaminated items with other residents' laundry. This oversight occurred despite the Infection Preventionist's awareness of the potential for further infestation and infection. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) for two residents. One resident, with wounds and a urinary catheter, had a care plan requiring staff to wear gowns and gloves during high-contact care. However, during observed care, staff did not wear gowns. Similarly, another resident with a gastrostomy tube required EBP, but staff only wore gloves during medication administration. The facility's protocol mandates gowns and gloves for high-contact activities, which were not followed in these instances.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications timely and according to physician's orders and manufacturer's instructions for four residents. A registered nurse was behind on the morning medication pass, resulting in late administration of medications for one resident, including Lantus insulin, Macrobid, Tylenol, and Metoprolol Tartrate. The nurse did not prime the Lantus insulin pen before administration, and there was no documentation that the physician was notified of the late administration and missed doses. Another resident received Humulin N insulin and Persantine late, and the nurse did not prime the insulin pen before administration, unaware of the requirement. The physician was not notified of the late administration. A licensed practical nurse administered Admelog insulin to a resident without food present, contrary to instructions to administer within 15 minutes prior to a meal or immediately after. Another resident received Brimonidine Tartrate eye drops late due to the nurse being behind in the medication pass. The facility's policy requires notifying the physician of medication errors and missed doses, but this was not documented in the cases reviewed.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for two residents, as required by regulations. During an observation, a light tan fabric chair in the sitting area of the residents' room was found to have dark and light brown stains covering at least half of the seat. The Housekeeping Supervisor, when interviewed, acknowledged that the chairs in residents' rooms are cleaned occasionally and mentioned that most were cleaned by an outside company a few months prior. However, she was unaware of the stained condition of the chair in question. The chair was subsequently removed for cleaning after the issue was identified. The facility's Fabric Furniture Cleaning policy outlines that furniture should be cleaned when soiled, but it appears this procedure was not followed in a timely manner for the chair in the residents' room.
Failure to Obtain Proper Authorization for Restraint Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints without proper authorization and documentation. A resident, diagnosed with unspecified dementia, muscle weakness, and other conditions, was observed with a lap cushion across his lap while in a wheelchair. The resident's care plan noted the lap cushion as a comfort device, and it was documented that the resident could place and remove it independently. However, during observations, the resident was unable to remove the lap cushion upon request, indicating it functioned as a restraint. The facility did not have a physician's order or a signed consent form for the use of the lap cushion as a restraint. The resident's medical records lacked documentation of restraint reduction attempts, and the facility's policies required informed consent and a plan for the progressive removal of restraints. Interviews with facility staff revealed a lack of awareness regarding the resident's inability to remove the lap cushion, and the necessary documentation and consent were not obtained until after the deficiency was identified.
Failure to Implement Hearing Devices and Care Plan for Resident
Penalty
Summary
The facility failed to implement hearing devices and develop a care plan for a resident with hearing loss. The resident, who has moderate cognitive impairment, was documented to have minimal difficulty hearing when using hearing aids. However, the care plan did not address the resident's hearing loss and hearing aid use until a specific date, despite the resident's admission assessment indicating the use of hearing aids for both ears. The resident's family reported that both hearing aids were missing, and although one was found, the other remained missing, impacting the resident's ability to communicate effectively. Staff interviews revealed that the resident was not wearing hearing aids during interactions, and there was confusion among staff regarding the resident's hearing aid needs. A Certified Nursing Assistant admitted to not applying the hearing aid due to fear of losing the remaining one. The Director of Nursing acknowledged that staff should have been applying the hearing aid daily and confirmed the absence of a care plan for the resident's hearing loss and devices prior to the noted date. This lack of a care plan and proper implementation of hearing devices led to the deficiency.
Failure to Properly Manage and Document G-Tube Care
Penalty
Summary
The facility failed to properly manage and document the care of a resident with a gastrostomy tube (g-tube). The resident, identified as R39, was observed receiving Osmolite 1.5 Cal at 60 ml per hour via g-tube, with water flushes set at 200 ml every four hours. However, the facility did not check and record the gastric residual volume to verify the g-tube placement before administering medications, as required by the facility's policy. Instead, a registered nurse used the air rush technique to check tube placement, which is not in line with the facility's protocol. Additionally, the total volume of feeding and water flushes administered was not recorded, and there were no orders to routinely check gastric residuals or parameters to hold feeding based on residual volumes. The resident's care plan and the facility's policies require checking tube placement and gastric contents/residual volume, and documenting these checks, which was not done. The Director of Nursing confirmed that the nurses should be checking g-tube placement by checking gastric residual volume prior to feeding and medication administration, and that water flush orders should be based on the dietitian's recommendations. The facility's policies also require recording the amount of feeding and water flushes administered, which was not adhered to in this case.
Deficiencies in Respiratory Care Equipment Management
Penalty
Summary
The facility failed to properly label, store, and change oxygen and nebulizer tubing for three residents, leading to deficiencies in respiratory care. For one resident, the oxygen tubing was found undated and uncovered on the bed, with no physician order or documentation indicating routine changes. This resident had used oxygen on multiple days over a period of nearly a month. Another resident's nebulizer mask and tubing were also undated and uncovered, with visible splatters of a brown substance on the nebulizer machine. The medication administration record indicated that the nebulizer tubing and mask should be changed weekly, but there was no documentation of this being done as scheduled. A third resident was found using oxygen via nasal cannula with tubing dated ten days prior, and the resident was unsure of the frequency of tubing changes. The treatment administration record indicated that the tubing should be changed weekly, and it was signed as completed on a specific date. A registered nurse confirmed that the oxygen and nebulizer equipment should be labeled with dates, changed weekly, and stored in plastic bags when not in use. The facility's policies on oxygen administration and aerosol treatments also required weekly changes and proper storage, which were not adhered to in these cases.
Inadequate Infection Control Measures for COVID-19
Penalty
Summary
The facility failed to implement effective infection control measures to prevent the spread of COVID-19. Specifically, the facility did not stock isolation carts with N95 masks, failed to post isolation signage, and did not ensure staff discarded personal protective equipment (PPE) upon leaving COVID-19 positive resident rooms. These deficiencies were observed in the care of five residents, where staff did not change their N95 masks after leaving the room of a COVID-19 positive resident, and isolation signage was missing from the doors of rooms housing COVID-19 positive residents. Additionally, the facility's policy required symptom monitoring and vital signs to be taken every four hours for COVID-19 positive residents, but this was not documented in the medical records. One resident, who tested positive for COVID-19, had a history of congestive heart failure, emphysema, atrial fibrillation, and type two diabetes mellitus. Despite the resident's positive COVID-19 test and physician orders for contact/droplet isolation and vital sign monitoring twice daily, there was no documentation of symptom monitoring or respiratory assessments after the initial note. Staff members, including a CNA and a housekeeper, were unaware of the proper procedures for handling PPE and identifying COVID-19 positive rooms, leading to potential exposure risks for other residents and staff.
Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident (R2) from physical abuse by another resident (R1). R1, who has severe cognitive impairment due to dementia, exhibited aggressive behaviors such as yelling, screaming, and physical aggression. On the day of the incident, R1 entered R2's room in a wheelchair and, when asked to leave by R2, became angry and struck R2 in the chest multiple times. This incident was witnessed by another resident (R3) and reported by a Certified Nursing Assistant (V4) to a Licensed Practical Nurse (V3). R2, who is cognitively intact, confirmed the account of the incident, stating that R1 hit them three times in the chest after being asked to leave the room. The facility's policy on abuse and neglect clearly states that all residents have the right to be free from physical abuse, yet this incident indicates a failure to uphold that policy. The report includes interviews with staff and residents, which corroborate the occurrence of the abuse, highlighting a deficiency in the facility's ability to prevent such incidents.
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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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