Goldwater Care Roseville
Inspection history, citations, penalties and survey trends for this long-term care facility in Roseville, Illinois.
- Location
- 145 S Chamberlain St, Box 770, Roseville, Illinois 61473
- CMS Provider Number
- 146020
- Inspections on file
- 24
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Goldwater Care Roseville during CMS and state inspections, most recent first.
A facility failed to provide a working call system or accessible alternative for all residents after the electronic call system became inoperable. One resident with significant cardiac and mobility issues was admitted without a functioning call light and experienced chest pain for over two hours without staff response, ultimately requiring emergency services. Other residents also lacked access to call lights or bells, and staff were unaware or did not provide alternatives, resulting in unmet care needs and delayed assistance.
Surveyors found that several resident bathrooms and the main dining room vent were not properly cleaned or maintained, with issues such as debris, stained caulking, missing paint, and damaged walls. Residents expressed dissatisfaction with the cleanliness, and staff interviews revealed confusion over cleaning responsibilities. The DON confirmed all residents use the affected dining area, and the Administrator acknowledged the need for repairs.
The facility did not provide required QAPI training to all staff, as confirmed by review of in-service schedules and staff training records, and verified by the DON. This deficiency potentially affected all 40 residents in the facility.
A review of facility records and staff interviews revealed that employees did not receive required training on the Compliance and Ethics Program. The in-service schedule and assessment tools omitted this training, and the DON confirmed that staff had not been trained, affecting all residents in the facility.
The facility did not maintain a working nurse call system in resident bathrooms, leaving several residents—many with significant mobility issues and fall risks—unable to summon assistance during toileting. Residents and staff reported the system had been non-functional for months, leading to delays in care, increased anxiety, and, in one case, a fall with injury. Despite repeated complaints to administration, the deficiency persisted, and alternative measures such as bells were inadequate.
The facility did not maintain a working bathroom nurse call light system, as documented in multiple concern forms and resident council minutes over several months. Observations confirmed that call buttons in several bathrooms failed to activate lights or audible alerts, and both residents and staff reported the system had been down for an extended period. The Maintenance Director and Administrator acknowledged the system's ongoing failure and the lack of available parts for repair, with no clear timeline for replacement.
The facility did not assess the risk of entrapment from side rails for five residents, despite their use for mobility assistance. Observations showed side rails in various positions, and interviews confirmed their use. The administrator acknowledged the lack of documentation for entrapment assessments, indicating a failure to follow policy and ensure resident safety.
A facility failed to conduct a required Level II PASRR evaluation for a resident with suspected schizophrenia, major depression, and anxiety. The resident's PASRR Level I Form indicated the need for a face-to-face Level II evaluation, as required by Federal law, but the medical record lacked documentation of this evaluation. The Regional Operation Manager confirmed the oversight.
A facility failed to assess a resident for the removal of an indwelling urinary catheter after returning from hospitalization. The resident, who was usually continent and used the bathroom with assistance before hospitalization, returned with a catheter but was not consulted about its removal. The DON stated that staff should obtain orders for removal if a catheter was not present before hospitalization, which was not done in this case.
A facility failed to weigh a resident weekly as recommended by a dietitian after a significant weight loss. The resident's weight dropped from 237 to 222 pounds, prompting a recommendation for weekly weights, which was not documented in the medical record after the initial weight loss.
A resident was prescribed Seroquel for mood disorder related to Vascular Dementia without documented behaviors justifying its use. Despite the facility's policy requiring psychotropic drugs only when necessary, the resident showed no aggressive behaviors, and the DON was unsure of antipsychotic regulations.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with Chronic Viral Hepatitis C, as required by their infection control policy. Observations showed no EBP signs or PPE in the resident's room, and the resident confirmed staff only wore gloves during care. Staff interviews revealed a lack of adherence to EBP protocol, despite acknowledging the resident's condition warranted such precautions.
A resident reported verbal and physical abuse by CNAs, including being called 'crazy' and experiencing pain during a transfer. The incidents were reported to the DON, but the facility failed to report the allegations to the State Agency as required by their policy.
A facility failed to investigate allegations of abuse involving a resident and CNAs. The resident reported incidents of verbal and physical mistreatment, which were communicated to the DON but not investigated or reported to the Administrator. Interviews confirmed the interactions, but no immediate action was taken, resulting in a deficiency.
The facility failed to ensure that staff had their hair and facial hair fully restrained during food production and clean-up activities. Multiple staff members, including the Dietary Manager, Cook, Dietary Aide, Dishwasher, and Maintenance Director, were observed with unrestrained hair while engaged in various kitchen activities. This non-compliance with the facility's dress code policy has the potential to affect all 43 residents currently residing in the facility.
The facility failed to implement Contact Isolation Precautions and Enhanced Barrier Precautions for residents with indwelling urinary catheters, leading to potential spread of MDROs. Staff were observed providing care without necessary PPE, and appropriate signage was not posted, despite documented orders and policies.
The facility failed to provide the required minimum of twelve hours of CNA training over a twelve-month period, affecting all 43 residents. The ADON could not find training records for the past year, except for those from January 2024 forward, which did not meet the twelve-hour requirement, nor did they include dementia care and abuse prevention training.
The facility failed to perform a PASARR level I re-screening for a resident with Bipolar Disorder, Depression, and PTSD. The initial screening was conducted and valid for 90 days, but no subsequent screenings were found in the resident's medical record.
The facility failed to update the care plans for three residents, leading to deficiencies in their care. One resident's care plan did not reflect contact isolation precautions for VRE, another's did not address significant edema, and a third's was not updated to reflect the resolution of a pressure ulcer. These deficiencies were confirmed by facility staff and indicate non-compliance with the facility's care planning policy.
The facility failed to implement fall prevention interventions for three residents. One resident's call light was out of reach, another's chair alarm was non-functional, and a third resident experienced a fall due to inadequate staff assistance during a transfer. These deficiencies highlight lapses in adhering to fall prevention policies.
The facility failed to secure an indwelling urinary catheter for a resident with Neuromuscular Dysfunction of the Bladder. CNAs and the DON confirmed the absence of a securement device, which is against the facility's policy.
The facility failed to develop a dementia care plan for a resident diagnosed with Alzheimer's Dementia. The diagnosis was documented, but the care plan did not address this condition, as confirmed by the Care Plan Coordinator.
The facility failed to ensure a physician evaluated and documented the rationale for the continued use of a PRN psychotropic medication for a resident. The resident had a PRN order for Haldol IM for Anxiety Disorder, but the required physician evaluation and documentation were missing since November 2023, as verified by the Care Plan Coordinator.
The facility failed to implement physician orders for a resident with Type 2 Diabetes Mellitus, as no Hemoglobin A1C tests were documented since the resident's admission. The DON confirmed the oversight and acknowledged the missed monitoring.
The facility failed to provide quarterly financial statements to residents whose personal funds were managed by the facility. Several residents reported not receiving account balance statements for months, and the Administrator in Training confirmed that no financial statements had been issued since the previous year, affecting all 43 residents.
The facility failed to ensure survey results from the past three years were available for review. Several residents were unaware of where to access these results. A binder near the entrance contained outdated information, and the Administrator in Training confirmed it had not been kept current.
Failure to Provide Accessible Call System During Outage
Penalty
Summary
The facility failed to ensure that a working call system was available and accessible to all residents, particularly in bathrooms and bathing areas, after the electronic call system became inoperable. This failure was observed through multiple interviews, record reviews, and direct observations, revealing that several residents, including those with significant medical needs, were left without a functioning call light or an alternative means to summon assistance. One resident, who was admitted with diagnoses including Atrial Fibrillation, repeated falls, heart failure, and morbid obesity, was placed in a bed without a working call system and was not provided with a bell or any alternative device to call for help. The resident experienced chest pain and shortness of breath for over two hours without staff response, ultimately requiring emergency services for a new onset of atrial fibrillation. Other residents were also found to be without working call lights or bells, and staff interviews confirmed that some residents had never been provided with a bell. Residents reported having to rely on roommates or yelling for help, and in some cases, staff were unaware of the inoperability of the call lights. Documentation showed that the facility's call light system had been out of service for an extended period, and there was no documented plan to ensure all residents had access to an alternative call system. The facility's own policy required that all residents have access to a call system at all times, and that defects be promptly reported and addressed, but these procedures were not followed. The lack of a functioning call system affected all 40 residents in the facility, with specific incidents of delayed care and unaddressed needs, including a resident who was left in soiled clothing for hours and another who was unable to call for help during a medical emergency. Staff interviews revealed confusion and lack of communication regarding the status of the call system and the provision of alternative devices. Maintenance records did not reflect timely reporting or repair of the call system failures, and care plans were not updated to reflect the need for increased supervision or alternative call systems during the outage.
Removal Plan
- All resident care plans were updated to ensure residents receive frequent rounding to ensure needs are met and bells are within reach if a call light is found to be inoperable. Staff will complete a work order and submit to the Maintenance Department for service or repairs. The Maintenance Director will keep all work orders which will document what type of repair was conducted. The Administrator and/or Director of Nursing will be responsible for overseeing and maintaining plan until call light system is back online and operating appropriately.
- All staff were in-serviced on the facility's Call Light policy including reporting call bell system defects promptly to the Maintenance Department for servicing and checking rooms frequently until the call light system is repaired, providing dependent residents with a hand bell whenever a call light is found to be inoperable, and answering call lights promptly.
- V2 was educated on the facility's Comprehensive Care Plan policy, including developing a comprehensive care plan after completion of the comprehensive assessment that includes services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, resident's goals for admission and desired outcomes, resident's preference and potential for future discharge, including the resident's desire to return to the community and any referrals to local contact agencies.
- V6 (Maintenance Director) was educated to document when call lights were out of service, when repairs were made, and to keep a service repair/work order binder to document when call lights are out of service and when repairs are made.
- All resident bathrooms were provided with hand bells.
- Daily audits were completed to ensure all call lights were operational and hand bells were within reach of all residents that did not have working call lights with the exception of 300 hall which closed and does not currently have residents. These audits will continue.
- All staff were re-in serviced on ensuring V17 receives a work order whenever call lights are not working and ensuring V17 documents in the maintenance binder when the call lights are inoperable and are repaired.
- The new call system was fully operational and working on all of 100 and 200 hallway bathrooms and resident rooms. All resident rooms and bathrooms had bells as back up call devices. These bells were within reach of all residents.
Failure to Maintain Clean and Safe Resident and Common Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and comfortable environment for its residents. During a facility tour, multiple resident bathrooms were found with significant maintenance and cleanliness issues, including cove base pulled away from the wall, missing chunks of drywall with debris on the floor, stained caulking around toilets, and bathroom walls with missing paint. Additionally, air conditioner vents in resident bathrooms were covered in debris. The main dining room's large heating/cooling vent was completely covered in thick, brown debris. These conditions were confirmed by the facility's Administrator during a follow-up tour. Interviews with residents revealed dissatisfaction with the cleanliness and maintenance of their bathrooms, with one resident expressing concern about the air quality due to a dirty vent, particularly given their asthma. Staff interviews indicated a lack of clarity regarding responsibility for cleaning the dining room vent, with both housekeeping and maintenance staff stating they had never cleaned it. The Director of Nursing confirmed that all residents, including those with special feeding needs, use the main dining room. The Administrator acknowledged awareness of the need for repairs and updates in many resident bathrooms.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to all employees, as required by its own Facility Assessment Tool. A review of the facility's census confirmed that 40 residents were present at the time of the deficiency. Examination of the Annual In-Service Schedule and staff in-service records from 9/1/24 through 9/6/25 revealed that QAPI training was not included. This was further verified by the Director of Nursing, who confirmed that staff had not received QAPI training.
Lack of Staff Training on Compliance and Ethics Program
Penalty
Summary
The facility failed to provide training on its Compliance and Ethics Program to all employees, as evidenced by a review of records and staff interviews. The Annual In-Service Schedule did not include any sessions related to the Compliance and Ethics Program, and the Facility Assessment Tool did not list this program as a required staff training. Additionally, a review of staff in-service records over a one-year period confirmed the absence of such training. This was further verified by the DON, who acknowledged that staff had not received training on the Compliance and Ethics Program. The facility census at the time documented 40 residents residing in the facility.
Failure to Maintain Functioning Nurse Call System in Resident Bathrooms
Penalty
Summary
The facility failed to provide a functioning nurse call system in resident bathrooms and bathing areas for all residents, as required by facility policy. Observations, interviews, and record reviews revealed that the nurse call system in resident bathrooms had been non-functional for an extended period. Multiple residents reported that the system had been down for months, and staff confirmed ongoing issues with the system despite attempts at repair. In several instances, activating the call system in resident bathrooms did not result in any visual or audible alert at the room door or nurse's station, and this was verified by both nursing and maintenance staff. Four residents with significant medical conditions and varying levels of dependence for toileting were directly affected by the non-functioning call system. These residents included individuals with diagnoses such as hemiplegia, chronic pain, osteoarthritis, diabetes with neuropathy, and a history of falls. Each resident's care plan emphasized the need for prompt response to call lights and the importance of having the call system within reach, especially given their fall risk and dependence on staff for toileting assistance. Despite these documented needs, residents were left without a reliable means to summon help while in the bathroom. Residents described experiencing fear, anxiety, and in some cases, actual harm due to the inability to call for assistance. One resident reported waiting up to 30 minutes for help after being left on the toilet, while another described falling in the bathroom and being unable to reach the provided bell or call for help, resulting in injury and a subsequent emergency room visit. Staff and residents both reported that complaints about the broken system had been made to the facility administrator over several months, but the issue remained unresolved at the time of the survey.
Failure to Maintain Functioning Bathroom Nurse Call Light System
Penalty
Summary
The facility failed to provide a functioning bathroom nurse call light system for its residents. Multiple facility documents, including Concern Forms and Resident Council Minutes from March through June, documented ongoing issues with non-functioning call lights. Observations on June 2nd confirmed that the nurse call buttons in several residents' bathrooms did not activate lights or audible alerts, either outside the rooms or at the nurse's stations. Residents reported that they had complained about the broken system for months, and staff, including an LPN and CNA, confirmed that the bathroom nurse call system had been down for an extended period. The Maintenance Director stated that the system had been inoperable since he began employment in February and that repeated repair attempts by a local company were unsuccessful due to the outdated nature of the system and lack of available parts. The Administrator confirmed that the system had been down since at least early January, that corporate staff were notified in January, and that bids for a replacement system were obtained in May, but there was no information on when the system would be replaced or operational. At the time of the report, 44 residents resided in the facility.
Failure to Assess Entrapment Risk with Bed Rails
Penalty
Summary
The facility failed to assess the risk of entrapment from side rails for five residents out of thirteen reviewed for siderails, within a total sample of 28 residents. The facility's policy requires an assessment for safety risks before installing bed rails, including checking compatibility with the bed frame and mattress, ensuring proper installation, and regularly inspecting for potential entrapment areas. However, the facility did not document any entrapment risk assessments for the residents in question, despite their use of side rails for mobility assistance and positioning. Observations revealed that the residents' beds had side rails in various positions, and interviews confirmed that the residents used these rails for assistance. The facility's administrator acknowledged the lack of documentation for entrapment assessments for these residents and mentioned ongoing training for the new Maintenance Director regarding these assessments. The absence of documented assessments indicates a failure to adhere to the facility's policy and ensure resident safety concerning the use of side rails.
Failure to Conduct Required Level II PASRR Evaluation
Penalty
Summary
The facility failed to obtain a Level Two PASRR (Preadmission Screening and Resident Review) for a resident who was identified as needing further evaluation. The resident's PASRR Level I Form, dated August 1, 2023, indicated that the resident had never undergone a PASRR Level I screen before and documented mental health diagnoses including suspected schizophrenia, current major depression, and current anxiety. The PASRR Level I screen concluded that a face-to-face Level II evaluation was required, as mandated by Federal law, due to the potential presence of a serious mental illness or an intellectual/developmental disability. However, the resident's medical record lacked any documentation of a completed Level II PASRR evaluation. This oversight was confirmed by the Regional Operation Manager, who acknowledged the absence of the necessary documentation and indicated that the evaluation had been missed.
Failure to Assess Indwelling Urinary Catheter Removal
Penalty
Summary
The facility failed to assess a resident, identified as R45, for the removal of an indwelling urinary catheter. R45 was admitted to the facility with several diagnoses, including unspecified diastolic congestive heart failure and chronic kidney disease. Initially, R45 was usually continent and required assistance to use the bathroom. However, after a hospitalization for sepsis, upper respiratory infection, and hypoxia, R45 returned to the facility with an indwelling urinary catheter. Despite this change, there was no documentation in R45's electronic medical record regarding any discussions about the necessity or potential removal of the catheter. Observations and interviews revealed that R45 was unaware of the reason for the catheter and had not been consulted about its removal. A Certified Nursing Assistant confirmed that R45 did not have a catheter before the hospitalization and used the bathroom with assistance. The Director of Nursing stated that it is expected for nursing staff to obtain orders for catheter removal if a resident returns from the hospital with a catheter they did not have before. This expectation was not met, leading to the deficiency noted in the report.
Failure to Monitor Resident's Weight as Recommended
Penalty
Summary
The facility failed to adhere to its dietary policy by not weighing a resident as recommended, which led to a deficiency. The policy stated that residents identified at nutritional risk should be weighed weekly or bi-weekly as per physician order or Interdisciplinary Team recommendation. A resident's medical record documented a weight of 237 pounds on January 9, 2025, and a subsequent weight of 222 pounds on February 11, 2025, indicating a 6.3% weight loss in one month. Following this, a dietitian recommended weekly weights for four weeks due to the weight loss. However, the resident's medical record did not contain any documentation of weights after February 11, 2025. On March 5, 2025, the Dietary Manager confirmed the absence of any weight documentation after the specified date, despite the dietitian's recommendation.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to provide an appropriate indication for the use of antipsychotic medication for one resident, identified as R47, who was part of a sample of 28 residents reviewed for unnecessary medications. R47 was admitted to the facility with multiple diagnoses, including Vascular Dementia with Mood Disturbance. Despite having a physician's order for Seroquel, an antipsychotic medication, to be administered daily for mood disorder related to Vascular Dementia, there was no documented evidence of behaviors that would necessitate the continued use of this medication. Observations and interviews revealed that R47 exhibited no aggressive behaviors towards others and had not shown any documented behaviors in the electronic medical record for the past month. The facility's policy on psychotropic medication requires that such drugs are only given when necessary to treat a specific condition and at the lowest therapeutic dose. However, the Director of Nursing was unsure of the regulations regarding antipsychotic medications, and the Licensed Practical Nurse confirmed that R47 had not displayed aggressive behaviors for some time. This lack of documented behavioral symptoms and the absence of a clear indication for the continued use of Seroquel suggest a failure to adhere to the facility's policy and regulatory standards for the use of psychotropic medications.
Failure to Implement Enhanced Barrier Precautions for Resident with Hepatitis C
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident diagnosed with Chronic Viral Hepatitis C, as required by their infection prevention and control program. The facility's policy mandates the use of EBP, which includes the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. However, observations revealed that there were no EBP signs or Personal Protective Equipment (PPE) available outside or inside the resident's room. The resident confirmed that staff only wore gloves during care and had never seen them wear a gown. Interviews with facility staff, including a Licensed Practical Nurse and the Assistant Director of Nursing, indicated a lack of adherence to the EBP protocol. Both staff members acknowledged that the resident's condition warranted the use of EBP, yet confirmed that the necessary precautions were not in place. The Assistant Director of Nursing verified that the resident should have been on EBP due to the infection risk posed by Hepatitis C, but acknowledged that the protocol was not being followed for this resident.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report alleged verbal, mental, and physical abuse of a resident to the State Agency as required by their policy. The policy mandates that any allegation of abuse be reported to the Department of Public Health immediately, but not more than two hours after the allegation. A resident, identified as R3, reported two incidents involving CNAs. In the first incident, a CNA was loud and called the resident 'crazy' when asked to be quiet. In the second incident, another CNA caused the resident pain while using a mechanical lift and subsequently denied causing harm, again calling the resident 'crazy.' The resident reported these incidents to the Director of Nursing, but the allegations were not documented or reported to the State Agency as required. The Director of Nursing confirmed that the allegations were not reported, and the facility was unable to provide documentation of any report being made.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of potential abuse and ensure the protection of a resident during the investigation. A resident, identified as R3, reported two separate incidents involving CNAs V5 and V6. In the first incident, R3 stated that V6 was loud and called her crazy when she asked for quiet. In the second incident, R3 reported that V5 caused her pain while using a mechanical lift and subsequently called her crazy. R3 communicated these concerns to the Director of Nursing (DON), V2, who acknowledged the reports but did not conduct an investigation or report the incidents to the Administrator, V1. Interviews with the involved staff, V5 and V6, confirmed the interactions with R3 but did not result in any immediate action or investigation. V5 and V6 both stated they worked throughout the building and did not remain in one hall, which could have implications for monitoring and supervision. V2 admitted to not investigating R3's allegations and failing to report them to V1, who was aware of the incident involving V6 but did not initiate an investigation. This lack of action and failure to follow the facility's abuse prevention policy resulted in a deficiency in addressing and investigating potential abuse allegations.
Failure to Restrain Hair and Facial Hair in Kitchen
Penalty
Summary
The facility failed to ensure that staff had their hair and facial hair fully restrained during food production and clean-up activities. This was observed on multiple staff members, including the Dietary Manager, Cook, Dietary Aide, Dishwasher, and Maintenance Director. Specifically, the Cook, Dietary Aide, and Dietary Manager had large strands of hair unrestrained on the tops, sides, and backs of their heads. The Dishwasher wore a ball cap that left the sides and back of his hair unrestrained and had no restraint covering his beard. Similarly, the Maintenance Director wore a ball cap that left the front, sides, and back of his hair unrestrained and had no restraint covering his beard. These observations were made while the staff were engaged in various kitchen activities, including cooking, stacking clean plates and cups, washing dishes, and removing screens above the stove. The facility's policy, revised in October 2016, mandates that all food service employees adhere to a dress code that includes hair nets or appropriate hair coverings, including facial hair coverings, while involved in food production and clean-up activities. The Dietary Manager confirmed that all staff should have their hair fully restrained while in the facility kitchen. This failure to comply with the facility's dress code policy has the potential to affect all 43 residents currently residing in the facility.
Failure to Implement Isolation and Barrier Precautions
Penalty
Summary
The facility failed to implement Contact Isolation Precautions and Enhanced Barrier Precautions to contain the potential spread of Multi Drug-Resistant Organisms (MDROs). This failure was observed in multiple instances involving residents with indwelling urinary catheters, which are high-contact care activities requiring enhanced precautions. Specifically, the facility did not post appropriate signage or provide necessary Personal Protective Equipment (PPE) for staff when caring for these residents, despite documented orders and policies requiring such measures. One resident with a urinary catheter and a confirmed case of Vancomycin Resistant Enterococcus (VRE) did not have isolation signage or PPE available at the entrance to his room. Staff members were observed providing care without wearing gowns, contrary to the facility's Contact Precautions policy. The resident's room lacked the necessary postings and PPE from the time the VRE was identified until the surveyor's visit, despite the resident being on contact isolation precautions. Another resident with an indwelling urinary catheter also did not have Enhanced Barrier Precautions signage or PPE available. Staff confirmed that no residents were on Enhanced Barrier Precautions, despite the resident's care plan and physician's orders indicating the need for such precautions. Similar deficiencies were noted with other residents requiring catheter care, where staff were observed providing care without the required PPE and without appropriate signage indicating isolation precautions.
Failure to Provide Required CNA Training
Penalty
Summary
The facility failed to provide the required minimum of twelve hours of nurse aide training over a twelve-month period, which has the potential to affect all 43 residents in the facility. The Certified Nursing Assistant (CNA) training folder, provided by the Assistant Director of Nursing (ADON), did not contain the required training documentation for the past year for CNAs currently working in the facility. During an interview, the ADON stated that they could not find any CNA training records for the last year, except for those from January 2024 forward, which did not meet the twelve-hour requirement. Additionally, there was no proof that all CNAs received training in dementia care and abuse prevention.
Failure to Perform PASARR Level I Re-Screening
Penalty
Summary
The facility failed to perform a PASARR (Pre-Admission Screening and Resident Review) level I re-screening for one of two residents reviewed for PASARR screening. The resident, identified as R4, was admitted with diagnoses including Bipolar Disorder, Depression, and Post-Traumatic Stress Disorder. The initial OBRA-I screen was conducted on 01/20/20 and was valid for 90 days. However, the current medical record for R4 did not include any subsequent PASARR screenings. The Administrator in Training confirmed that no additional screenings beyond the initial OBRA-I screen were available for R4.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update the care plans for three residents, leading to deficiencies in their care. Resident R4 had a urine specimen that tested positive for Vancomycin Resistant Enterococcus (VRE) and was on contact isolation precautions. However, R4's care plan did not reflect this status. This was confirmed by the Licensed Practical Nurse/Care Plan Coordinator. Resident R32 had significant edema in the bilateral lower legs and was prescribed Lasix for the condition, but the care plan did not address the edema. This omission was also verified by the Care Plan Coordinator. Resident R35 had a previously documented stage 2 pressure ulcer on the right gluteal fold, which had resolved by the time of the survey. However, the care plan had not been updated to reflect the resolution of the skin issue, as confirmed by the Director of Nurses. The facility's policy on Comprehensive Care Planning mandates that care plans be reviewed and revised as necessary to reflect the resident's current medical, nursing, and psychological needs. The failure to update the care plans for these residents indicates non-compliance with this policy. The deficiencies were identified through observations, interviews, and record reviews, highlighting lapses in the facility's adherence to its own care planning procedures. These lapses could potentially impact the quality of care provided to the residents, as their care plans did not accurately reflect their current medical conditions and required interventions.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to reduce the risk of falls for three residents. Resident R32, who has diagnoses including Alzheimer's Disease and is at high risk for falls, was found without a call light within reach, which was on the floor under the bed. This was confirmed by a Registered Nurse. Resident R41, diagnosed with Dementia and other conditions, was found in a wheelchair with a non-functioning chair alarm that was not connected to a power source, as verified by a Registered Nurse. Resident R23, who requires substantial assistance for mobility and has a high fall risk, experienced a fall while being assisted to bed. The fall occurred when the resident leaned forward and fell to her knees. The incident was witnessed by a CNA who was the only staff member present, contrary to the facility's policy requiring two staff members for lift assistance. The Assistant Director of Nursing confirmed the lack of a witness statement and the Director of Nursing acknowledged the policy breach. These deficiencies highlight the facility's failure to adhere to its fall prevention policies, including ensuring call lights are within reach, maintaining functional alarm systems, and providing adequate staff assistance during transfers. These lapses contributed to the increased risk of falls and potential harm to the residents involved.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter was secured with a securement device for a resident diagnosed with Neuromuscular Dysfunction of the Bladder. During an observation, the resident's catheter was found unsecured while she was lying in bed. Certified Nursing Assistants confirmed the absence of a securement device and acknowledged that the catheter should have been secured. The Director of Nursing also confirmed that all indwelling urinary catheters should be secured with a securement device, as per the facility's policy.
Failure to Develop Dementia Care Plan
Penalty
Summary
The facility failed to develop a dementia care plan for a resident diagnosed with Alzheimer's Dementia. The resident's electronic diagnoses dated 3/6/24 documented the diagnosis, but the current care plan dated 2/28/24 did not include a comprehensive care plan addressing this condition. This deficiency was confirmed by the Care Plan Coordinator on 4/17/24.
Failure to Document Physician Evaluation for Continued PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure the physician evaluated and documented the rationale for the continued use of a PRN psychotropic medication for one resident. The facility's policy requires that residents must not have PRN orders for psychotropic medications unless necessary to treat a diagnosed specific condition, and PRN orders for antipsychotic medications are limited to 14 days unless re-evaluated by the physician. Resident R24 had a physician order for Haldol IM every 12 hours as needed for Anxiety Disorder, dated 3/8/24, with a second clarification order dated 3/15/24. However, the resident's chart lacked any physician visit notes after 11/16/2023, indicating that the required evaluation and documentation for the continued use of the antipsychotic medication were missing. This was verified by the Care Plan Coordinator on 4/17/24, who confirmed that R24 had not been seen by her physician since November 2023.
Failure to Implement Physician Orders for Laboratory Tests
Penalty
Summary
The facility failed to ensure physician orders were implemented for laboratory tests for a resident reviewed for Insulin. The resident had a physician's order for Insulin Glargine to be injected subcutaneously twice a day for Type 2 Diabetes Mellitus without complications. Additionally, there was an order for Hemoglobin A1C to be conducted every three months. However, the resident's medical record did not document any Hemoglobin A1C results since their admission to the facility on 7/12/23. The Director of Nursing confirmed that a Hemoglobin A1C test had not been completed for the resident since admission, acknowledging that it was missed and should have been monitored.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to provide quarterly financial statements to residents whose personal funds were managed by the facility. According to the facility's Resident Right Manual, residents are entitled to receive a current, itemized written statement of their financial records at least once every three months. However, during a group meeting, several residents reported that they had not received any account balance statements for several months. One resident mentioned that it took two weeks to get information about their balance, which required the facility staff to contact the corporate office. This indicates a significant delay and lack of transparency in managing residents' funds. The Administrator in Training (V1) confirmed that the facility had not been providing the required quarterly financial statements. V1 admitted to not being aware of the necessity to keep these statements current manually. The facility manages funds for all 43 residents, and none of them had received a financial statement since the previous year. This lapse in providing financial statements affects all residents currently residing in the facility, as verified by the Center for Medicare and Medicaid Services Form 671.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that the results of surveys, certifications, and complaint investigations conducted during the past three years were available for review. During a group meeting with residents who have previously attended Resident Council meetings, several residents did not know where to access the facility's previous annual and complaint survey results and were unaware that all State Agency survey results were accessible. A binder titled 'Certification Survey Results for Public Inspection' was found near the entrance to the building, but it only contained the most recent survey results from a complaint investigation conducted on 01/18/2023. The Administrator in Training confirmed that the binder had not been kept current and that the facility's 2023 annual survey and additional complaint investigations conducted after 01/18/2023 were not included.
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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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